Authors
- Parker, Leslie PhD
- Torrazza, Roberto Murgas MD
- Li, Yuefeng MD
- Talaga, Elizabeth RN
- Shuster, Jonathan PhD
- Neu, Josef MD
Abstract
The routine aspiration of gastric residuals (GR) is considered standard care for critically ill infants in the neonatal intensive care unit (NICU). Unfortunately, scant information exists regarding the risks and benefits associated with this common procedure. This article provides the state of the science regarding what is known about the routine aspiration and evaluation of GRs in the NICU focusing on the following issues: (1) the use of GRs for verification of feeding tube placement, (2) GRs as an indicator of gastric contents, (3) GRs as an indicator of feeding intolerance or necrotizing enterocolitis, (4) the association between GR volume and ventilator-associated pneumonia, (5) whether GRs should be discarded or refed, (6) the definition of an abnormal GR, and (7) the potential risks associated with aspiration and evaluation of GRs. Recommendations for further research and practice guidelines are also provided.
Article Content
In the neonatal intensive care unit (NICU), it is customary to routinely perform gastric residual (GR) aspiration and evaluation prior to every feeding in critically ill infants.1 Aspiration and evaluation of GRs is thought to accomplish 3 tasks: (1) confirm correct orogastric/nasogastric (OG/NG) tube placement, (2) monitor whether the previous feeding remains in the stomach, and (3) prevent aspiration of gastric contents, which may contribute to ventilator-associated pneumonia (VAP).1-3 It is unclear, however, whether routine aspiration and evaluation of GRs confers any clinical benefit and whether this practice should continue in the NICU. Specifically, there is insufficient evidence that aspiration and evaluation of GRs is a reliable indicator of OG/NG tube placement, assists in monitoring for feeding intolerance and necrotizing enterocolitis (NEC), or prevents aspiration of gastric contents.4 In addition, there is lack of clarity regarding the volume and appearance of GRs deemed concerning whether GRs should be refed and the potential risks associated with the routine aspiration and evaluation of GRs. To determine potentially better practices for the NICU, this article summarizes available evidence regarding GR aspiration and evaluation in critically ill infants and offers recommendations for future research and clinical implications. Table 1 summarizes the current knowledge regarding GR aspiration and evaluation in the neonatal population.
USE OF GRs FOR VERIFICATION OF FEEDING TUBE PLACEMENT
An OG/NG tube correctly placed in the body of the stomach is necessary to avoid potentially serious complications including aspiration, apnea, bradycardia, desaturations, and trauma such as esophageal perforation.5,6 While radiographic assessment is the criterion standard for verification of OG/NG tube placement, this technique is unfeasible in critically ill infants due to cost, time delay, radiation exposure, and the frequent need for OG/NG tube reinsertion. Therefore, assessment of OG/NG tube placement is routinely determined via clinically based methods.
Although the presence of an aspirated GR is an unreliable indicator of feeding tube placement, 83% of neonatal nurses continue to utilize this technique (L. A. Parker et al., unpublished data, 2014).7,8 The absence of GR does not necessarily indicate malposition of the feeding tube and may be dependent upon multiple factors such as body position, gastric emptying time, previous feeding volume, and whether or not the feeding tube tip is positioned in the pool of gastric fluid. In fact, 38% of aspiration attempts in premature infants fail to obtain a GR.9 Inadvertent placement of an OG/NG tube into the infant's respiratory system is the most serious complication of OG/NG tube placement. Unfortunately, a positive aspirate of what appears to be gastric contents does not ensure protection against this potentially life-threatening occurrence. Straw-colored aspirates can be obtained from the respiratory system, providing a false sense of security that the feeding tube is placed correctly within the stomach.10
GASTRIC RESIDUALS AS AN INDICATOR OF GASTRIC CONTENTS
The use of GR evaluation is based upon the assumption that the volume of aspirated GR is a valid and accurate measure of residual gastric content. While decisions regarding advancement or withholding of feedings are frequently made on the basis of the volume of aspirated GR, this volume may be significantly less than the actual residual gastric contents. Since errors in volume estimation increase as the volume of gastric contents decreases, errors may be particularly common in small premature infants.11
Gastric residual volume is also influenced by body position.11,12 In a prospective study of 147 premature infants, Sangers et al found that larger GRs were aspirated from infants positioned left laterally or supine compared to a right lateral or prone position.13 Similarly, Cohen et al14 reported that GRs decreased in order of position: left lateral, supine, prone, and right lateral. Finally, Chen et al in a randomized time series with crossover study of 33 premature infants found a lower GR volume when infants were positioned prone.15 However, in these studies, the volume of gastric contents remaining in the stomach was not verified making it unclear whether body position influenced gastric emptying or affected whether tube holes were more likely to be positioned in the pool of gastric fluid.
The size of the feeding tube can also influence GR volume, with larger-bore tubes aspirating up to 2 to 3 times the volume of smaller-bore tubes. This may be particularly important when caring for infants in the NICU where smaller-bore tubes are usual.16 Positioning of the feeding tube holes within the pool of gastric fluid, aspiration technique, and feeding temperature and viscosity can all influence the volume of gastric contents aspirated.16-19
The majority of studies investigating the reliability of GR evaluation are limited by the use of in-vivo models where analysis of actual gastric content volume is impossible. To avoid this study limitation, Bartlett-Ellis and Fuchne used a simulated model of gastric aspiration to test known gastric content volumes. They found that aspirated GRs underestimated the actual gastric content volume by 19% and that this amount varied with feeding tube size, aspiration technique, and feeding viscosity.20
GASTRIC RESIDUALS AS AN INDICATOR OF FEEDING INTOLERANCE OR NEC
Premature infants frequently experience feeding intolerance due to gastrointestinal immaturity and decreased intestinal motility.20,21 While the definition of feeding intolerance varies, the term is typically associated with the presence of emesis, visible bowel loops, increased abdominal girth, abdominal distension, and the presence of an abnormal GR.22,23 Since the volume and appearance of GRs is one of the most commonly employed indicators of feeding intolerance, it is often used to determine advancement or withholding of enteral feedings.1
Necrotizing enterocolitis is a potentially fatal condition characterized by intestinal necrosis and inflammation affecting 7% to 11% of very-low-birth-weight (VLBW) infants25-27 and is associated with a significant increase in morbidity and mortality.28,29 The presence of abnormally large GRs has historically been thought to be an early indicator of NEC.30,31
The utilization of GRs as an indicator of feeding intolerance or an early sign of NEC is based on the following assumptions: (1) the volume of aspirated GR is an accurate measure of residual gastric contents; (2) the volume of GR provides information regarding gastric emptying; (3) an elevated GR volume indicates delayed gastric emptying and feeding intolerance; (4) a low GR volume indicates the stomach is emptying properly and the infant can tolerate feedings; and (5) elevated GRs are reflective of distal intestinal necrosis. Unfortunately, the validity of these assumptions has not been supported.
Feeding intolerance
Research in adults reveals a lack of evidence supporting the relationship between large GR volumes and feeding intolerance.32 In a multicenter randomized clinical trial (RCT) of 449 critically ill adults, Reignier et al33 found that subjects who underwent routine evaluation of GRs failed to meet their enteral nutritional goals. Similarly, there is a lack of evidence supporting the relationship between GR volume or appearance and feeding intolerance in the neonatal population. In the absence of other clinical signs, Mihatsch et al1 found no correlation between light green GRs and either NEC or feeding intolerance in premature infants and suggested that light green GRs should not delay advancement of enteral feedings. In an RCT of 61 VLBW infants, Torrazza et al34 found that undergoing routine aspiration and evaluation of GRs delayed attainment of full feedings (150 mL/kg/d) by 6 days and Shulman et al35 found no correlation between enteral nutrition outcomes and GR volume.
Necrotizing enterocolitis
Cobb et al, in a case-control single-center study of VLBW infants (51 with NEC and 102 controls), investigated GR volumes during the 6 days prior to the diagnosis of NEC. Infants who were diagnosed with NEC had a maximum GR of 4.5 mL compared to 2 mL in the control group and the maximal residual, as a percentage of the previous feeding, was 40% in the NEC group and 14% in the control group. While differences were statistically significant, overlap in maximal residual volumes between groups potentially decreased the clinical relevancy of these findings. The authors suggested infants with a GR greater than 3.5 mL or 33% of the previous feeding were at higher risk of developing NEC.30
Bertino et al conducted a retrospective case-control single-center study of 17 VLBW infants with NEC and 17 control infants, comparing GRs from birth to the diagnosis of NEC. They found that infants diagnosed with NEC had significantly higher GRs. The maximum GR was 7.46 mL in infants diagnosed with NEC and 4 mL in control infants. Although this finding was statistically significant, there was a 17-day delay between obtainment of the maximum GR and the diagnosis of NEC. Infants with NEC were also more likely to experience hemorrhagic residuals, with a time delay of 19 days prior to diagnosis.31
It is currently unclear whether the presence of large GRs is a reliable indicator of feeding intolerance or NEC and the definition of a "concerning" volume of GR is unknown. In addition, the timing of increases in GR volume prior to the diagnosis of NEC is unpredictable, preventing it from serving as a reliable red flag to warn of clinical deterioration.
Other less invasive assessment parameters may prove useful in monitoring for feeding intolerance and NEC such as emesis, visible bowel loops, increased abdominal girth, and abdominal distension and tenderness. These signs can provide important information for making clinical decisions and can be used as a guide to determine whether aspiration and evaluation of a GR is necessary. It may be reasonable to forego the routine evaluation of GRs and instead evaluate only in the presence of other gastrointestinal symptoms.36 Li et al37, in their feeding algorithm for preterm infants, suggest performing GR aspiration and evaluation only in the presence of other signs of feeding intolerance or NEC. In addition, they recommend considering further evaluation and treatment if the GR is greater than 50% of the previous feeding.37 Algorithms such as this are essential to standardize the evaluation and treatment of GRs.
THE ASSOCIATION BETWEEN GASTRIC RESIDUAL VOLUMES AND VAP
Ventilator-associated pneumonia is defined as a nosocomial pneumonia that develops after more than 48 hours of ventilation.38 Historically, large GR volumes have been thought to correlate with an increased risk of aspiration and VAP in both critically ill, ventilated children and adults.3,39 This association was based upon the assumption that large GR volumes facilitated reflux of gastric contents into the esophagus, thereby increasing the risk of aspiration and VAP. However, the correlation between GR volume and VAP has not been well established and the lower limit of GR that may protect against aspiration is unknown.40-42 A large RCT of 227 adults found no correlation between the routine evaluation of GRs and VAP in adults and it is likely that aspiration of oropharyngeal secretions poses a greater risk of VAP than aspiration of gastric contents.32,43
In critically ill infants in the NICU, the incidence of VAP ranges from 8.1% to 57.1%.44 The use of uncuffed endotracheal tubes and the high prevalence of gastroesophageal reflux may place premature infants at a greater risk of aspiration and VAP.45 While VAP is more common in infants who are enterally fed, little is known about the association between GR volume and VAP in this population.44 Farhath et al found 92% of ventilated VLBW infants aspirated gastric contents, as evidenced by the presence of pepsin in tracheal secretions. Pepsin levels were highest when sampled during a feeding; however, the authors did not comment on the volume or presence of GRs.46
SHOULD GASTRIC RESIDUALS BE DISCARDED OR REFED?
Following aspiration, GRs are often discarded and decisions to discard or refeed GRs are generally based upon individual nurse's judgment, beliefs, and experiences as well as unit tradition.47,48 In a small study of NICU nurses, only 4% consistently refed aspirated GRs.47 If GRs are discarded, important elements including hydrochloric acid and pepsin may also be lost. Hydrochloric acid is essential in limiting the intestinal bacterial overgrowth of intestinal bacteria. If GRs are discarded, hydrochloric acid is lost, and the number of intestinal bacteria may increase, leading to intestinal inflammation and possibly increasing the risk of late onset sepsis and NEC.49,50,51
Juve-Udina et al randomized 125 adults to discard or refeed GRs. They found no increase in complications and improved gastric emptying in adults who were refed GRs.48 In addition, a very small RCT with 35 adults found no difference in complication rates between refeeding and discarding GRs.52 Unfortunately, no studies have been conducted regarding discarding or refeeding GRs in infants.
DEFINITION OF AN ABNORMAL GASTRIC RESIDUAL
Although important feeding decisions are made on the basis of GR volume, little consensus exists regarding the definition of an abnormally large GR or the point at which feedings should be decreased or withheld. Tremendous variation exists regarding the definition of an abnormal GR volume which may be based upon the total GR volume or more commonly upon a percentage of the previous feeding.1,30 Previously published definitions have included 10% of the daily feeding volume,53 greater than 30% of either the previous feeding54 or more than 1 feeding,55 and greater than 33% of the previous 1 to 2 feedings.1,30 The most commonly cited parameter is a GR volume greater than 50% of a single feeding,24,54 although 50% of 2 consecutive feedings56 or 50% of 2 of the 3 previous feedings57 have also been used. This lack of a clear definition of an abnormal GR results in significant variability in clinical practice.
Scant information also exists regarding how to adjust subsequent feedings in response to GR volume, for example, the length of time to withhold feedings, whether the entire volume of feeding should be withheld or whether the feeding should be decreased by a certain percentage. The lack of standardized feeding guidelines that address GR volume increases the probability that feeding decisions will be based upon individual clinician preference resulting in significant variation between and within institutions.
POTENTIAL RISKS ASSOCIATED WITH ASPIRATION AND EVALUATION OF GASTRIC RESIDUALS
Decisions regarding advancement or withholding of feedings are often based upon the volume of GR aspirated, so an earlier attainment of full enteral feedings may occur when GRs are not routinely evaluated.58,59 The volume of feedings and the time necessary to attain full feedings are inversely related to the number of higher volume GRs.1,60 Large GRs are the most common reason feedings are interrupted, with 96% of clinicians citing GRs as the main determinate in feeding decisions.61,62
The importance of adequate enteral nutrition in premature infants, including attainment of full enteral feedings, is well known and is necessary to facilitate optimal growth and development.63 A delay in attainment of full enteral feedings is associated with significant complications, including adverse neurodevelopmental outcomes and prolonged need for parenteral nutrition (PN).64,65 Extended use of PN is associated with PN-associated liver disease and the length of time infants receive PN increases the risk and severity of the PN-associated liver disease.66 A central venous line is often required for administration of PN, resulting in an increased risk of late onset sepsis,67,68 as well as more serious complications, including thromboembolic events and pericardial effusions.69,70 Torrazza et al34 reported that infants who did not undergo routine evaluation of GRs required a central venous line 6 fewer days than infants who did.
Aspiration of GRs may also damage the gastric mucosa due to the close contact of the feeding tube tip with the delicate gastric mucosa and the negative pressure required to withdraw the gastric contents. In addition, decisions to delay or discontinue enteral feedings due to aspiration of large GRs may alter secretion of essential gastrointestinal peptides. Since gastrointestinal peptides are important in the structural and functional development of the gastrointestinal system, alteration in secretion of these peptides may significantly affect feeding tolerance.71
DISCUSSION AND RECOMMENDATIONS
Routine aspiration and evaluation of GRs are standard procedure in most NICUs despite limited research concerning the risks and benefits. This article summarizes current knowledge regarding the most pressing issues surrounding the routine use of GR aspiration and evaluation. Discrepancies concerning the definition of an abnormal GR, a lack of consistency regarding the treatment of large GRs, and a lack of control for variables potentially altering the volume of gastric contents aspirated make interpretation of practice parameters and research difficult.54,56 The presence of a small GR may provide a false sense of security, so it is necessary for clinicians caring for critically ill infants to be aware of the potential unreliability of GR evaluation.72 Furthermore, the significant limitations associated with the use of GR aspiration and evaluation emphasizes the need for less invasive, innovative strategies to ensure infants in the NICU are provided with the highest level of care. Table 2 provides research opportunities and suggestions for practice parameters regarding aspiration and evaluation of GRs.
Since aspiration of a GR is an unreliable marker for correct OG/NG tube placement, other more reliable verification mechanisms are necessary. For example, the combination of more than 1 insertion method may increase the accuracy rate of feeding tube placement and charting the infant's insertion length in a visible location may help to verify correct feeding tube placement prior to the administration of a feeding.73 Research specifically focused on neonates is needed to develop and validate insertion strategies such as previously published weight- and height-based formulas to improve the accuracy rate of feeding tube placement.74,75
Since GR aspiration is not a valid indicator of gastric content volume, its usefulness as a reliable assessment tool has been questioned and warrants further investigation.19 If important clinical decisions are to be based on the volume of residual gastric contents, the utilization of a more accurate measurement strategy is necessary. An example of an alternative strategy is the use of abdominal ultrasound. Although, to date, this approach has not been used clinically, it has been shown to provide a valid and reliable measurement of gastric contents.75 While abdominal ultrasound may not prove useful as a routine assessment tool, it may contribute valuable information for use when evaluating infants exhibiting other signs of feeding intolerance or NEC. If evaluation of GRs is utilized in feeding decisions, a more consistent definition of abnormal volume or appearance is necessary. Furthermore, guidelines defining when aspiration and evaluation of GRs is indicated need to be developed, along with the diagnostic and/or treatment strategies required when abnormally large GRs are obtained. Such guidelines are essential for the provision of evidence-based care.
Although aspiration and evaluation of GRs occurs frequently in the NICU, the full range of potential associated risks is rarely considered. In addition to physiologic risks for infants, routine aspiration and evaluation of GRs also increases the bedside nurse's workload. The lack of specific guidance regarding when to report GR volumes to the physician or nurse practitioner may also potentially lead to increased work stress.
CONCLUSION
Scant information exists concerning the risks and benefits of performing routine aspiration and evaluation of GRs in the neonatal population. Although routine GR evaluation is considered a standard of care in most NICUs, its lack of reliability, as a measure of gastric contents and for verification of feeding tube placement, makes its clinical usefulness questionable. There is also insufficient evidence that its routine use can assist in the diagnosis of feeding intolerance or NEC or in preventing VAP. An adequately powered RCT is needed to specifically provide evidence as to whether routine aspiration and evaluation of GRs is a necessary clinical tool and if it causes inadvertent harm to the infant.
References
1. Mihatsch WA, von Schoenaich P, Fahnenstich H, et al. The significance of gastric residuals in the early enteral feeding advancement of extremely low-birth-weight infants. Pediatrics. 2002;109(3):457-459. [Context Link]
2. Cordero L, Nankervis CA, Coley BD, Giannone PJ. Orogastric tube placement in extremely low-birth-weight infants. J Neonatal Perinat Med. 2009;2(4):253-259. [Context Link]
3. Ibrahim EH, Mehringer L, Prentice D, et al. Early versus late enteral feeding of mechanically ventilated patients: results of a clinical trial. J Parenter Enteral Nutr. 2002;26(3):174-181. [Context Link]
4. Metheny N, McSweeney M, Wehrle MA, Wiersema L. Effectiveness of the auscultatory method in predicting feeding tube location. Nurs Res. 1990;39(5):262-267. [Context Link]
5. Ben Aoun J, Gasmi M, Jemai R, Sghairoun N, Sahli S, Hamzaoui M. Iatrogenic esophageal perforation in the neonate. La Tunis Med. 2012;90(1):72-74. [Context Link]
6. Metheny N. Minimizing respiratory complications of nasoenteric tube feedings: state of the science. Heart Lung. 1993;22(3):213-223. [Context Link]
7. Ellett ML, Beckstrand J. Examination of gavage tube placement in children. J Soc Pediatr Nurs. 1999;4(2):51-60. [Context Link]
8. Ellett ML. What is known about methods of correctly placing gastric tubes in adults and children. Gastroenterol Nurs. 2004;27(6):253-259; quiz 260-251. [Context Link]
9. Nyqvist KH, Sorell A, Ewald U. Litmus tests for verification of feeding tube location in infants: evaluation of their clinical use. J Clin Nurs. 2005;14(4):486-495. [Context Link]
10. Metheny N, Dettenmeier P, Hampton K, Wiersema L, Williams P. Detection of inadvertent respiratory placement of small-bore feeding tubes: a report of 10 cases. Heart Lung. 1990;19(6):631-638. [Context Link]
11. Geraldo V, Pyati S, Joseph T, Pildes RS. Gastric residual (GR): reliability of the measurement. Pediatr Res. 1997;41:150. [Context Link]
12. Bankhead R, Boullata J, Brantley S, et al. Enteral nutrition practice recommendations. J Parenter Enteral Nutr. 2009;33(2):122-167. [Context Link]
13. Sangers H, de Jong PM, Mulder SE, et al. Outcomes of gastric residuals whilst feeding preterm infants in various body positions. J Neonatal Nurs. 2013;19(6):337-341. [Context Link]
14. Cohen S, Mandel D, Mimouni FB, Solovkin L, Dollberg S. Gastric residual in growing preterm infants: effect of body position. Am J Perinatol. 2004;21(3):163-166. [Context Link]
15. Chen SS, Tzeng YL, Gau BS, Kuo PC, Chen JY. Effects of prone and supine positioning on gastric residuals in preterm infants: a time series with cross-over study. Int J Nurs Stud. 2013;50(11):1459-1467. [Context Link]
16. Metheny NA, Stewart J, Nuetzel G, Oliver D, Clouse RE. Effect of feeding-tube properties on residual volume measurements in tube-fed patients. J Parenter Enteral Nutr. 2005;29(3):192-197. [Context Link]
17. Taylor WJ, Champion MC, Barry AW, Hurtig JB. Measuring gastric contents during general anaesthesia: evaluation of blind gastric aspiration. Can J Anaesth. 1989;36(1):51-54. [Context Link]
18. Bartlett Ellis RJ, Fuehne J. Examination of accuracy in the assessment of gastric residual volume: a simulated, controlled study [published online ahead of print February 21, 2014]. J Parenter Enteral Nutr. doi:10.1177/0148607114524230. [Context Link]
19. Gonzales I, Duryea EJ, Vasquez E, Geraghty N. Effect of enteral feeding temperature on feeding tolerance in preterm infants. Neonatal Netw. 1995;14(3):39-43. [Context Link]
20. Berseth C, Nordyke C. Enteral nutrients promote postnatal maturation of intestinal motor activity in preterm infants. Am J Physiol. 1993;264:G1046. [Context Link]
21. Jadcherla SR, Kliegman RM. Studies of feeding intolerance in very low-birth-weight infants: definition and significance. Pediatrics. 2002;109(3):516-517. [Context Link]
22. Hsueh W, Caplan MS, Qu X-W, Tan X-D, De Plaen IG, Gonzalez-Crussi F. Neonatal necrotizing enterocolitis: clinical considerations and pathogenetic concepts. Pediatr Dev Pathol. 2003;6(1):6-23. [Context Link]
23. Moore TA, Wilson ME. Feeding intolerance: a concept analysis. Adv Neonatal Care. 2011;11(3):149-154. [Context Link]
24. Yee WH, Soraisham AS, Shah VS, Aziz K, Yoon W, Lee SK. Incidence and timing of presentation of necrotizing enterocolitis in preterm infants. Pediatrics. 2012;129(2):e298-e304. [Context Link]
25. Stoll BJ, Hansen NI, Bell EF, et al. Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics. 2010;126(3):443-456. [Context Link]
26. Fitzgibbons SC, Ching Y, Yu D, et al. Mortality of necrotizing enterocolitis expressed by birth weight categories. J Pediatr Surg. 2009;44(6):1072-1076. [Context Link]
27. Lin PW, Stoll BJ. Necrotising enterocolitis. Lancet. 2006;368(9543):1271-1283. [Context Link]
28. Neu J, Walker WA. Necrotizing enterocolitis. N Eng J Med. 2011;364(3):255-264. [Context Link]
29. Cobb BA, Carlo WA, Ambalavanan N. Gastric residuals and their relationship to necrotizing enterocolitis in very low-birth-weight infants. Pediatrics. Jan 2004;113(1, pt 1):50-53. [Context Link]
30. Bertino E, Giuliani F, Prandi G, Coscia A, Martano C, Fabris C. Necrotizing enterocolitis: risk factor analysis and role of gastric residuals in very low-birth-weight infants. J Pediatr Gastroenterol Nutr. 2009;48(4):437-442. [Context Link]
31. Kuppinger DD, Rittler P, Hartl WH, Ruttinger D. Use of gastric residual volume to guide enteral nutrition in critically ill patients: a brief systematic review of clinical studies. Nutrition. 2013;29(9):1075-1079. [Context Link]
32. Reignier J, Mercier E, Le Gouge A, et al. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA. 2013;309(3):249-256. [Context Link]
33. Torrazza RM, Parker LA, Li Y, Talaga E, Shuster J, Neu J. The value of routine evaluation of gastric residuals in very low-birth-weight infants [published online ahead of print August 28, 2014]. J Perinatol. doi:10.1038/jp.2014.147. [Context Link]
34. Shulman RJ, Ou CN, Smith EO. Evaluation of potential factors predicting attainment of full gavage feedings in preterm infants. Neonatology. 2011;99(1):38-44. [Context Link]
35. Berman L, Moss RL. Necrotizing enterocolitis: an update. Semin fetal Neonatal Med. 2011;16(3):145-150. [Context Link]
36. Li YF, Lin HC, Torrazza RM, Parker L, Talaga E, Neu J. Gastric residual evaluation in preterm neonates: a useful monitoring technique or a hindrance? Pediatr Neonatol. 2014;55(5):335-340. [Context Link]
37. Center for Disease Control and Prevention (CDC). Ventilator-Associated Pneumonia (VAP). Atlanta, GA: CDC; 2013. [Context Link]
38. McClave SA, Dryden GW. Critical care nutrition: reducing the risk of aspiration. Semin Gastrointest Dis. 2003;14(1):2-10. [Context Link]
39. McClave SA, Lukan JK, Stefater JA, et al. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care Med. 2005;33(2):324-330. [Context Link]
40. Metheny NA, Schallom L, Oliver DA, Clouse RE. Gastric residual volume and aspiration in critically ill patients receiving gastric feedings. Am J Crit Care. 2008;17(6):512-519; quiz 520. [Context Link]
41. Montejo JC, Minambres E, Bordeje L, et al. Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Med. 2010;36(8):1386-1393. [Context Link]
42. Bouadma L, Wolff M, Lucet JC. Ventilator-associated pneumonia and its prevention. Curr Opin Infect Dis. 2012;25(4):395-404. [Context Link]
43. Tan B, Zhang F, Zhang X, et al. Risk factors for ventilator-associated pneumonia in the neonatal intensive care unit: a meta-analysis of observational studies. Eur J Pediatr. 2014;173(4):427-434. [Context Link]
44. Gopalareddy V, He Z, Soundar S, et al. Assessment of the prevalence of microaspiration by gastric pepsin in the airway of ventilated children. Acta Paediatr. 2008;97(1):55-60. [Context Link]
45. Farhath S, Aghai ZH, Nakhla T, et al. Pepsin, a reliable marker of gastric aspiration, is frequently detected in tracheal aspirates from premature ventilated neonates: relationship with feeding and methylxanthine therapy. J Pediatr Gastroenterol Nutr. 2006;43(3):336-341. [Context Link]
46. Hodges C, Vincent PA. Why do NICU nurses not refeed gastric residuals prior to feeding by gavage? Neonatal Netw. 1993;12(8):37-40. [Context Link]
47. Juve-Udina ME, Valls-Miro C, Carreno-Granero A, et al. To return or to discard? Randomised trial on gastric residual volume management. Intensive Crit Care Nurs. 2009;25(5):258-267. [Context Link]
48. Basaran UN, Celayir S, Eray N, Ozturk R, Senyuz OF. The effect of an H2-receptor antagonist on small-bowel colonization and bacterial translocation in newborn rats. Pediatr Surg Int. 1998;13(2-3):118-120. [Context Link]
49. Graham PL 3rd, Begg MD, Larson E, Della-Latta P, Allen A, Saiman L. Risk factors for late onset gram-negative sepsis in low-birth-weight infants hospitalized in the neonatal intensive care unit. Pediatr Infect Dis J. 2006;25(2):113-117. [Context Link]
50. Guillet R, Stoll BJ, Cotten CM, et al. Association of H2-blocker therapy and higher incidence of necrotizing enterocolitis in very low-birth-weight infants. Pediatrics. 2006;117(2):e137-e142. [Context Link]
51. Booker KJ, Niedringhaus L, Eden B, Arnold JS. Comparison of 2 methods of managing gastric residual volumes from feeding tubes. Am J Crit Care. 2000;9(5):318-324. [Context Link]
52. Ng E, Shah VS. Erythromycin for the prevention and treatment of feeding intolerance in preterm infants. Cochrane Database Syst Rev. 2008;(3):CD001815. [Context Link]
53. Aly H, Abdel-Hady H, Khashaba M, El-Badry N. Erythromycin and feeding intolerance in premature infants: a randomized trial. J Perinatol. 2007;27(1):39-43. [Context Link]
54. Oei J, Lui K. A placebo-controlled trial of low-dose erythromycin to promote feed tolerance in preterm infants. Acta Paediatr. 2001;90(8):904-908. [Context Link]
55. Kairamkonda VR, Deorukhkar A, Bruce C, Coombs R, Fraser R, Mayer AP. Amylin peptide is increased in preterm neonates with feed intolerance. Arch Dis Child Fetal Neonatal Ed. 2008;93(4):F265-F270. [Context Link]
56. Khashu M, Harrison A, Lalari V, Gow A, Lavoie JC, Chessex P. Photoprotection of parenteral nutrition enhances advancement of minimal enteral nutrition in preterm infants. Semin Perinatol. 2006;30(3):139-145. [Context Link]
57. Neu J, Zhang L. Feeding intolerance in very low-birth-weight infants: what is it and what can we do about it? Acta Paediatr. 2005;94(449):93-99. [Context Link]
58. Schanler RJ, Shulman RJ, Lau C, Smith EO, Heitkemper MM. Feeding strategies for premature infants: randomized trial of gastrointestinal priming and tube-feeding method. Pediatrics. 1999;103(2):434-439. [Context Link]
59. McClave SA, Sexton LK, Spain DA, et al. Enteral tube feeding in the intensive care unit: factors impeding adequate delivery. Crit Care Med. 1999;27(7):1252-1256. [Context Link]
60. Payne C KJ, Morse J. The use of gastric residuals as a determinant of tube feeding tolerance: a survey of clinical practices. Paper presented at: ASPEN 20th Clinical Congress; February 1996; Washington, DC. [Context Link]
61. Rice TW, Swope T, Bozeman S, Wheeler AP. Variation in enteral nutrition delivery in mechanically ventilated patients. Nutrition. 2005;21(7-8):786-792. [Context Link]
62. Hans DM, Pylipow M, Long JD, Thureen PJ, Georgieff MK. Nutritional practices in the neonatal intensive care unit: analysis of a 2006 neonatal nutrition survey. Pediatrics. 2009;123(1):51-57. [Context Link]
63. Okumura A, Hayakawa M, Oshiro M, Hayakawa F, Shimizu T, Watanabe K. Nutritional state, maturational delay on electroencephalogram, and developmental outcome in extremely low-birth-weight infants. Brain Dev. 2010;32(8):613-618. [Context Link]
64. Hartel C, Haase B, Browning-Carmo K, et al. Does the enteral feeding advancement affect short-term outcomes in very low-birth-weight infants? J Pediatr Gastroenterol Nutr. 2009;48(4):464-470. [Context Link]
65. Duro D, Mitchell PD, Kalish LA, et al. Risk factors for parenteral nutrition-associated liver disease following surgical therapy for necrotizing enterocolitis: a Glaser Pediatric Research Network Study [corrected]. J Pediatr Gastroenterol Nutr. 2011;52(5):595-600. [Context Link]
66. Cooley K, Grady S. Minimizing catheter-related bloodstream infections: one unit's approach. Adv Neonatal Care. 2009;9(5):209-226; quiz 227-208. [Context Link]
67. de Brito CS, de Brito DV, Abdallah VO, Gontijo Filho PP. Occurrence of bloodstream infection with different types of central vascular catheter in critically neonates. J Infect. 2010;60(2):128-132. [Context Link]
68. Hermansen MC, Hermansen MG. Intravascular catheter complications in the neonatal intensive care unit. Clin Perinatol. 2005;32(1):141-156, vii. [Context Link]
69. Beardsall K, White DK, Pinto EM, Kelsall AW. Pericardial effusion and cardiac tamponade as complications of neonatal long lines: are they really a problem? Arch Dis Child Fetal Neonatal Ed. 2003;88(4):F292-F295. [Context Link]
70. Costalos C, Gounaris A, Sevastiadou S, et al. The effect of antenatal corticosteroids on gut peptides of preterm infants-a matched group comparison: corticosteroids and gut development. Early Hum Dev. 2003;74(2):83-88. [Context Link]
71. McClave SA, Snider HL. Clinical use of gastric residual volumes as a monitor for patients on enteral tube feeding. J Parenter Enteral Nutr. 2002;26(6)(suppl):S43-S48; discussion S49-S50. [Context Link]
72. Arrowsmith H. Nursing management of patients receiving a nasogastric feed. Br J Nurs. 1993;2(21):1053-1058. [Context Link]
73. Cirgin Ellett ML, Cohen MD, Perkins SM, Smith CE, Lane KA, Austin JK. Predicting the insertion length for gastric tube placement in neonates. J Obstet Gynecol Neonatal Nurs. 2011;40(4):412-421. [Context Link]
74. Freeman D, Saxton V, Holberton J. A weight-based formula for the estimation of gastric tube insertion length in newborns. Adv Neonatal Care. 2012;12(3):179-182. [Context Link]
75. Perrella SL, Hepworth AR, Simmer KN, Geddes DT. Validation of ultrasound methods to monitor gastric volume changes in preterm infants. J Pediatr Gastroenterol Nutr. 2013;57(6):741-749. [Context Link]
The CE test for this article is available online only. Log onto the journal website, http://www.JPNONline.com, or to http://www.NursingCenter.com/CE/JPNN to access the test. For more than 37 additional continuing education articles related to perinatal and neonatal nursing, go to http://NursingCenter.com\CE.
feeding; feeding tube; gastric residuals; neonatal intensive care unit; premature infant