Gastrostomy Tube Placement in Extremely Low Birthweight Infants

A recent analysis (MG Warren et al J Pediatr 2019; 214: 41-6) examined gastrostomy tube (GT) placement among 4569 extremely low birthweight (ELBW) infants (birth wt <1000 gm) who were enrolled in the National Instittue of Child Health and Human Development Neonatal Research Network (25 centers).

Key findings:

  • 333 (7.3%) underwent GT placement; 76% had GT placed postdischarge from NICU
  • Among patients with GT placement, 56% had weight <10th percentile, 61% had neurodevelopmental impairment (NDI), and 55% had chronic breathing problems
  • At last follow-up, 32% of infants who required GT placement were taking full oral feeds.
  • Rates of fundoplication varied widely between centers, ranging from 0% to 6.4% among the centers.

In the discussion, the authors note the well-recognized associations between feeding difficulties and language delays in ELBW infants.  In addition, “behavioral and emotional problems have …been described in children with feeding problems.”

The authors also state, without evidence, that the high rate of GT placement after discharge suggests that “a large proportion of ELBW infants were first discharged from the NICU orally feeding but could not maintain these skills.”  Alternative explanations include the following:

  • Many infants were sent home with NG (nasogastric) supplementation and after not making progress with oral feedings, elective GT placement was done when the infant was a more suitable candidate (eg. improved respiratory status, better nourished, etc.)
  • Problems with oral feeding became apparent after discharge including poor growth and aspiration.  In fact, the authors note that “orormotor dysfunction and avoidant feeding behaviors at 3 and 12 months corrected age” were nearly twice as likely in infants born <34 weeks
  • While this study did not fully capture data regarding home NG feedings, 14% of patients sent home with NG feedings eventually received a GT

My take: This study indicates that 7% of ELBW infants undergo GT placement and that about one-third out-grow the need for GT supplementation after ~2 years.

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Probiotics For NEC -More Work is Needed (part 1)

From Kipp Ellsworth’s Twitter Feed:

The Time for a Confirmatory NEC Probiotic Prevention Trial in ELBW Infants is Now. Editorial in J Peds  (The Journal of Pediatrics
Volume 165, Issue 2 , Pages 389-394, August 2014)

This editorial reviews previous studies and recommends implementing a Probiotic Trial in North America. Here’s an excerpt:

An adequately powered double-blinded placebo-controlled trial replicating a previous effective NEC prevention study in VLBW infants was published (the ProPrem trial)…the study revealed a significant reduction of NEC: from 4.4%-2.0% but no effect on mortality (4.9% vs 5.1%)…A closer look at the results of the ProPrem study, however, reveals that the probiotic supplementation did not have any effect on NEC in the ELBW (<1000 g) infants, which is consistent with two small previous studies reporting data on these infants separately.3642 Thus, there is currently no compelling evidence for recommending prophylactic probiotics to prevent NEC in infants with a birth weight <1000 g. Especially important is the lack of safety information in these most immature and highly vulnerable babies…Probiotics appear promising for use as prevention strategy for NEC, but there is still insufficient data for general recommendation of the use of probiotics in the ELBW infant. We argue, therefore, that now is the time to conduct in the North American setting, a high quality confirmative NEC prevention trial using probiotics in at-risk ELBW infants.”

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