OPTIMIZING NUTRITION IN INFANTS AT RISK OF INTESTINAL FAILURE-ASSOCIATED LIVER DISEASE

Statement of Problem: Infants undergoing intestinal surgery are at risk for feeding intolerance and resultant complications, including intestinal failure and intestinal failure-associated liver disease (IFALD). In infants, IFALD is defined as a persistent direct bilirubin (DB) >2mg/dl for >1 week in the setting of parenteral nutrition (PN) and can lead to liver failure. The optimal strategy for feeding post-operative infants to reduce PN exposure is poorly understood. We hypothesized that a more systematic approach to providing enteral nutrition (EN) would reduce the risk of IFALD. Methods: We conducted three studies: 1) A retrospective descriptive analysis of the baseline feeding practices and incidence of IFALD among surgical infants in the Neonatal Intensive Care Unit, 2) An interval analysis (pre- and post-intervention) 15 months after implementation of newly devised feeding guidelines using run-charts to measure adherence to feeding recommendations and peak direct bilirubin in real-time, and 3) A final analysis 2.5 years after guideline implementation to measure the overall impact of the feeding guidelines on IFALD incidence and severity using logistic regression. Results: We identified variable feeding practices and a high baseline incidence of IFALD, 66% (confidence interval [CI] 0.55 - 0.76) among all surgical infants and 90% (CI 0.78 – 1.01) among those needing >60 days of PN from 2007-2012. In the 15-month post-guideline analysis, a shift to reduced time to reach feeding goals (initiation and 50% EN) and decreased peak DB were seen on run-charts. In the final analysis, the initial post-operative EN median volume increased from 10 to 20 ml/kg/day (P=0.001). Time to reach 50% EN decreased from a median of 10 to 5 days (P=0.013). The overall incidence of IFALD improved from 71 to 53% in infants needing >7 days of PN (P=0.03), and the median peak DB decreased from 5.7 to 2.3 mg/dl (P=0.003). The adjusted odds for developing moderate-severe IFALD were reduced by 67% in the post-guideline cohort, compared to the pre-guideline baseline (P=0.002). Conclusions: The feeding intervention was well tolerated and resulted in shorter time to initiate EN and reach 50% of goal EN post-operatively. The incidence and severity of IFALD also improved