Growth, feeding, and nutrition outcomes of very low birth weight neonates in a remote patient monitoring program compared with hospitalized infants

Technical Summary: Growth, Feeding, and Nutrition Outcomes of VLBW Neonates in Remote Patient Monitoring vs. Hospitalized Care

Problem Statement
Very low birth weight (VLBW) infants require optimal nutrition to support growth trajectories that mimic intrauterine development, as these trajectories are linked to neurodevelopmental outcomes. While Remote Patient Monitoring (RPM) programs have emerged to facilitate earlier hospital discharge for medically stable but immature infants—specifically those whose primary barrier to discharge is inadequate oral feeding—there is a lack of comprehensive data comparing their growth and nutritional outcomes against historical cohorts who remained hospitalized until achieving full oral feeds. Existing literature suggests RPM supports adequate weight gain, but direct comparisons regarding growth trajectories, time to full oral feeding, and nutrient intake between RPM-discharged infants and hospitalized controls are insufficient.

Methodology
This study employed a retrospective case-control design conducted at the Level IV NICU of Doernbecher Children's Hospital (Oregon Health & Science University).

• Subjects: The study included 67 VLBW infants divided into two groups:
  • Cases (n=34): Infants discharged between May 2019 and April 2022 with nasogastric tube (NGT) feeds and enrolled in the "Growing @ Home" (G@H) RPM program.
  • Controls (n=33): A historical cohort of VLBW infants discharged between 2013 and 2018 who remained hospitalized until full oral feeds were achieved. These controls were retrospectively identified as meeting the current RPM eligibility criteria (e.g., postmenstrual age ≥35 weeks, weight ≥2 kg, stable cardiorespiratory status, >30% oral intake) but were excluded from RPM due to the program's non-existence at the time.
• Data Collection: Data were extracted from electronic medical records and the RPM research repository. Key variables included demographic characteristics, anthropometric measurements (weight, length, head circumference) with Fenton 2013 z-scores, and feeding metrics (milk type, volume, caloric intake).
• Outcomes: Primary outcomes were assessed at three standardized time points: birth, RPM eligibility (or estimated eligibility date for controls), and discharge. Metrics included:
  • Mean daily weight gain (g/day).
  • Change in weight z-scores.
  • Time to attainment of full oral feeds (from birth and from eligibility).
  • Caloric intake (kcal/kg/day) at discharge.
• Statistical Analysis: Univariate analysis and T-tests were used to compare differences between groups. Analyses accounted for stratified design, with significance set at p < 0.05 and marginal significance at p < 0.10.

Key Results

• Weight Gain and Z-Scores:
  • From birth to discharge, the RPM group demonstrated significantly higher mean daily weight gain (27.43 g vs. 24.25 g; p < 0.01) and a significantly smaller decline in weight z-score (-0.38 vs. -0.88; p < 0.01) compared to controls.
  • From birth to RPM eligibility, RPM infants also showed higher weight gain (28.17 g vs. 24.20 g; p < 0.01) and less z-score decline (-0.19 vs. -0.84; p < 0.01).
  • However, during the interval from eligibility to discharge, there was no significant difference in daily weight gain (24.76 g vs. 24.33 g; p = 0.86). Notably, the RPM group experienced a significantly greater decline in weight z-score during this specific period (-0.19 vs. -0.03; p = 0.02).
• Feeding Progression:
  • The time from birth to achieving full oral feeds was significantly longer for the RPM group (12.96 weeks) compared to controls (9.62 weeks; p < 0.01).
  • When measured from the point of RPM eligibility, the time to full oral feeds remained longer for the RPM group (1.54 weeks vs. 1.04 weeks), though this difference did not reach statistical significance (p = 0.08).
  • The duration from achieving full oral feeds to final discharge was significantly longer for RPM infants (1.47 weeks vs. 0.29 weeks; p < 0.01), attributed to a structured one-week monitoring period required by the RPM protocol.
• Caloric Intake:
  • There was no significant difference in caloric intake at discharge between the two groups (114.59 kcal/kg/day for RPM vs. 116.19 kcal/kg/day for controls; p = 0.71).

Significance and Claims
The authors claim that this study provides evidence that VLBW infants discharged with NGT feeds and supported by RPM exhibit growth and nutritional intake patterns comparable to, and in some early metrics superior to, those of infants who remain hospitalized. Specifically, the study concludes that RPM supports similar enteral intake and weight gain during the home monitoring period, though the RPM cohort achieved full oral feeding at a later postnatal age and demonstrated a greater decline in weight z-score during the interval from eligibility to discharge compared to controls.

The paper posits that the RPM model offers a promising strategy to reduce hospital length of stay and costs while maintaining safety and supporting growth. The structured multidisciplinary approach, combining medical oversight with daily data transmission, allows for the early detection of feeding difficulties. The authors note that the observed decline in weight z-score during the home period may reflect differences in home feeding practices (e.g., availability of fortifiers) or adjustment to the home environment, suggesting a need for future prospective studies with detailed nutritional logs and long-term follow-up.

The study acknowledges limitations, including its retrospective nature, potential selection bias, modest sample size from a single center, and the lack of long-term neurodevelopmental outcome data. Consequently, the authors advocate for further expansion and rigorous evaluation of RPM-enabled home feeding programs as part of comprehensive neonatal care strategies, rather than claiming definitive superiority over traditional care in all aspects.