Medical Professional Publications

Targeted Evaluation and Management of Difficult NICU Feeders Lead to Better Long-Term Outcomes

Columbus, OH - December 2016

Feeding decision challenges are frequent among neonatal intensive care units (NICUs) and consume a significant amount of resources. Insurance companies, hospitals and other payers are concerned about escalating costs of a prolonged stay for difficult feeders and may prefer earlier discharge with a gastrostomy tube in place. Parents, however, may worry about the problems of G-tube placement. G-tube complications after an infant has been discharged from the NICU are well known; infection, recurrent hospitalization, cost and effects on family quality-of-life all are just some of the reasons why oral feeds are often preferred.

But what about long-term outcomes? A new study from clinician-scientists at Nationwide Children’s Hospital demonstrates that when infants were referred to an innovative feeding disorders program for gastrostomy feeding strategies, about two-thirds went home without a G-tube and on oral feeding. When long-term neurodevelopmental outcomes were measured at 2 years, those who went home on G-tube feeding had greater neurodevelopmental delays at 18-24 months – and G-tube at discharge appears to be an independent predictor of future neurodevelopmental delay.  

The study, published in The Journal of Pediatrics, examined a cohort of premature infants referred to the Neonatal and Infant Feeding Disorders Program at Nationwide Children’s for possible placement of a G-tube and other interventions. Clinicians attempted targeted, individualized strategies to help these infants with their severe oral feeding difficulties. Ultimately, 60 percent of the 194 infants were discharged on oral feeds, while 40 percent were discharged after G-tube placement.

All were followed normally after discharge by specialists and primary care providers, and were given Bayley Scales of Infant Development III exams at 18-24 months corrected age.    

“These babies were struggling with eating during their hospital stay until we sent them home,” says Sudarshan R. Jadcherla, MD, lead author of the study and director of the Neonatal and Infant Feeding Disorders Program. “Most went home on oral feeds. If all of them received G-tubes, what would have happened to their development? Based on our study, they would have more neurodevelopmental impairment.”

Among the study’s key findings:

  • Regardless of gestational age, respiratory morbidity and other common risk factors, the presence of a G-tube at discharge was associated with cognitive, motor and communicative neurodevelopmental delays at 18-24 months
  • Among the referrals, 96 percent of infants discharged on oral feeds remained on oral feeds at 1 year
  • In contrast, 40 percent of the infants discharged on a G-tube remained dependent on it for nutrition at 1 year of age (60% were weaned towards independent oral feeding)
  • Length of initial hospitalization and incidence of respiratory morbidity at discharge were significant higher among G-tube fed babies

Infants who need a G-tube at discharge may be predisposed to neurodevelopmental delay before one is placed, says Dr. Jadcherla, who is also a professor of Pediatrics at The Ohio State University College of Medicine. That likely does not tell the whole story, however.

“A G-tube bypasses several structures above the stomach,” says Dr. Jadcherla.  “When there is minimal utilization of the esophagus, the airway and oro-motor skills, how are these functions going to develop? We are minimizing the effect of supra-gastric stimulations on the brain when babies are getting nutrition directly into the stomach. That’s an important concept to understand in the rehabilitation of feeding-centric neural pathways. Feeding is an important function, but concurrent airway protection is perhaps an even more important function. Our approach is to pay attention to both these aspects in personalizing feeding strategies.”

The new research suggests a number of future directions for neonatal units and follow-up programs, such as a recommitment to early feeding therapies and the development of neurorehabilitation initiatives for infants who require G-tubes.

The findings also highlight the importance of patience, says Dr. Jadcherla. Insurance companies, hospitals, clinical care teams and parents should understand that a decision to send a child home with a G-tube in place can have long-term negative effects.  

“Allowing a baby to stay in a hospital for two to four weeks for intensive inpatient feeding-related neuro-rehabilitation therapies, if that prevents a G-tube, is more important to me than sending the baby home earlier on G-tube without giving him/her a chance to succeed,” he says.  “We know that the cost and complications of G-tubes are high over long term, and now we know about neurodevelopmental consequences after two years.”

Reference:
Jadcherla S, Khot T, Moore R, Malkar M, Gulati I, Slaughter J. Feeding methods at discharge predict long-term feeding and neurodevelopmental outcomes in preterm infants referred for gastrostomy evaluation. The Journal of Pediatrics. 2016 Dec 7. [Epub ahead of print]

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