Should Checking Gastric Residual Volume Be Part of Your Routine Assessments?

Understanding Gastric Residual Volume and Checks

Gastric residual checks (GRC) have been part of neonatal assessments for many years, but are they necessary? Do they give us the information we are looking for regarding how a neonate is tolerating his or her feedings?

A number of research articles suggest that routine GRC – in the absence of other assessment standards including, but not limited to, abdominal distention, apneic/bradycardic episodes, oxygen desaturation, lethargy, and temp instability – may cause unnecessary delays in enteral feeding advancement. Compounded this results in extra TPN and intravenous line days, an increased chance of neurodevelopmental impairment, and extrauterine growth restriction, to name a few.

Aspirating gastric contents may damage the mucosa and lead to loss of acid and gastric juices required for digestion. Due to a low percentage of stomach electrical slow waves, gut motility in the preterm infant is diminished. Inadequate esophageal sphincter tone and decreased acid production contribute to a reduction in gastric motility, all which results in gastric residuals. The challenge then becomes “what do we do with residual aspirates?” Should they be returned to the patient, discarded in part, or discarded entirely? Only 4% of NICU nurses, according to Hodges and Vincent, replace residuals. Should GRC be eliminated in consideration of this, as well as what research has shown concerning extrauterine growth restriction and the absence of clinical proof that GRC lower the risk of NEC?

For consideration, I am going to outline a few of the more recent studies that discuss GRC and whether or not they are clinically significant, despite an otherwise unremarkable assessment.

What Does The Latest Research Share About Gastric Residual Checks?

• A randomized controlled trial (RCT) published in Advances in Neonatal Care included neonates at 27-37 weeks gestation and found that measuring abdominal girth without GRC allows preterm infants to attain full enteral feeds sooner, perhaps reducing length of hospital stay. In this trial, no infants developed NEC.
• A Cochran review monitoring GRC vs no GRC highlighted two RCTs that included 141 neonates weighing <1500 grams. Both trials showed that monitoring GRC may have little or no impact on predicting NEC. In turn, this review showed that the time to reach full enteral feeds may be increased, time to regain birth weight may be increased, and included additional TPN days that could’ve otherwise been reduced if routine GRC were not in place.
• In addition, a study published in the Journal of Perinatology compared feeding amounts at two and three weeks of age, including the time it took to reach full enteral feedings, growth, and complications between the GRC group and the non-GRC group. All (61) neonates were 23+1-32 weeks old and weighed less than 1250 grams. Although there was no statistical difference in the time to full enteral feeds between the two groups, the non-GRC group did attain full enteral feeds 6 days sooner and had central lines removed nearly 7 days sooner. Morbidities (including NEC, sepsis, and liver disease) were not different among the two groups.
• In an article published in a 2019 edition of the Journal of Enteral and Parenteral Nutrition,  researchers compared infants <32 weeks with and without GRC. In 2018, the hospital gradually changed protocol to feed all infants without GRC and, by 2019, GRC had been omitted. They looked at data between 2016-17 when GRC were a routine practice and compared this to the data once the protocol was changed, omitting GRC. In total, 137 infants were part of the study.  They evaluated incidence of intestinal intolerance, time to reach full feeds, and growth parameters. Both groups had similar incidence of NEC. NICU hospitalization days were similar, but weight, head circumference, and length were significantly higher in the group that omitted GRC. Clinically statistical significance was only found in head circumference, which could be indicative of improved neurodevelopment outcomes. In clinically stable neonates with otherwise normal assessments, skipping the standard GRC prior to each feed reduced the time to full enteral feedings without increasing the risk of NEC. In addition, these infants were released with increased weight, height, and head circumference.

What Can We Take From The Latest Research on Gastric Residual Volume and Checks?

If you are like me, omitting GRC is a hard, scary practice to change! Although more RCTs are needed, increasing evidence supports omitting GRC and relying on alternative assessment parameters for feeding and feeding advancement. Without any increased incidence of NEC noted in studies with GRC versus no GRC, I think it is important we evaluate the necessity (or lack thereof) as routine practice in light of noted improved clinical outcomes.

Perhaps the reduction in morbidities secondary to delays in feeding advancement based off of “routine practice” with little to no supportive evidence is worth re-evaluating. I'd like to hear about how your hospital has enhanced or refined clinical practice standards in relation to GRC prior to feedings!

References

1. Abiramalatha, T., Thanigainathan, S., & Ninan, B.  Routine monitoring of gastric residual for prevention of necrotising enterocolitis in preterm neonates.  Cochrane Database of Systemic Reviews 2019 July 9, 7:CD012937. DOI: 10.1002/14651858.CD012937.pub2.
2. Thomas, S. et al.  Gastric Residual Volumes Versus Abdominal Girth Measurement in Assessment of Feed Tolerance in Preterm Neonates.  Advances in Neonatal Care. 2018. 18:4, E13-19.
3. Torrazza, RM et al.  The value of routine evaluation of gastric residuals in very low birth weight infants.  Journal of Perinatology.  2015. 35, 57-60.
4. Terek D, Celik M, Ergin F, Erol E, Koroglu OA, Yalaz M, Akisu M, Kultursay N. Omitting Routine Gastric Residual Checks May Help To Accelerate Enteral Feeds And Postnatal Growth In Stable Preterm Infants. JPEN J Parenter Enteral Nutr. 2021 Oct 2. doi: 10.1002/jpen.2270. Epub ahead of print. PMID: 34599757.