Update Course Rewind: Gastroschisis Feeding protocols 2022

Hi, I'm Cecilia Jijena from Cincinnati Children's Hospital. Hi, I'm Britney Levy, also from Cincinnati Children's Hospital. If you miss our Update Course 2022, don't worry, because we are making an upcoming series with the rewinds of every talk. Today's talk is What You on Feeding Protocols for Gastroschisis. In this talk, we will cover three topics. One, when to start feeds. Two, advances of using a feeding protocol. Three, what to do when there's emesis. As moderator for this talk, we have Dr. Steven Lee. As the speakers, we have doctors Beth Frymoyer and Jason Fraser. So, our first question is, you just performed a sutureless abdominal wall closure in a newborn with gastroschisis. The bedside nurse and family asked you when you want to start feedings. You reply. All right guys, you're not off the hook. I'm going to be calling on you. When do you feed a gastroschisis baby? When the output's going down, says Miguel. Justin? It's just volume. So it's NG volume. Mier's nodding her head. NG volume, same thing? 20 per kilo. Once it's less than 20 per kilo, you start feeds. Wait, wait, wait. What do the poles say? Sorry Steve. It's split between that when the OG output is clear, that's about half. And then the next up is um when the OG output is less than 10 per kilo. Okay, I'm going to go out on a limb. I would have said B myself because we use, we do consider quality and and quantity, but. We found many options here. Let's hear what Dr. Fraser has to tell us. So, so we start feeding essentially, you have to put the dressing on. Uh as long as the baby's not sick, not having horrible output, not puking or anything like that. There's been several protocols that have been published on this. Um it's kind of all over the place. You know, some say 20, uh some say when the baby's had a bowel movement, some say when the output's kind of clear. keep the NG goes through, you know, 100 in one time completely very dark green. Bilious rain. So we'll start essentially that, you know, we don't end up in our babies at all. So we put the dressing, plastic dressing on and as long as the kid's not, you know, has voluminous output, we'll try to start start feedings on it. So no, this this is an important good thing because everybody is so different on the way they do this. So, I mean even the way that people use feeding pros protocols is different. Ours is pretty aggressive and it's kind of based upon some of the data that's out there from the rest of the world where they don't have TPN. So, in the literature, there is a lot of controversy about this. Some papers say to start feedings right after the dressing's placed. Others say to wait for return of bowel function, like passing stools or flatus, but the tendency is to start feedings as soon as possible, as long as the baby is not vomiting and they can tolerate it. Great. So let's see what a protocol is. For that, we have Dr. Beth Frymoyer. Our feeding protocol came about by looking at outcomes and once the dressing is on or the abdomen is surgically closed, which almost never happens, then it goes by volume. We have a standardized increase for the feeds and then we introduce sham feeding because what we realize is a lot of our gastroschisis babies have very poor oral feeding skills from, you know, delayed access to feeding. Okay, then start feeding, increase the volume periodically and introduce sham feedings. Sounds easy enough to follow. Wait, Beth. What does sham feeding means? Sham feeding is to give food and recover it before it's been digested to stimulate oral chewing and sucking. Oh great. I see. Let's jump to the next question. Um does your institution have a gastroschisis feeding protocol? So a, yes and I follow it. Uh B, yes, but I don't follow it. No or unsure. Ellen, what does the poll tell us? Yeah, it's uh most people, half of them are saying. over half, yes, and they follow the protocol. That's why I think all these protocols, whether it's gastrosis or anything are important so that your nurse practitioners and your nurses and your residents just know know what what's going on and how to feed or manage these patients. That was Dr. Whit Hoopa and what he's saying is that lately, we've seen that having a protocol betters the outcomes for our patients. And let's hear what Dr. Beth Frymoyer and Dr. Fraser have to say about this topic. Uh of a study that we recently published out of the MWPSC about outcomes of patients who were and were not fed by protocol where it was roughly two-thirds by protocol, one-third not. The study showed that, you know, most likely due to the fact that there was lots of different feeding protocols that were used uh across our our member institutions. Um and I think the the SSI thing was probably just because patients that were fed via protocol were cared for via protocol. And so that they actually had less variability and less uh out less changes uh in the way that these these patients are are you know, looked for. Okay. So in this retrospective study, they found that having a protocol for feeding gastrosis led to less SSIs. That it didn't reduce TPN time or length of stay. But some may have some concerns about these protocols as Dr. Justin Huntington. Justin. I have a question. So I love the protocol because it allows us to sort of fade into the distance. But the downside of what I've seen from doing that of us not being that involved is there's like this tendency of the neonatologist, some of them love like continuous feeds and then they're not taking anything orally and then a lot of them get uh oral aversion and that prolongs their length of stay. Do your guys's protocols say how to feed? You're right. We we do try to do both uh intermittent feeds to start, but it doesn't specifically say you have to. Uh but I think that's where the sham feeds are, hopefully we'll see it soon. We only been doing that for like a year. Ours ours does include how to feed, when to feed, how to advance, all of those things. Uh we actually took it for the prenatal care for our whole gastroschisis protocol. That's a great point. And so although a protocol helps to smooth things over, that doesn't mean we don't need to be connected to the patient and we really have to still be aware that there's a need to stimulate oral feeding and reduce the rate of oral aversion. Can't wait to hear the last question. After two days of successful feeding advancement, the baby has one bout of bilious emesis. Now what? What do you do with your feedings now? Keep going. So keep going, NPO over there. So it's all all over the map. So Okay, it seems that nor the room neither the poll can decide if there is the correct answer. But let's hear Dr. Fraser, if he has one to show us. You know, a lot of the protocols that are out there talk about, you know, there's this what study from New Zealand talks about the you know, their attitudes towards feeding. And it's a little bit different, but the most important thing that just keeps showing up is the fact that we really need to define what your own institution has for tolerance and to kind of stay on the protocol and then really just look at the infant condition as you continue to go is the most important thing. Right, so let's clarify that it's really important to have a protocol and to follow it, but we also need to define what tolerance means and what it doesn't that we can all be on the same page. And here's another important thing that he said. What we did put in our protocol for that for our nursing colleagues as well as our families is that emesis is is expected. We put that within our reading protocol to make that expectation known that it's okay. It's okay that they're going to throw up and we'll just keep working through it. Yes, agree. It is important to know that emesis is expected in patients with gastroschisis and that everyone who takes care of the patients, whether it is nurses, doctors or the family has to be aware of it in order to give the patients the best treatment. Okay, time to summarize. First, though there may be some controversy, you should try to feed the patient as soon as possible as long as they tolerate the feed, meaning that they're not vomiting and they're not descended. Second, having a protocol in gastroschisis improve the patient's outcomes. Third, emesis is normal. And as long as the baby is fine and looking well, you can continue with oral feeding after one episode of emesis, even if it's bilious. Okay, that was everything for today. Hope you like it and if you want to see more, give this the stake or not. But until then, I'm Cecilia Jijena. And I'm Britney Levy. Thank you for watching and check out more update course rewinds on the stake or not.