A quality improvement study that includes CHOC, part of Rady Children’s Health, has yielded significant improvement in standardized nutritional guidelines for newborns who undergo intestinal surgery and experience growth impairment during a critical stage of life.
The Growth Advancement in the NICU (GAIN): Surgical Patients Collaborative was organized by the California Perinatal Quality Care Collaborative (CPQCC). CHOC neonatologist and Surgical NICU director Dr. Irfan Ahmad served as lead faculty member. The effort involved eight neonatal intensive care units (NICUs) that offer surgical care in California.
NICU clinicians face challenges in delivering proper nutrition to this fragile population of infants who have undergone intestinal surgery and receive essential nutrients intravenously as opposed to via their mouths or feeding tubes that connect to their gastrointestinal (GI) tracts.
The GAIN initiative brought together the group of NICUs to share best practices and develop agreed-upon nutritional guidelines for newborns who undergo intestinal surgeries for such GI disorders as necrotizing enterocolitis (NEC), a serious gastrointestinal condition characterized by inflammation and death of intestinal tissue.
Other GI disorders in newborns requiring surgery include intestinal atresia, meconium ileus, colorectal malformations, intestinal malrotation, and abdominal wall defects.
At-risk newborns
The Journal of Parenteral and Enteral Nutrition recently published results of the GAIN-Surgical study, which involved 581 infants who underwent intestinal surgery in the NICU between January 2021 and June 2023. Dr Ahmad served as senior author of the report.
“The babies that were part of this study are most at risk of having nutritional problems because of intestinal obstructions, surgical removal of part of their intestine or other pathologies in their intestines that prevent them from being fed for multiple days,” Dr. Ahmad explained. “And many of them are dependent on total parenteral nutrition (TPN, or IV nutrition) for their growth.”
Every day, between 70 and 90 babies are in the NICU unit in Orange, and between 10 and 15% of these patients require surgery of some type.
Foundational study
Dr. Ahmad and another Rady Children’s participant in the GAIN Surgical Initiative, senior NICU clinical dietician Gina O’Toole, a study co-author, said the work of the collaborative was an important first step in improving growth outcomes in this population of NICU patients.
“We were hoping to see overall improved growth by implementing nutritional guidelines in this complex group of babies,” Gina said. “While we did not see the improvement in growth we hoped for, the study was successful, however, in the adoption and execution of standardized nutritional practices.”
Previously, the eight NICUs had no standard guidelines for IV-dependent newborns following intestinal surgeries.
The project also encouraged regular rounding of multi-disciplinary specialists who collaborated on how to best deliver nutrition to these newborns.
Inadequate nutrition in the early weeks and months of life can negatively impact not only physical growth, but also neurodevelopmental growth that could affect their learning, memory and social skills, Dr. Ahmad said.
Added Gina: “When you think about neonatal care, nutrition is at the center of it because if you can’t get a baby to grow you can’t optimize long-term outcomes.”
Gina’s job is to formulate individualized IV nutrition including fats, protein, sugars, vitamins, minerals, and electrolytes that will meet the very specific needs of each infant so each one has the best chance of healing and growth after surgery.
Previous work
The GAIN Surgical Initiative comes on the heels of a previous study by the CPQCC that examined feeding guidelines for NICU patients; the new study included both premature and full-term babies who required intestinal surgeries.
CHOC has been a member of the CPQCC, which is based at Stanford University, for more than 20 years. CHOC opened one of the first surgical NICUs in 2014, with Dr. Ahmad serving as medical director and Dr. Mustafa Kabeer as surgical director.
CHOC has been sharing its feeding guidelines with other NICUs for several years, noted Gina, one of the hospital’s five NICU clinical dieticians. She began working with the surgical NICU population in 2014 and has worked with Dr. Ahmad since then developing guidelines and protocols for the surgical NICU team.
“There’s a lot of collaboration involved in running a surgical NICU,” Dr. Ahmad noted. “That’s one of the reasons CHOC was so interested in participating in this study.”
Added Gina: “We have made a lot of progress over the last decade to improve outcomes in this nutritionally challenging population, and collaborating with other NICUs is essential to glean new insights, practices and ideas. There are lots of parties involved when you seek to make changes, and change can be challenging, but it can also be incredibly insightful and rewarding.”
In addition to Rady Children’s Health hospitals in Orange and San Diego, the collaborative includes Children’s Hospital Los Angeles, Loma Linda Children’s Hospital, Lucile Packard Children’s Hospital Stanford, Miller Children’s and Women’s Hospital Long Beach, University of California San Francisco Benioff Children’s Hospital Oakland, and Sutter Health Medical Center Sacramento.
CHOC was named one of the nation’s best children’s hospitals for neonatology by U.S. News & World Report in its 2025-26 Best Children’s Hospitals rankings.
