235 - Implementation of a Nutritional Pathway Across California Hospitals Improves Linear Growth in Neonates with Gastroschisis: A University of California Fetal Consortium Study

Poster Number: 235
Publication Number: 235.128

Katie M. Strobel, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States; Katelin Kramer, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA, United States; Catherine A. Rottkamp, University of California Davis, Sacramento, CA, United States; Cherry Uy, University of California, Irvine, School of Medicine, Orange, CA, United States; Laurel Moyer, Rady Children's Hospital San Diego/ UC San Diego, San Diego, CA, United States; Erika Fernandez, University of California, San Diego School of Medicine, Arroyo Grande, CA, United States; David Elashoff, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States; Animesh Sabnis, UCLA Mattel Childrens Hospital, Los Angeles, CA, United States; Kara L. Calkins, University of California, Los Angeles David Geffen School of Medicine, LA, CA, United States

Background: The University of California Fetal Consortium (UCfC) has published that 55% of infants with gastroschisis develop growth failure (GF) by hospital discharge.

Objective: To address this problem, we developed a standardized nutritional pathway emphasizing: 1) early provision of parenteral macronutrients, 2) human milk, and 3) GF assessment and treatment.  This study’s goal was to assess adherence to and efficacy of this pathway in infants with gastroschisis across 6 UCfC sites.

Design/Methods: In 2015, the UCfC developed ante- and post-natal guidelines to standardize the care of infants with gastroschisis. This study’s outcome was GF, calculated by subtracting birth weight or length z-score from discharge z-score. GF was a difference of ≤-0.8. Prior to creating the pathway, a survey was conducted to assess nutritional practices in August 2020. Nutritional guidelines were proposed, discussed, and revised (Fig 1). The pathway was launched in January 2020. Adherence measures, GF incidence, and z-score changes were assessed. A P-type statistical process control (SPC) chart displayed quarterly weight or length GF during the study period.

Results:
125 infants with gastroschisis were in the pre-pathway group, and 42 were in the post-pathway group. Median (IQR) gestational age (37 (35, 37) vs 37 (35, 37) weeks, p=0.7) and birth weight (-0.9 (-1.8, -0.4) vs -1.3 (-1.8, -0.4), p=0.06) and birth length z-scores (-0.9 (-1.7, -0.1) vs -1.1 (-2, -0.4), p=0.1) were similar when the two groups were compared.  Table 1 describes adherence measures. Compared to the pre-pathway group, the linear GF frequency was less in the post-pathway group at 14 days of age (p=0.005) and discharge (p=0.002). There were no changes in weight GF frequency at 14 days, 30 days, and discharge (p=0.15, p=0.14, p=0.24). When controlling for gestational age, the pathway was associated with length z-score change (estimate 0.25, p=0.03), but not weight z-score change (estimate 0.07, p=0.2). Fig 2 depicts a p-chart for weight or length GF.  When controlling for gestational age, the pathway was associated with decreased length GF (OR 0.26 (0.11-0.64), p=0.003) and weight or length GF (OR 0.4 (0.2-0.8), p=0.02). These findings were also observed when controlling for small for gestational age (length OR 0.3 (0.1-0.7) p=0.004; either weight or length OR 0.4 (0.2-0.9) p=0.04).
Conclusion(s):
In this multi-site study, adherence to a nutritional pathway was observed and led to a reduction in linear GF in infants with gastroschisis. Future studies are warranted to assess if decreased GF rates are associated with improved clinical outcomes in this population.

CV Katie StrobelCV_KatieStrobel_oct2021.pdf
Table 1.Adherence measures and safety checks for the University of California Fetal Consortium gastroschisis nutritional pathway