Review question
Does re-feeding (giving again) stomach aspirates (partially digested milk and gut hormones withdrawn from feeding tube) in premature babies promote growth without causing feeding problems?
Key messages
• Limited evidence suggests re-feeding stomach aspirates in premature babies may have little or no effect on important outcomes such as:
• the occurrence of severe intestinal disease that causes damage and death of intestinal tissue and may result in a hole in the premature baby's intestine (necrotising enterocolitis);
• time to regain birth weight;
• time to establish full enteral feeds (milk fed either orally or via a tube into the stomach or small bowel);
• number of days total parenteral nutrition (feeding through vein); and
• death before discharge.
• The available evidence is insufficient to assess the potential benefits, as well as the possible risks, of re-feeding of stomach aspirates in premature babies.
Background
It is common practice to monitor the stomach aspirates of preterm infants on tube feeds. Tube feeding means that the baby is fed through a small soft tube which is either placed in their nose or mouth and runs down their throat through the food pipe (oesophagus) to their stomach. The baby's stomach aspirates are monitored to identify possible feed intolerance (difficulty in digesting feeds) and necrotising enterocolitis. There is no agreement on whether to re-feed or discard the stomach aspirates. Re-feeding the aspirates may replace the partially digested milk and gut hormones that are necessary for gut maturity. However, re-feeding abnormal aspirates may result in vomiting, necrotising enterocolitis, or infection. We looked for evidence from clinical trials that assessed whether re-feeding stomach aspirates is beneficial or harmful in premature babies.
What did we want to find out?
We wanted to find out whether re-feeding stomach aspirates helps or harms premature babies.
What did we do?
We searched for studies that investigated re-feeding of stomach aspirates in premature babies. We compared and summarised the results of the studies. We rated our confidence in the evidence, based on factors such as the size of the study and the methods used.
What did we find?
We found only one small study with 72 premature babies that investigated this question. Re-feeding stomach aspirates may have little or no effect on important outcomes such as the occurrence of necrotising enterocolitis, death before discharge, time to establish full feeds, number of total parenteral nutrition days, and in-hospital weight gain. We did not find information on other outcomes.
What are the limitations of the evidence?
More studies are needed before we will be able to tell whether re-feeding is helpful or harmful to premature babies.
How up to date is this evidence?
The search is up-to-date as of February 2022.
We found only limited data from one small unmasked trial on the efficacy and safety of re-feeding gastric residuals in preterm infants. Low-certainty evidence suggests re-feeding gastric residual may have little or no effect on important clinical outcomes such as necrotising enterocolitis, all-cause mortality before hospital discharge, time to establish enteral feeds, number of total parenteral nutrition days, and in-hospital weight gain. A large RCT is needed to assess the efficacy and safety of re-feeding of gastric residuals in preterm infants with adequate certainty of evidence to inform policy and practice.
Routine monitoring of gastric residuals in preterm infants on tube feeds is a common practice in neonatal intensive care units used to guide initiation and advancement of enteral feeding. There is a paucity of consensus on whether to re-feed or discard the aspirated gastric residuals. While re-feeding gastric residuals may aid in digestion and promote gastrointestinal motility and maturation by replacing partially digested milk, gastrointestinal enzymes, hormones, and trophic substances, abnormal residuals may result in vomiting, necrotising enterocolitis, or sepsis.
To assess the efficacy and safety of re-feeding when compared to discarding gastric residuals in preterm infants.
Searches were conducted in February 2022 in Cochrane CENTRAL via CRS, Ovid MEDLINE and Embase, and CINAHL. We also searched clinical trial databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs.
We selected RCTs that compared re-feeding versus discarding gastric residuals in preterm infants.
Review authors assessed trial eligibility and risk of bias and extracted data, in duplicate. We analysed treatment effects in individual trials and reported the risk ratio (RR) for dichotomous data and the mean difference (MD) for continuous data, with respective 95% confidence intervals (CIs). We used the GRADE approach to assess the certainty of evidence.
We found one eligible trial that included 72 preterm infants. The trial was unmasked but was otherwise of good methodological quality.
Re-feeding gastric residual may have little or no effect on time to regain birth weight (MD 0.40 days, 95% CI −2.89 to 3.69; 59 infants; low-certainty evidence), risk of necrotising enterocolitis stage ≥ 2 or spontaneous intestinal perforation (RR 0.71, 95% CI 0.25 to 2.04; 72 infants; low-certainty evidence), all-cause mortality before hospital discharge (RR 0.50, 95% CI 0.14 to 1.85; 72 infants; low-certainty evidence), time to establish enteral feeds ≥ 120 mL/kg/d (MD −1.30 days, 95% CI −2.93 to 0.33; 59 infants; low-certainty evidence), number of total parenteral nutrition days (MD −0.30 days, 95% CI −2.07 to 1.47; 59 infants; low-certainty evidence), and risk of extrauterine growth restriction at discharge (RR 1.29, 95% CI 0.38 to 4.34; 59 infants; low-certainty evidence). We are uncertain as to the effect of re-feeding gastric residual on number of episodes of feed interruption lasting for ≥ 12 hours (RR 0.80, 95% CI 0.42 to 1.52; 59 infants; very low-certainty evidence).