Discharging Medically Complex Infants with Supplemental Nasogastric Tube Feeds: Impact on Neonatal Intensive Care Unit Length of Stay and Prevention of Gastrostomy Tubes

Abstract

Objective The aim of this study is to evaluate the feasibility, safety, and efficacy of discharge with supplemental nasogastric tube (NGT) feeds in medically complex infants. Study Design Cohort study of 400 infants enrolled in the Transitional Medical Home (TMH) program at Duke University Level IV neonatal intensive care unit from January 2013 to 2017. Results Among 400 infants enrolled in the TMH, 57 infants were discharged with an NGT. A total of 45 infants with a variety of diagnoses and comorbidities were included in final analysis. Among 45 infants, 5 obtained a gastrostomy tube (GT) postdischarge. Median (25–75th percentile) length of use of NGT in 40 infants was 12 days (4–37). Excluding four outliers who used NGT for ≥140 days, the median length of use was 8 days (3–24). This extrapolates to a median of 288 hospital days saved for the remaining 36 infants. There were only three emergency room visits related to parental concern for incorrect NGT placement. There was no statistically significant difference in percent oral feeding predischarge or growth in first month postdischarge between infants who orally fed versus those who obtained GTs. Conclusion Discharge with supplemental NGT feeds is safe and feasible utilizing a standardized protocol and close postdischarge follow-up. This practice can decrease length of stay and prevent need for GT. Key Points

Actual and Potential Impact of a Home Nasogastric Tube Feeding Program for Infants Whose Neonatal Intensive Care Unit Discharge Is Affected by Delayed Oral Feedings

“…9 More programs are now reporting positive experiences with home NG programs. [9][10][11][12]19 Our study adds to this growing literature by comparing outcomes for infants discharged with G tubes and NG tubes to a unique reference group of infants who could have been discharged with home NG feeds but who instead remained in the NICU until achieving full oral feeding. Another unique feature of our study was the inclusion of patient-reported outcomes.…”

“…Implementing a home enteral feeding transition program in one center increased the use of NG tubes and reduced NICU length of stay. 10 In that study, as with our clinical practice, inpatient care and discharge decisions were guided by a protocol but left to clinician and family discretion. Our study extends those findings by examining the potential for additional reductions in NICU stay.…”

“…We also continue to anticipate the needs of more complex patients discharged with NG feeds, like those reported in programs for medically complex infants, infants with BPD, and infants whose families or specialist providers choose to defer G tube placement for a variety of reasons. 10,19,21 A team from Cincinnati found that most infants attaining full oral feeds had done so by 60 days of age; more complex infants may be less likely progress to full oral feeds and will need consideration of G tube placement. 12 One issue hopefully unique to our study is that 3 infants who needed G tubes toward the end of the study period were unable to receive them in a timely fashion due to COVID-19 delaying elective procedures.…”

“…[3][4][5][6][7] Recently there has been interest in the use of home nasogastric (NG)-tube feedings for neonates, with retrospective studies describing lower rates of readmission and tube-related complications compared with infants with G tubes. [8][9][10][11][12] A home NG program may be an option for hospitals managing their NICU census, or for families who would prefer to attempt oral skill development at home before committing their infant to a surgical procedure. Although oral feeding impacts NICU discharge timing, it is unknown how many infants could be candidates for home NG feedings.…”

Clinical Outcomes of Neonatal Intensive Care Unit Graduates with Bridled Nasogastric Feeding Tubes

“…This is consistent with recent studies in which ED visits were significantly higher among infants with GTs compared with those with NGTs. [3][4][5][6][7] Thus, bridled NGTs appear to be feasible for routine use in the pediatric outpatient setting. Bridled NGTs seem to be a suitable approach for many infants who require AHF support to discharge from the NICU but in whom GT is not desired by family or in whom the timing of surgery needs to be postponed.…”