685 - Time to full oral feeds and length of stay for neonates with postnatal, fetoscopic or open fetal surgery for myelomeningocele

Publication Number: 2668.685

Renee Shellhaas, Washington University in St. Louis School of Medicine, St Louis, MO, United States; Stefanie L. Riddle, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Ellen Bendel-Stenzel, Mayo Clinic Children's Center, Rochester, MN, United States; Brandon G. Rocque, University of Alabama School of Medicine, Birmingham, AL, United States; Jagruti S. Anadkat, Washington University in St. Louis School of Medicine, St. Louis, MO, United States; Stephanie A. Eyerly-Webb, Midwest Fetal Care Center, North Oaks, MN, United States; Thornton Mason, Perelman School of Medicine at the University of Pennsylvania, Haddonfield, NJ, United States; Ramesha Papanna, University of Texas at Houston, Houston, TX, United States; Regina M. Reynolds, Children's Hospital Colorado, Denver, CO, United States; Stephanie Rau, University of Michigan Medical School, Ann Arbor, MI, United States; Harlan McCaffery, University of Michigan Medical School, Ann Arbor, MI, United States; Niko Kaciroti, University of Michigan Medical School, Ann Arbor, MI, United States; Ronald D. Chervin, University of Michigan Medical School, Ann Arbor, MI, United States; John D. Barks, University of Michigan Medical School, Ann Arbor, MI, United States

Background: Time to achieve full oral feeds and length of hospital stay (LOS) are key resource utilization metrics for neonatal intensive care. We evaluated feeding as a potential driver of LOS in neonates with fetal v. postnatal myelomeningocele (MMC) repair.

Objective: In this secondary analysis of a 9-center study of sleep physiology for neonates with MMC, decisions regarding MMC closure timing (fetal v. postnatal) and technique (fetoscopic v. open maternal fetal surgery - OMFS), and feeding targets were made by clinical teams and families.

Design/Methods: Propensity weighting adjusted for differences in maternal and infant characteristics across surgical groups and analyses accounted for study center. Cox proportional hazards models evaluated time to full feeds, with surgery type, gestational age (GA), and their interaction as predictors. Infants who did not achieve full oral feeds were right censored at discharge. For LOS, log-transformed data were analyzed using propensity-weighted linear regression with surgery type, GA, and their interaction as predictors.

Results: Among 173 infants, 83 had postnatal MMC closure and 90 had fetal surgery (34 fetoscopic, 56 OMFS). In univariate analyses, time to full oral feeds and LOS were highest for infants with fetoscopic MMC closure (Table). In adjusted analyses, interaction terms revealed that differences between surgery groups varied by GA. Infants born at < 34 weeks' GA who had fetal v. postnatal surgery required somewhat longer (though not significant) to achieve full feeds. At 34 weeks, the association reversed: fetal surgery was associated with shorter time to full feeds; the effect was more pronounced as GA approached term (Figure 1). Feeding outcomes were similar between the fetoscopic and OMFS groups. For neonates born at < 34 weeks, OMFS was associated with longer LOS than postnatal repair, but neonates with OMFS born at >34 weeks had shorter LOS. OMFS was also linked to marginally shorter LOS than fetoscopic repair for infants born at >34 weeks (Figure 2). In adjusted analyses, no substantial LOS differences emerged between fetoscopic and postnatal repair at any GA.

Conclusion(s): Among infants delivered at >34 weeks GA, fetal MMC repair is associated with shorter time to full feeds and decreased LOS compared with postnatal surgery. When pregnancy is maintained for longer after fetal MMC repair, newborns achieve full oral feeds and leave the hospital sooner than infants who receive postnatal surgery. These observations may inform counseling regarding surgical strategies and motivate further research on ways to optimize gestation after fetal repair.

Clinical characteristics of 173 neonates with myelomeningocele


Time to Full Feeds by EGA and Surgery
Figure 1: In propensity adjusted models, after 34 weeks estimated gestational age (EGA), fetal surgery was associated with shorter time to full feeds; the effect was more pronounced as EGA approached term (e.g. at 38 weeks Hazard Ratio (HR) was 4.2, p<0.001 for fetoscopic v. postnatal; HR 3.2, p=0.03 for open maternal fetal surgery (OMFS) v. postnatal; HR 0.75, p=0.7 for OMFS v. fetoscopic)
Note: HR <1 = longer time to full feeds for fetal surgery compared to postnatal, HR >1 = shorter time to full feeds for fetal surgery.


Length of Stay by EGA and surgery type
Figure 2: For neonates born at <34 weeks, open maternal fetal surgery (OMFS) was associated with longer length of stay (LOS) than postnatal repair, but neonates with OMFS born at >34 weeks had shorter LOS.