Postoperative Enteral Nutrition Guidelines Reduce the Risk of Intestinal Failure–Associated Liver Disease in Surgical Infants

Objective: To assess the effectiveness of postoperative feeding guidelines in reducing the incidence and severity of intestinal failure–associated liver disease (IFALD) among infants. Study design: Two cohorts of infants <6 months old undergoing intestinal surgery were compared: preguideline (retrospective data from 2007 to 2013; n = 83) and postguideline (prospective data from 2013 to 2016; n = 81). The guidelines included greater initial enteral nutrition volumes of 20 mL/kg/d and daily feeding advancement if tolerated. The primary outcomes were incidence of IFALD (peak direct bilirubin [DB] >2 mg/dL) and severity (DB >5 mg/dL for moderate-severe). Multiple logistic regression was used to determine the odds of developing IFALD. Other outcomes were time to reach 50% and 100% goal calories from enteral nutrition and the incidence of necrotizing enterocolitis after feeding. Results: The incidence of IFALD decreased from 71% to 51% (P =.031), and median peak DB decreased from 5.7 to 2.4 mg/dL (P =.001). After adjusting for diagnosis and prematurity, the odds of developing IFALD of any severity were reduced by 60% (OR 0.40, 95% CI 0.20-0.85), and the odds of developing moderate-to-severe IFALD were reduced by 72% (OR 0.28, 95% CI 0.13-0.58) with guideline use. Time to reach 50% enteral nutrition decreased from a median of 10 to 6 days (P =.020) and time to reach 100% enteral nutrition decreased from 35 to 21 days (P =.035) with guideline use. The incidence of necrotizing enterocolitis after initiating enteral nutrition did not change (5% vs 9%, P =.346). Conclusions: Implementation of feeding guidelines reduced time to reach feeding goals, significantly reducing IFALD incidence and severity.