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Human Milk Versus Formula After Gastroschisis Repair: Effects on Time to Full Feeds and Time to Discharge

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Human Milk Versus Formula After Gastroschisis Repair: Effects on Time to Full Feeds and Time to Discharge Journal of Perinatology (2013) 33, 627–630 & 2013 Nature America, Inc. All rights reserved 0743-8346/13 www.nature.com/jp ORIGINAL ARTICLE Human milk versus formula after gastroschisis repair: effects on time to full feeds and time to discharge JA Kohler Sr, AM Perkins and WT Bass OBJECTIVE: To determine if the choice of enteral feeds after gastroschisis repair relates to the time to achieve full feeds and time to discharge. STUDY DESIGN: A retrospective study of infants with gastroschisis from 2000 to 2010 examined demographics, days at closure, days at initiation of feeds, days to full feeds, time to discharge and length of stay. RESULT: Ninety infants were identified, 22 received (human milk) HM exclusively, 15 were fed 450% HM, 16 were fed o50% HM and 26 were fed only cow milk-based formulas. Infants fed exclusively HM had significantly shorter times to full enteral feedings (median 5 days versus 7 days, P ¼ 0.03). The time from initiation of feedings to hospital discharge, which accounts for initiation age, significantly favored the exclusively HM-fed infants (median 7 days versus 10 days, P ¼ 0.01). CONCLUSION: Exclusive HM feeding after gastroschisis repair decreases time to achieve full enteral feeds and time to discharge. Journal of Perinatology (2013) 33, 627–630; doi:10.1038/jp.2013.27; published online 21 March 2013 Keywords: total parenteral nutrition; parenteral nutrition-associated liver disease; intestinal permeability INTRODUCTION METHODS Gastroschisis is a congenital defect of the ventral abdominal wall. Study population The lesion consists of a small full-thickness periumbilical cleft This retrospective study included all patients who were admitted to the usually to the right of the umbilicus, which allows for the neonatal intensive care unit of the Children’s Hospital of The King’s herniation of abdominal contents into the amniotic sac. In addition Daughters during the study period of 1 January 2000 through 31 to small intestines, herniated viscera may include stomach, colon December 2010, who had an International Classification of Disease (ICD)- and the genitourinary organs. The exposed bowel is not covered as 9 procedure code of 54.71 (repair of gastroschisis). This procedure for obtaining gastroschisis patients has been validated previously.10 The in an omphalocele and often becomes matted and thickened with research protocol was approved by the Institutional Review Board of a fibrous peel. Gastroschisis is not associated with known Eastern Virginia Medical School. chromosomal defects, but may be associated with gastrointestinal anomalies such as intestinal atresia, stenosis and malrotation. The incidence of this abnormality is increasing.1–5 As the Study design and data acquisition population affected by this defect continues to grow, the optimal Chart reviews were performed and data were obtained from the attending post-operative feeding regimens for these infants remain neonatologist’s admission history and physical, daily notes and bedside unclear. Much attention has been placed on whether the mode nursing charts. Gestational age was recorded as the number of completed of delivery, type of closure or timing of delivery affects outcomes. gestational weeks. Age at closure, age at initiation of feeds and LOS Following repair, the infant has a prolonged functional ileus were calculated as days of life (DOL), with day of birth serving as DOL 1. Days to full feeds was calculated by subtracting age at initiation of feeds requiring administration of total parenteral nutrition (TPN). from days required to achieve full feeds. Full feeds were defined as an Prolonged TPN has adverse effects on the liver (parenteral enteral feeding volume, either oral or gavage, of 140 ml kg À 1 day À 1 þ / À nutrition-associated liver disease) with elevation of liver enzymes 10 ml kg À 1 day À 1. Days to discharge was calculated by subtracting age at 6 and direct bilirubin. initiation from LOS. Age at initiation was defined as the DOL on which After the return of bowel function, enteral feeds are usually either formula or human milk was first provided for the infant, not by the begun. Previous studies have shown that the earlier the initiation first use of an oral electrolyte solution. Percentage of human milk of enteral feedings, the better the outcome in infants post consumption was calculated from the bedside nursing chart by dividing gastroschisis repair.7,8 Part of this improved outcome can be the total human milk volume by the total enteral feeding volume for the attributable to shorter duration of TPN and reduced length of stay entire hospitalization. (LOS).7 An independent predictor of mortality in these infants is the development of necrotizing enterocolitis. This finding Statistical analysis appears to be mitigated by the timing and type of enteral 9 The data were analyzed using SAS 9.3 software (SAS Institute, Cary, NC, feeds. The focus of this study was to determine if the type of USA). Descriptive statistics (counts, percentages, medians and interquartile enteral feeds, human milk (HM) or formula, improves time to full ranges) were reported for all variables and stratified in two ways both enteral feeds or LOS. based on the percentage of HM consumed. Initially infants were divided Department of Pediatrics, Children’s Hospital of The King’s Daughters, Eastern Virginia Medical School, Norfolk, VA, USA. Correspondence: Dr JA Kohler Sr, Department of Pediatrics, Children’s Hospital of The King’s Daughters, Eastern Virginia Medical School, 601 Children’s Lane, Norfolk, VA 23507, USA. E-mail: [email protected] Received 25 January 2013; accepted 15 February 2013; published online 21 March 2013 Human milk improves course after gastroschisis JA Kohler Sr et al 628 Table 1. Demographics by percentage of human milk Percentage of human milk P1 P2 P3 P4 PC 100% 50–99% 1–49% 0% N 22 15 16 26 Gender, n (%) 0.48a 0.67a 0.43a 0.38a 0.34b Male 10 (45.45) 10 (66.67) 8 (50.00) 11 (42.31) Female 12 (54.55) 5 (33.33) 8 (50.00) 15 (57.69) Mode of delivery, n 0.66a 0.43a 0.21a 0.47a 0.25b (%) Vaginal 13 (59.09) 9 (60.00) 7 (43.75) 12 (46.15) Cesarean section 9 (40.91) 6 (40.00) 9 (56.25) 14 (53.85) Closure type, n (%) 0.86a 0.73a 0.76a 0.69a 0.65b Primary 11 (50.00) 7 (46.67) 6 (37.50) 13 (50.00) Silo 11 (50.00) 8 (53.33) 10 (62.50) 13 (50.00) Birth weight (g), 2670 (2350–2950) 2620 (2270–2950) 2400 (1989–2810) 2463 (2220–2710) 0.10c 0.13d 0.01d 0.09d 0.02e median (IQR) Gestational age 36 (35–38) 37 (35–38) 37 (35–37) 36 (34–37) 0.41c 0.26d 0.15d 0.11d 0.19e (weeks), median (IQR) Age at closure (days), 2 (1–5) 3 (1–8) 5 (2–8) 2 (1–8) 0.58f 0.23g 0.30g 0.84g 0.10h median (IQR) Age at initiation 14 (10–18) 17 (13–20) 17 (13–25) 22 (15–29) 0.003c 0.001d 0.001d 0.01d 0.0001h (days), median (IQR) Abbreviation: IQR, interquartile range. P1 ¼ P-value for test of 100% versus 50–99% versus 1–49% versus 0% human milk; P2 ¼ P-value for test of 100% versus 0–99% human milk; P3 ¼ P-value for test of 50–100% versus 0–49% human milk; P4 ¼ P-value for test of 1–100% versus 0% human milk; PC ¼ P-value for model with a continuous variable for percentage of human milk. aP-value calculated using w2 test. bP-value calculated using logistic regression model. cP-value calculated using analysis of variance. dP-value calculated using two-sample t-test. eP-value calculated using simple linear regression model. fP-value calculated using Kruskal–Wallis test. gP-value calculated using Mann–Whitney U-test. hP-value calculated using Cox proportional hazard model. Bolded values are considered significant. Table 2. Patient outcomes by percentage of human milk consumption Percentage of human milk P1 P2 P3 P4 PC 100% 50–99% 1–49% 0% N 22 15 16 26 Days to full feed, median (IQR) 5 (3–9) 7 (5–14) 8 (7–16) 7 (5–13) 0.10a 0.03b 0.08b 0.79b 0.14c LOS (days), median (IQR) 22 (18–24) 26 (22–32) 28 (22–51) 32 (24–54) 0.004a 0.001b 0.001b 0.01b 0.0002c Days to discharge, median (IQR) 7 (5–12) 10 (6–18) 12 (9–25) 10 (8–26) 0.02a 0.01b 0.01b 0.27b 0.01c Abbreviation: IQR, interquartile range. P1 ¼ P-value for test of 100% versus 50–99% versus 1–49% versus 0% human milk; P2 ¼ P-value for test of 100% versus 0–99% human milk; P3 ¼ P-value for test of 50–100% versus 0–49% human milk; P4 ¼ P-value for test of 1–100% versus 0% human milk; PC ¼ P-value for model with a continuous variable for percentage of human milk. aP-value calculated using Kruskal–Wallis test. bP-value calculated using Mann–Whitney U-test. cP-value calculated using Cox proportional hazard model. Bolded values are considered significant. into four groups: 100% HM, 50 to 99% HM, 1 to 49% HM and 0% HM. As these cases exhibit different clinical courses independent of Secondly, infants were divided into only two groups: exclusive HM (100%) enteral feeding, they were also excluded.11,12 and non-exclusive HM (0 to 99%). w2 tests were used to compare proportions for gender, mode of delivery and closure type among (or between) the percentage groups. Analysis of variance, Kruskal–Wallis tests, Demographic comparison of four percentage groups two-sample t-tests, or Mann–Whitney U-tests were used, where appro- The four percentage groups were similar with respect to gender, priate, to assess differences in birth weight, gestational age, age at closure, mode of delivery (vaginal versus cesarean section), type of closure age at initiation, age at full feed, days to full feed, LOS and days to (primary versus silo), gestational age and the age at closure.
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