P0722 - Development and Implementation of an Earlier Refeeding after Necrotizing Enterocolitis (NEC) Guideline for Non-Surgical NEC

Background:
For infants with NEC treated non-surgically, there is no consensus for when to re-initiate enteral feeds after NEC. In a previous meta-analysis, earlier refeeding (4-7 days after diagnosis of NEC) suggested a decreased incidence of the combined adverse outcome (NEC recurrence or stricture) and possible other benefits. Based on this analysis, we implemented a standardized guideline for non-surgical NEC through a consensus survey of key stakeholders involved in the decision to start refeeding at our institution. We aimed to implement and monitor a multidisciplinary clinical consensus guideline to standardize the timing of initiation and rate of feeding advancement for infants with medical NEC (Bell’s Stage IIA to IIIA) to decrease time to initiate trophic enteral feeds by 20% between 1/2018 and 12/2018.

Methodology:
We created a survey of our neonatology and pediatric surgery divisions to develop a clinical consensus for refeeding after NEC. Subsequently, we created a guideline to re-initiate feeds earlier, based on severity of Bell’s stage, after normalization of abdominal exam and being clinically well appearing. There was no previous guideline for when to refeed at our institution. Outcome measures were days to initiation of feeds and days to full enteral feeds. Balancing measures were incidence of recurrent NEC and post-NEC intestinal stricture. Baseline data were collected from 1/2017 to 12/2017. Education was provided at neonatology division meetings and uploaded to the intranet. Infants with Bell’s Stage IIA to IIIA were included in the guideline, but there were no IIIA patients during the studied period. Infants with congenital heart disease and those requiring abdominal surgery were excluded a priori. Statistical analysis was done using Wilcoxon rank-sum tests.

Discussion:
Clinical data including birth weight, gestational age, and day of life at diagnosis are shown in Table 1. For infants with Bell’s stage IIA and IIB combined, we demonstrated that the median days to initiation of feeds decreased by 61% from baseline of 9 days (range 4-14 days) to 3.5 days (range 3-12 days) (p<0.001) (Figure 1A) exceeding our goal target. Median days to full feeds were also significantly decreased by 35% from baseline of 20 days (range 6-93 days) to 13 days (range 8-20 days) (p=0.002)(Figure 1B).

Conclusion:
A multidisciplinary clinical consensus guideline for refeeding after NEC can decrease time to initiation of feeds and time to reach full enteral feeds. There was no increase in adverse outcomes including recurrence or stricture during the study period.