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Update Course Rewind: Gastroschisis Feeding protocols 2022
With Dr. Jason Fraser & Dr. Beth Frymoyer & Dr. Whit Hoopa · hosted by Dr. Cecilia Jijena & Dr. Brittany Levy & Dr. Steven Lee
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Dr. Fraser's institution starts feeds essentially once the dressing is placed, as long as the baby is not sick, not having horrible output, and not vomiting
Dr. Fraser's institution does not decompress gastroschisis babies at all
Dr. Frymoyer's institution developed their feeding protocol by looking at outcomes, starting feeds once the dressing is on or abdomen is surgically closed, with standardized volume increases
Sham feeding is introduced in Dr. Frymoyer's protocol because many gastroschisis babies have poor oral feeding skills from delayed access to feeding
Protocols are important so that nurse practitioners, nurses, and residents know how to feed and manage gastroschisis patients
A recently published MWPSC study examined outcomes of patients fed by protocol (roughly two-thirds) versus not by protocol (one-third)
The MWPSC study did not show reduction in TPN time or length of stay with protocol use
The MWPSC study showed reduced surgical site infections in protocol-fed patients, likely because they had less variability and fewer changes in care
Study results may reflect the fact that many different feeding protocols were used across member institutions
When surgeons are less involved due to protocols, some neonatologists favor continuous feeds, which can lead to oral aversion and prolonged length of stay
Dr. Fraser's institution tries to do intermittent feeds to start, though the protocol does not specifically mandate it
Dr. Frymoyer's protocol includes specifications for how to feed, when to feed, and how to advance feeds
The most important thing shown across studies is the need to define institutional tolerance criteria, stay on protocol, and assess infant condition continuously
Dr. Fraser's protocol explicitly states that emesis is expected, communicating this expectation to nursing colleagues and families
It is acceptable for gastroschisis patients to vomit and clinicians should continue working through it
Some published protocols recommend starting feeds when OG output is less than 20 per kilogram per day
Some protocols say to start feeds when the baby has had a bowel movement or when output is clear
Some literature from regions without TPN access supports aggressive early feeding protocols
Literature shows controversy with some papers recommending feeds right after dressing placement and others recommending waiting for return of bowel function (passing stools or flatus)
The tendency in current practice is to start feedings as soon as possible, as long as the baby is not vomiting and can tolerate it
Sham feeding involves giving food and recovering it before digestion to stimulate oral chewing and sucking
Although protocols help standardize care, clinicians still need to be connected to the patient and aware of the need to stimulate oral feeding and reduce oral aversion
A study from New Zealand discusses attitudes toward feeding in gastroschisis with somewhat different approaches
Emesis is expected in gastroschisis patients and awareness of this by nurses, doctors, and families allows for optimal treatment
As long as the baby is fine and looking well, oral feeding can continue after one episode of bilious emesis