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Intestinal complications of nasojejunal feeding in low-birth-weight infants
July 1974 The Journal o f P E D I A T R I C S 1 0 9
i
Intestinal complications of nasojejunal feeding in low-birth-weight infants Naso]ejunal feeding was carried out in 13 low-birth-weight infants who Were unable to receive oral feeding. O f the six it~fants who died, .four had signs and symptoms' o f gastrointestinal disturbances. A t autopsy, one infant hadjejunojr intussusception and another hadjr perforation. Although the relationship o f nasojejunal .feeding to the causes o f death in these it!['ants cannot be definitely established, our observations suggest that a controlled study to establish the safety o f this procedure is warranted.
Jackson W. C h e n , M . D . , a n d P a u l W. K. W o n g , M . D . , M . S c . , * C h i c a g o ,
RECENTLY, Cheek and Staub reported their experience with continuous nasojejunal feeding in 46 patients, 36 of whom were low-birth-weight infants. No serious complication was reported. In this paper we report our experience with nasojejunal feeding in 13 low-birth-weight infants and its potential hazards. MATERIALS
AND METHODS
From July 1 to Oct. 31, 1973, 13 low-birth-weight infants were given nasojejunal feeding in the intensivecare nursery at the University of Illinois Hospital. The m e t h o d and technique were essentially the same as those described by Cheek and Staub. Radiopaque polyvinyl chloride tubes (Argyle No. 5 Fr., 36 inches) were used for intubation. A commercial formula, containing approximately 4.3% fat, 8.3% carbohydrate, 2.2% protein, and 80 Cal. per 100 ml, was given at a constant rate to all infants by means of an infusion pump. Initially, a volume of 70 ml/kg/24 hr was given and was increased gradually to a m a x i m u m of 150 ml/kg/day, according to the tolerance of the infants. Dextrose 5% in 0.2% sodium chloride was administered intravenously to supplement fluid intake when necessary. RESULTS The clinical data on these 13 infants may be summarized as follows: There were seven black infants, six From the Department o f Pediatrics, Abraham Lincoln School o f Medicine, University o f Illinois. *Reprint address: Department of Pediatrics, Abraham Lincobl School of Medicine, University of Illinois, 840 S. Wood St., Chicago, Ill. 60612.
Ill.
white infants; 6 males and 7 females. Their mean gestational age was 29.61 + 1.68 wk (range, 28-32 wk) and their m e a n birth weight was 1,176.15 + 208.23 gm (range, 800-1,660 gm). With one exception, all infants had the respiratory distress syndrome (RDS) and other clinical problems. None was able to receive oral feeding. Eight infants required assisted ventilation. Nasojejunal intubation was initiated at 2 to 9 days of age (average 4.00 ___ 1.96 days). Average duration of nasojejunal feeding was 16.00 + 11.78 days (range, 2-47 days). At the terAbbreviation used RDS: respiratory distress syndrome
]
m i n a t i o n of nasojejunal feeding, eight i n f a n t s were heavier and five infants were lighter than their respective birthweights. Three infants had clinical evidence to suggest aspiration; one of them survived. Seven infants survived and six died. The cause of death in two infants was unrelated to nasojejunal feeding. In the other four infants, there were signs and symptoms of gastrointestinal disturbances. Their clinical and pathologic findings are summarized below. CASE REPORTS Case 1. A black male infant, delivered at 31 weeks of gestation, had a birth weight of 1,240 gm; his Apgar score was 3 at one minute and 7 at five minutes after birth. Endotracheal intubation was performed for resuscitation at one minute; extubation was carried out at 10 minutes. He was treated for RDS with oxygen, humidity, and intravenous sodium bicarbonate and 10% dextrose. Over the next 36 hours, there was marked improvement and nasojejunal tube feeding was started at the age of two
Vol. 85, No. 1, pp. 109-110
110
Chen and Wong
days. He was doing well until five days of age when abdominal distension became evident. Nasojejunal feeding was discontinued. Over the next three or four hours, he had several episodes of bradycardia and his abdomen remained distended. Abdominal roentgenogram showed no free air in the peritoneal cavity, but air was observed in numerous areas of the intestinal wall. He was treated with antibiotics but died within a few hours. Blood culture grew enteropathogenic E. coli. Unfortunately, the milk was not cultured. At autopsy there was evidence of necrotizing gastroenterocolitis with possible rupture of the intestine. A 20 ml quantity of bloody fluid was found in the peritoneal cavity. There was passive congestion of lungs, liver, and spleen. Case 4. A black female infant, delivered at 28 weeks of gestation, had a birth weight of 1,100 gin; her Apgar score at one minute was 1 and at five minutes was 5. She had severe RDS, 9 which required assisted ventilation, and dextrose and sodium bicarbonate were given intravenously. There was a transient patent ductus murmur. She improved progressively and at the age of nine days nasojejunal tube feeding was started. On day 16 she vomited and had abdominal distension. Roentgenogram showed haziness in the right upper lung but no air in the peritoneal cavity. Nasojejunal feeding was discontinued and antibiotics were given, but no surgery was performed because of her poor condition. She died at the age of 20 days. Autopsy showed focal necrosis of jejunum with perforation, diffuse peritonitis with adhesions, bronchopneumonia, patent ductus arteriosus, and focal old subarachnoid hemorrhage of the right temporal and left parieto-occipital lobes. Case 8. A black male infant was delivered at 28 weeks of gestation; the membranes were ruptured two days prior to delivery. His birth weight was 1,080 gin; and his Apgar score was 4 at one minute and 5 at five minutes after birth. He was treated with oxygen, intravenous dextrose, sodium bicarbonate, and antibiotics for mild RDS. Continuous nasojejunal feeding was started on the third day of life. He was doing relatively well until the age of 12 days, when he had abdominal distension, vomiting, and aspiration. Nasojejunal feeding was discontinued and assisted ventilation was required. Roentgenogram of the abdomen showed distended bowel without free air in the peritoneal cavity. Abdominal distension increased and his general condition deteriorated. He died at the age of 15 days. Autopsy showed aspiration pneumonitis, distension of jejunum and the proximal two thirds of the ileum, without evidence of mechanical obstruction or perforation. Case 13. A white female infant, delivered at 29 weeks of gestation, had a birth weight of 1,050 gin; her Apgar score was 8 at one minute and 10 at five minutes. She had RDS on the first day of life and required assisted ventilation on the second day. Treatment consisted of intravenous dextrose, sodium bicarbonate, and antibiotics. Continuous nasojejunal feeding was
The Journal of Pediatrics July 1974
started at the age of four days. A murmur compatible with patent ductus arteriosus was heard initially at nine days of age and signs of heart failure were observed at the age of 22 days. Full digitalization was unable to control her heart failure and she could not be weaned from the respirator. Ligation of the patent ductus was performed at the age of 30 days and a lung biopsy obtained at the same time showed pulmonary interstitial fibrosis. Subsequently, her heart failure was under control but she was dependent on assisted respiration. Her condition was stable and nasojejunal feeding was continued. At the age of 50 days she had abdominal distension and two normal bowel movements without any blood. Nasojejunal feeding was discontinued. She died at the age of 51 days. Autopsy showed chronic pulmonary fibrosis with focal interstitial emphysema, closed ductus arteriosus, and jejunojejunal intussusception. DISCUSSION O u r i m p r e s s i o n w a s t h a t n a s o j e j u n a l f e e d i n g was beneficial to t h o s e i n f a n t s w h o survived. H o w e v e r , this was n o t s u b s t a n t i a t e d w i t h a controlled s t u d y c o m p a r i n g n a s o j e j u n a l feeding w i t h a l t e r n a t i v e m e t h o d s o f providi n g n u t r i e n t s to s m a l l i n f a n t s u n a b l e to f e e d orally. T h e r e f o r e , w h e t h e r n a s o j e j u n a l feeding i m p r o v e d survival in t h e s e i n f a n t s could n o t be j u d g e d by our o b s e r v a tions. It was alarming, h o w e v e r , t h a t four i n f a n t s had g a s t r o i n t e s t i n a l s y m p t o m s . A l t h o u g h the r e l a t i o n s h i p of n a s o j e j u n a l feeding to t h e causes o f d e a t h in cases 1, 8, a n d 13 could n o t b e established, t h e r e was s t r o n g evid e n c e suggesting that t h e n a s o j e j u n a l tube m i g h t be the c a u s e o f d e a t h in case 4. It was o b s e r v e d t h a t after four to five days t h e intestinal portion o f t h e n a s o j e j u n a l tubes was discolored ( m o r e o p a q u e a n d yellowish) a n d stiffer t h a n t h e u n u s e d tubes. It m i g h t well b e t h a t the h a r d e n e d p o r t i o n o f the n a s o j e j u n a l tubes caused jejunal p e r f o r a t i o n in case 4 a n d j e j u n o j e j u n a l i n t u s s u s c e p t i o n in case 13. It is essential, t h e r e f o r e , t h a t before n a s o j e j u n a l feeding can b e accepted as a safe or r o u t i n e m e t h o d for feeding small infants, controlled studies m u s t be carried out to c o n f i r m or r e f u t e t h e p o t e n t i a l hazards s u g g e s t e d by o u r o b s e r v a t i o n . Only after it can be d e m o n s t r a t e d that n a s o j e j u n a l feeding does not increase the m o r t a l i t y rate in t h e s e i n f a n t s can it be r e c o m m e n d e d e i t h e r in place o f or in p r e f e r e n c e to o t h e r m e t h o d s of feeding. We would like to thank Ana Sotrel, M.D., and Gerald Vermeulen, M.D., for their detailed pathologic examinations and the nursing staff for their devotion to the infants.
i
Intestinal complications of nasojejunal feeding in low-birth-weight infants Naso]ejunal feeding was carried out in 13 low-birth-weight infants who Were unable to receive oral feeding. O f the six it~fants who died, .four had signs and symptoms' o f gastrointestinal disturbances. A t autopsy, one infant hadjejunojr intussusception and another hadjr perforation. Although the relationship o f nasojejunal .feeding to the causes o f death in these it!['ants cannot be definitely established, our observations suggest that a controlled study to establish the safety o f this procedure is warranted.
Jackson W. C h e n , M . D . , a n d P a u l W. K. W o n g , M . D . , M . S c . , * C h i c a g o ,
RECENTLY, Cheek and Staub reported their experience with continuous nasojejunal feeding in 46 patients, 36 of whom were low-birth-weight infants. No serious complication was reported. In this paper we report our experience with nasojejunal feeding in 13 low-birth-weight infants and its potential hazards. MATERIALS
AND METHODS
From July 1 to Oct. 31, 1973, 13 low-birth-weight infants were given nasojejunal feeding in the intensivecare nursery at the University of Illinois Hospital. The m e t h o d and technique were essentially the same as those described by Cheek and Staub. Radiopaque polyvinyl chloride tubes (Argyle No. 5 Fr., 36 inches) were used for intubation. A commercial formula, containing approximately 4.3% fat, 8.3% carbohydrate, 2.2% protein, and 80 Cal. per 100 ml, was given at a constant rate to all infants by means of an infusion pump. Initially, a volume of 70 ml/kg/24 hr was given and was increased gradually to a m a x i m u m of 150 ml/kg/day, according to the tolerance of the infants. Dextrose 5% in 0.2% sodium chloride was administered intravenously to supplement fluid intake when necessary. RESULTS The clinical data on these 13 infants may be summarized as follows: There were seven black infants, six From the Department o f Pediatrics, Abraham Lincoln School o f Medicine, University o f Illinois. *Reprint address: Department of Pediatrics, Abraham Lincobl School of Medicine, University of Illinois, 840 S. Wood St., Chicago, Ill. 60612.
Ill.
white infants; 6 males and 7 females. Their mean gestational age was 29.61 + 1.68 wk (range, 28-32 wk) and their m e a n birth weight was 1,176.15 + 208.23 gm (range, 800-1,660 gm). With one exception, all infants had the respiratory distress syndrome (RDS) and other clinical problems. None was able to receive oral feeding. Eight infants required assisted ventilation. Nasojejunal intubation was initiated at 2 to 9 days of age (average 4.00 ___ 1.96 days). Average duration of nasojejunal feeding was 16.00 + 11.78 days (range, 2-47 days). At the terAbbreviation used RDS: respiratory distress syndrome
]
m i n a t i o n of nasojejunal feeding, eight i n f a n t s were heavier and five infants were lighter than their respective birthweights. Three infants had clinical evidence to suggest aspiration; one of them survived. Seven infants survived and six died. The cause of death in two infants was unrelated to nasojejunal feeding. In the other four infants, there were signs and symptoms of gastrointestinal disturbances. Their clinical and pathologic findings are summarized below. CASE REPORTS Case 1. A black male infant, delivered at 31 weeks of gestation, had a birth weight of 1,240 gm; his Apgar score was 3 at one minute and 7 at five minutes after birth. Endotracheal intubation was performed for resuscitation at one minute; extubation was carried out at 10 minutes. He was treated for RDS with oxygen, humidity, and intravenous sodium bicarbonate and 10% dextrose. Over the next 36 hours, there was marked improvement and nasojejunal tube feeding was started at the age of two
Vol. 85, No. 1, pp. 109-110
110
Chen and Wong
days. He was doing well until five days of age when abdominal distension became evident. Nasojejunal feeding was discontinued. Over the next three or four hours, he had several episodes of bradycardia and his abdomen remained distended. Abdominal roentgenogram showed no free air in the peritoneal cavity, but air was observed in numerous areas of the intestinal wall. He was treated with antibiotics but died within a few hours. Blood culture grew enteropathogenic E. coli. Unfortunately, the milk was not cultured. At autopsy there was evidence of necrotizing gastroenterocolitis with possible rupture of the intestine. A 20 ml quantity of bloody fluid was found in the peritoneal cavity. There was passive congestion of lungs, liver, and spleen. Case 4. A black female infant, delivered at 28 weeks of gestation, had a birth weight of 1,100 gin; her Apgar score at one minute was 1 and at five minutes was 5. She had severe RDS, 9 which required assisted ventilation, and dextrose and sodium bicarbonate were given intravenously. There was a transient patent ductus murmur. She improved progressively and at the age of nine days nasojejunal tube feeding was started. On day 16 she vomited and had abdominal distension. Roentgenogram showed haziness in the right upper lung but no air in the peritoneal cavity. Nasojejunal feeding was discontinued and antibiotics were given, but no surgery was performed because of her poor condition. She died at the age of 20 days. Autopsy showed focal necrosis of jejunum with perforation, diffuse peritonitis with adhesions, bronchopneumonia, patent ductus arteriosus, and focal old subarachnoid hemorrhage of the right temporal and left parieto-occipital lobes. Case 8. A black male infant was delivered at 28 weeks of gestation; the membranes were ruptured two days prior to delivery. His birth weight was 1,080 gin; and his Apgar score was 4 at one minute and 5 at five minutes after birth. He was treated with oxygen, intravenous dextrose, sodium bicarbonate, and antibiotics for mild RDS. Continuous nasojejunal feeding was started on the third day of life. He was doing relatively well until the age of 12 days, when he had abdominal distension, vomiting, and aspiration. Nasojejunal feeding was discontinued and assisted ventilation was required. Roentgenogram of the abdomen showed distended bowel without free air in the peritoneal cavity. Abdominal distension increased and his general condition deteriorated. He died at the age of 15 days. Autopsy showed aspiration pneumonitis, distension of jejunum and the proximal two thirds of the ileum, without evidence of mechanical obstruction or perforation. Case 13. A white female infant, delivered at 29 weeks of gestation, had a birth weight of 1,050 gin; her Apgar score was 8 at one minute and 10 at five minutes. She had RDS on the first day of life and required assisted ventilation on the second day. Treatment consisted of intravenous dextrose, sodium bicarbonate, and antibiotics. Continuous nasojejunal feeding was
The Journal of Pediatrics July 1974
started at the age of four days. A murmur compatible with patent ductus arteriosus was heard initially at nine days of age and signs of heart failure were observed at the age of 22 days. Full digitalization was unable to control her heart failure and she could not be weaned from the respirator. Ligation of the patent ductus was performed at the age of 30 days and a lung biopsy obtained at the same time showed pulmonary interstitial fibrosis. Subsequently, her heart failure was under control but she was dependent on assisted respiration. Her condition was stable and nasojejunal feeding was continued. At the age of 50 days she had abdominal distension and two normal bowel movements without any blood. Nasojejunal feeding was discontinued. She died at the age of 51 days. Autopsy showed chronic pulmonary fibrosis with focal interstitial emphysema, closed ductus arteriosus, and jejunojejunal intussusception. DISCUSSION O u r i m p r e s s i o n w a s t h a t n a s o j e j u n a l f e e d i n g was beneficial to t h o s e i n f a n t s w h o survived. H o w e v e r , this was n o t s u b s t a n t i a t e d w i t h a controlled s t u d y c o m p a r i n g n a s o j e j u n a l feeding w i t h a l t e r n a t i v e m e t h o d s o f providi n g n u t r i e n t s to s m a l l i n f a n t s u n a b l e to f e e d orally. T h e r e f o r e , w h e t h e r n a s o j e j u n a l feeding i m p r o v e d survival in t h e s e i n f a n t s could n o t be j u d g e d by our o b s e r v a tions. It was alarming, h o w e v e r , t h a t four i n f a n t s had g a s t r o i n t e s t i n a l s y m p t o m s . A l t h o u g h the r e l a t i o n s h i p of n a s o j e j u n a l feeding to t h e causes o f d e a t h in cases 1, 8, a n d 13 could n o t b e established, t h e r e was s t r o n g evid e n c e suggesting that t h e n a s o j e j u n a l tube m i g h t be the c a u s e o f d e a t h in case 4. It was o b s e r v e d t h a t after four to five days t h e intestinal portion o f t h e n a s o j e j u n a l tubes was discolored ( m o r e o p a q u e a n d yellowish) a n d stiffer t h a n t h e u n u s e d tubes. It m i g h t well b e t h a t the h a r d e n e d p o r t i o n o f the n a s o j e j u n a l tubes caused jejunal p e r f o r a t i o n in case 4 a n d j e j u n o j e j u n a l i n t u s s u s c e p t i o n in case 13. It is essential, t h e r e f o r e , t h a t before n a s o j e j u n a l feeding can b e accepted as a safe or r o u t i n e m e t h o d for feeding small infants, controlled studies m u s t be carried out to c o n f i r m or r e f u t e t h e p o t e n t i a l hazards s u g g e s t e d by o u r o b s e r v a t i o n . Only after it can be d e m o n s t r a t e d that n a s o j e j u n a l feeding does not increase the m o r t a l i t y rate in t h e s e i n f a n t s can it be r e c o m m e n d e d e i t h e r in place o f or in p r e f e r e n c e to o t h e r m e t h o d s of feeding. We would like to thank Ana Sotrel, M.D., and Gerald Vermeulen, M.D., for their detailed pathologic examinations and the nursing staff for their devotion to the infants.