Getting the Bowel Back Inside: Why the Speed of Closing a Baby's Tummy Matters After Gastroschisis

What a decade of babies treated in Western Australia, a small series of an unusual and severe form, and a 2025 review of the condition say when read together

Gastroschisis is a birth defect in which a baby's intestines develop outside the body, pushing through a small opening in the abdominal wall beside the belly button. Surgeons return the bowel to the tummy gradually, using a soft pouch called a silo, and then close the opening. New research suggests that finishing this process within five days of birth is linked to babies feeding sooner and going home sooner.

Five days sounds like a small detail, but for a family beside an incubator it can be the difference between under three weeks in hospital and closer to five.

Three pieces of research, and how they fit together

The main study comes from the newborn intensive care unit at Perth Children's Hospital in Nedlands, Western Australia, where Sharma, Gera and Rao looked back at every baby with gastroschisis they had treated with a silo over eleven years, comparing those whose tummy was closed within five days of birth with those who took longer [1]. The second is a small report by Morozov and colleagues about an uncommon, more dangerous version of the condition, in which the opening tightens or seals shut around the bowel before the baby is born [2]. We should be open about a limit: only the summary of that second paper, not the full article, could be obtained, so everything said about it below is confined to what that summary states — nothing about where it was done or about the individual babies' operations. The third is a review article by Rustemov and colleagues, surgeons in Astana, Kazakhstan, gathering what is known about diagnosing, predicting and treating gastroschisis and giving the wider picture the other two sit inside [3].

How families and doctors used to face this problem

For most of the last century, the question was not how fast a baby could go home but whether the baby would survive at all. The first operations were done from 1951, adapting a technique developed a few years earlier for a different abdominal wall problem; in the reported group of 36 babies, around 70 out of every 100 died [3]. The turning point came in 1967, when a surgeon named Schuster suggested stitching a bag to the edges of the opening, so the intestines could sit safely outside the body and be eased in a little at a time over about a week instead of being forced into a tummy too small to hold them [3]. That invention is the ancestor of today's silo, and it is why gastroschisis went from usually fatal to usually survivable.

Meanwhile the condition became more common. A large international project pooling birth defect records from 27 monitoring programmes in 24 countries — the International Clearinghouse for Birth Defects Surveillance and Research — found gastroschisis in about 3 of every 10,000 babies born, and rising [4]. The Kazakh review puts it another way: roughly 1 baby in 4,000 in 1990 and 1 in 1,800 by 2018, with about 80 in every 100 born early, at 35 to 37 weeks [3].

As more babies survived, doctors noticed they did not all do equally well. Some had otherwise healthy bowel — "simple" gastroschisis — while others had extra damage such as a blockage, a hole, or a section of intestine that had lost its blood supply, called "complex" gastroschisis. Molik and colleagues first argued these two groups should be counted separately [5], and Arnold and colleagues confirmed it in more than 4,000 children [6]. Surgeons also argued for decades about closing the tummy in one operation versus using a silo first. Two small clinical trials tried to settle it — one testing a ready-made spring-loaded silo [7], the other comparing immediate closure with a bedside silo [8] — but included only 92 babies between them, and two later research summaries disagreed: one favoured the silo [9], the other found no strong evidence for any strategy [10]. A committee of the American Pediatric Surgical Association concluded that closing straight away should be tried whenever the baby is stable enough and there is room in the tummy [11]. Many hospitals adopted the silo as their first step anyway, replacing the old argument with a new one: if the silo is used, how long should it stay on?

The number five first appeared in a large study across many American hospitals by Hawkins and colleagues, who found that babies whose tummy was closed more than five days after the silo went on stayed in hospital longer, took longer to feed, and spent longer on a breathing machine and on intravenous nutrition [12]. The Kazakh review reached the same figure by a different route, concluding the silo bag should not stay in place longer than five days [3]. The Perth team had its own reason to be curious: an earlier review of their own practice had shown that pushing the bowel back in one go at the cot side, without a general anaesthetic, could increase short-term problems [13]. That is why they switched to routine silo use from 2010 — and the study below checks, a decade later, how that worked out [1].

What the Western Australian team did, and what they found

The team looked at every baby with gastroschisis admitted to their newborn intensive care unit between January 2010 and December 2020 [1]. Nearly all had been born at King Edward Memorial Hospital for Women in Perth, described by the authors as the only specialist maternity centre in Western Australia, and moved to the children's hospital straight after birth. Of 113 babies admitted, 109 were treated with a silo and included: 34 had their tummy closed within five days and 75 took longer. Nobody was assigned to a group in advance; the researchers recorded what happened to each baby.

The differences were large. Babies closed within five days reached full milk feeds at around 15 days of age, compared with about 24 and a half days for the others — roughly ten days earlier — and went home at about 19 days old rather than 32, nearly two weeks sooner. They also needed intravenous feeding for less time (about 14 days rather than 24) and fewer days of antibiotics (about 10 rather than 18). The researchers then used statistics to allow for differences between the groups — how early each baby was born, birth weight, simple or complex disease, and how sick the baby was. Even after that, closing later than five days was still linked to slower feeding and a longer stay, though having complex gastroschisis mattered even more than timing did. Serious complications were uncommon, and 3 of the 109 babies died before going home — two in the early group, one in the later; two of the three had bowel already beyond saving at birth.

The babies for whom hurrying is the wrong idea

Not every baby should be rushed — the most important qualification in the story. Morozov and colleagues found that 5 of 24 babies with gastroschisis admitted during 2023 and 2024 had the "closing" or "closed" form, in which the opening tightens around the bowel before birth and cuts off its blood supply: about 21 in every 100 in that series, against roughly 6 in every 100 gastroschisis cases worldwide [2]. Three of the five had signs of a bowel blockage on ultrasound scans late in the pregnancy. Based on their summary, the authors suggest that when such signs appear earlier, in the middle third of pregnancy, they may warn of serious damage to the exposed bowel's blood supply, and that for one pattern of the condition a step-by-step approach preserves more intestine. With five babies and no statistical testing, this is a signal worth noticing rather than proof. The Kazakh review agrees: when the bowel is already crushed and scarred before birth, doctors go slowly on purpose, sometimes bringing part of the bowel out onto the abdomen temporarily and waiting a month or more before the next operation; roughly 70 to 76 out of 100 such babies keep enough working intestine [3]. Put simply: for ordinary gastroschisis the enemy is time, but for the closing form what matters is the length of the intestine, and rushing spends it.

This is also why ultrasound scans in pregnancy matter, and why they cannot answer everything. Fisher and colleagues showed that scan findings — for example an unusually large amount of fluid around the baby — only partly predict which babies will have the complex form [14], so doctors often do not know for certain until the baby arrives.

What this means for your family

If your baby is being treated with a silo, the pouch is not a sign that something has gone wrong: it is the normal way of making room, done gently in small steps because the tummy has to stretch. The team will usually be aiming to close within about five days, and it is reasonable to ask where your baby is in that plan. But a target is not a deadline: some babies genuinely need longer, or need a patch of surgical mesh to close a large opening. In the Perth study, babies who took longer had bigger defects and needed mesh far more often, suggesting the delay reflected a harder problem rather than a slower team [1]. Breast milk appears to help: a large national study found that babies with uncomplicated gastroschisis given only breast milk had better outcomes [15], and since feeding is what everyone is waiting for, expressing milk early is one of the most useful things a parent can do. The timing of the birth also matters — a study across many American children's hospitals, the Children's Hospitals Neonatal Consortium, has examined how the number of weeks of pregnancy completed at birth relates to how babies do afterwards [16], which is why your obstetric and surgical teams should plan together.

What researchers are working on next

Three things are still unresolved. The first is cause and effect: because the Perth study looked backwards, it can show that late closure and long stays go together but cannot prove that closing sooner causes the shorter stay. Settling that needs a study in which hospitals agree in advance to aim for five-day closure in some babies and let the tummy set the pace in others — a study the Perth authors themselves call for. The second is whether the finding travels. This was one well-resourced hospital in a wealthy country; a very large international study across 264 hospitals in 74 countries showed how much survival from birth defects of the gut depends on where a baby is born [17], and the Kazakh review reports gastroschisis death rates from about 6 to 47 in every 100 depending on centre and region, against under 3 in 100 in Perth [3]. The third is prediction before birth: if scans partway through pregnancy really can flag the babies whose bowel is being damaged, families could be counselled and delivery planned differently, months before any operation [2].

The honest summary is a hopeful one. Gastroschisis has gone from a condition most babies did not survive to one most babies do; the silo is a large part of why; and current work is about shaving weeks off a hospital stay rather than saving lives — with the clear exception of the small group whose bowel was harmed before birth, for whom slower, staged surgery remains the deliberate choice.

References

  1. Sharma P, Gera P, Rao S. Early versus delayed silo closure in gastroschisis: a retrospective study. Pediatric Surgery International. 2025;41(1):138. doi:10.1007/s00383-025-06042-6 ↩
  2. Morozov D, Vanyan L, Morozova M, Erokhina N, Velichko E, et al. Closing/Closed Gastroschisis (CGS): Antenatal Predictors and Surgical Strategies in Cases of Unique Anatomy from a Case Series. Children (Basel). 2026;13(3):408. doi:10.3390/children13030408 ↩
  3. Rustemov D, Sakuov Z, Kucherbayeva Z, Shayakhmetov S, Bilal R. Gastroschisis: diagnosis, prognosis and treatment options. Frontiers in Pediatrics. 2025;13:1717874. doi:10.3389/fped.2025.1717874 ↩
  4. Feldkamp ML, Canfield MA, Krikov S, Prieto-Merino D, Šípek A Jr, et al. Gastroschisis prevalence patterns in 27 surveillance programs from 24 countries, International Clearinghouse for Birth Defects Surveillance and Research, 1980–2017. Birth Defects Research. 2024;116:e2306. doi:10.1002/bdr2.2306 ↩
  5. Molik KA, Gingalewski CA, West KW, Rescorla FJ, Scherer LR, et al. Gastroschisis: a plea for risk categorization. Journal of Pediatric Surgery. 2001;36:51–55. doi:10.1053/jpsu.2001.20004 ↩
  6. Arnold MA, Chang DC, Nabaweesi R, Colombani PM, Bathurst MA, et al. Risk stratification of 4344 patients with gastroschisis into simple and complex categories. Journal of Pediatric Surgery. 2007;42:1520–1525. doi:10.1016/j.jpedsurg.2007.04.032 ↩
  7. Pastor AC, Phillips JD, Fenton SJ, Meyers RL, Lamm AW, et al. Routine use of a SILASTIC spring-loaded silo for infants with gastroschisis: a multicenter randomized controlled trial. Journal of Pediatric Surgery. 2008;43:1807–1812. doi:10.1016/j.jpedsurg.2008.04.003 ↩
  8. Poola AS, Aguayo P, Fraser JD, Hendrickson RJ, Weaver KL, et al. Primary closure versus bedside silo and delayed closure for gastroschisis: a truncated prospective randomized trial. European Journal of Pediatric Surgery. 2019;29:203–208. doi:10.1055/s-0038-1627459 ↩
  9. Kunz SN, Tieder JS, Whitlock K, Jackson JC, Avansino JR. Primary fascial closure versus staged closure with silo in patients with gastroschisis: a meta-analysis. Journal of Pediatric Surgery. 2013;48:845–857. doi:10.1016/j.jpedsurg.2013.01.020 ↩
  10. Ross AR, Eaton S, Zani A, Ade-Ajayi N, Pierro A, et al. The role of preformed silos in the management of infants with gastroschisis: a systematic review and meta-analysis. Pediatric Surgery International. 2015;31:473–483. doi:10.1007/s00383-015-3691-2 ↩
  11. Slidell MB, McAteer J, Miniati D, Sømme S, Wakeman D, et al. Management of gastroschisis: timing of delivery, antibiotic usage, and closure considerations (a systematic review from the American Pediatric Surgical Association Outcomes & Evidence Based Practice Committee). Journal of Pediatric Surgery. 2024;59(8):1408–1417. doi:10.1016/j.jpedsurg.2024.03.044 ↩
  12. Hawkins RB, Raymond SL, St Peter SD, Downard CD, Qureshi FG, et al. Immediate versus silo closure for gastroschisis: results of a large multicenter study. Journal of Pediatric Surgery. 2020;55(7):1280–1285. doi:10.1016/j.jpedsurg.2019.08.002 ↩
  13. Rao SC, Pirie S, Minutillo C, Gollow I, Dickinson JE, et al. Ward reduction of gastroschisis in a single stage without general anaesthesia may increase the risk of short-term morbidities: results of a retrospective audit. Journal of Paediatrics and Child Health. 2009;45:384–388. doi:10.1111/j.1440-1754.2009.01505.x ↩
  14. Fisher SG, Anderson CM, Steinhardt NP, Howser LA, Bhamidipalli SS, et al. It is complex: predicting gastroschisis outcomes using prenatal imaging. Journal of Surgical Research. 2021;258:381–388. doi:10.1016/j.jss.2020.08.067 ↩
  15. Hodgson E, Briatico D, Klapman S, Skarsgard E, Beltempo M, et al. Association of exclusive breast milk intake and outcomes in infants with uncomplicated gastroschisis: a national cohort study. Journal of Pediatric Surgery. 2024;59:863–868. doi:10.1016/j.jpedsurg.2024.01.045 ↩
  16. Riddle S, Acharya K, Agarwal N, Ahmad I, Bendel-Stenzel E, et al. Gestational age at delivery and neonatal outcomes among infants with gastroschisis in the Children's Hospitals Neonatal Consortium (CHNC). American Journal of Perinatology. 2024;41:756–763. doi:10.1055/s-0042-1744510 ↩
  17. Global PaedSurg Research Collaboration. Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study. The Lancet. 2021;398(10297):325–339. doi:10.1016/S0140-6736(21)00767-400767-4) ↩