Disparities in Home Tube Feeding Approaches for Preterm Infants

Research study background

Feeding dysfunction is common among preterm infants, affecting an estimated 16% to 33% of the neonatal population. Infants who are still developing oral feeding skills may be discharged home from neonatal intensive care units (NICU) on supplemental nutrition delivered by a nasogastric tube (NGT) or a gastrostomy tube (GT).

Because no standardized guidelines exist for tube feeding at discharge, use of NGT versus GT varies among providers and hospitals. GT placement is fairly common among medically complex infants, particularly those with extremely low birth weight. In adult populations, GT placement is disproportionately higher among hospitals that primarily serve racial and ethnic minority groups with public insurance, a practice associated with poorer long-term outcomes and higher mortality. Racial and ethnic inequities in NICU care are well documented, but disparities in tube feeding have not been addressed in neonatal literature.

“There is little known about what demographic, socioeconomic, or clinical characteristics make some infants more likely to be discharged home with one type of feeding method over another,” says Pavika Varma, MD, a neonatologist at Children’s Hospital Colorado and lead author of this study. “Here, we sought to identify those factors at a national level, focusing on practice variation based on patient race and ethnicity, to help improve equity in care.”

Dr. Varma and her team examined data from premature infants discharged with tube feedings from 42 North American level IV NICUs within the Children's Hospitals Neonatal Consortium between 2015 and 2020. Their analysis revealed that 61% of the 3,521 infants in the final cohort had GT tubes, with several factors associated with GT placement. Hispanic infants were 1.5 times more likely to be discharged with a GT than non-Hispanic white infants, while privately insured infants were roughly half as likely to receive a GT. Infants small for gestational age and with lower Apgar scores at five minutes were also more likely to receive a GT. Compared to infants discharged with GTs, those with NGTs had shorter average NICU stays (70 days compared to 86 days with GT) and were discharged at earlier postmenstrual ages. Multivariate analysis found that GT use at discharge ranged from 15% to 100% across hospitals, confirming significant inter-center variability in practice.

Clinical implications

This study is the first to report evidence of racial and ethnic disparities in home NGT and GT use and identify specific clinical and demographic factors linked to increased rates of GT placement among infants in the NICU. These findings highlight the need for standardized criteria to guide clinical decision-making around feeding tube modality and to improve equity. Drawing on these results, Children’s Colorado developed a home nasogastric tube program with a multidisciplinary telehealth follow-up clinic designed to facilitate earlier hospital discharge, support feeding skills and development, and monitor infant growth.