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Intragastric versus nasojejunal feeding of low-birth-weight infants
Volume 83 Number 6
Letters to the Editor
10 9 5
garding insensible water loss were not made by us. However, comparison among the various groups of infants of body weight gain at 14 days of age did not show significant differences. Since all infants in our study received early feedings, within 6 to 12 hours, either parenterally or orally, it is possible that excess of water losses may have been minimized. More detailed water-balance studies are needed in order to evaluate the effects of a radiant heater on the insensible water loss in the small, immature infant.
found greater deceleration of skeletal age than of height. We have described 3 the same phenomenon after treatment of congenital adrenal hyperplasia with corticoids, a matter previously recognized but perhaps not sufficiently emphasized.
Forrest H. Adams, M.D. George C. Emmanouilides, M.D. UCLA School o[ Medicine Los Angeles, Cali[ornia 90024
1. Guthrie, R. D., Smith, D. W., and Graham, C. B.: Testosterone treatment for mlcropenis during early childhood, J. PEDrATm 83: 247, 1973. 2. van Gelderen, H. H., and van Gemund, J. J.: Repair after abnormally rapid growth. Helv. Paediatr. Acta 25: 280, 1970. 3. Bongiovanni, A. M., Moshang, T., and Parks, J. S." Maturational deceleration after treatment of congenital adrenal hyperplasia, Helv. Paediatr. Acta 28: 127, 1973.
REFERENCES 1. Fanaroff, A. A., Wald, M., Gruber, H. S., and Klaus, M. H.: Insensible water loss in low birth weight infants, Pediatrics 50: 236, 1972. 2. Oh, W.,, and Kareeki, H.: Phototherapy and insensible water loss in the newborn infant, Am. J. Dis. Child. 124: 120, 1972.
AI[red M. Bongiovanni, M.D. The Children's Hospital o[ Philadelphia 1740 Bainbridge St. Philadelphia 46, Pa. REFERENCES
Reply To the Editor:
M a t u r a t i o n a l deceleration f o l l o w i n g
We thank Bongiovanni for his additional pertinent comments.
Robert Guthri'e, M.D. David W. Smith, M.D. Pro[essor in Pediatrics School o] Medicine Dept. o/Pediatrics RR234 Health Sciences RD-20 University o[ Washington Seattle, Wash. 98105
t r e a t m e n t w i t h testosterone To the Editor: In the August issue of the JOURNAL, Guthrie and co-workers 1 describe their results with testosterone treatment for micropenis. They consider the question of general growth and maturation in connection with this treatment and in Fig. 4 show the change in linear growth velocity during and after treatment. In two of the four cases there is an actual deceleration of velocity below that of the pretreatment baseline. In 1970 van Gelderen and van Gemund 2 describe what they termed "repair" after abnormally rapid growth. They show that "the reverse of catch-up growth . . . has not received much attention" and they describe seven children unduly advanced in growth and skeletal age because of prior administration of androgens or the presence of virilizing tumor. Following removal of such androgenic stimulation, they found significant deceleration of skeletal age and height, which tended to restore these children to their original channels. It would seem that there may be control mechanisms, the converse of those described in "catch-up growth" and these authors
I n t r a g a s t r i c rersus n a s o j e j u n a l f e e d i n g o f low-birth-weight i n f a n t s To the Editor: We were pleased to see the paper of Cheek and Staub, 1 which has confirmed our observation of the safety of continuous alimentation with milk feeds in infants of low birth weight. 2 In our series the tube was in the stomach, which is technically easier than the jejunal site and in our hands proved to be quite safe. We should like to mention that one of us (R. J. K. B.) has used this method routinely in feeding low-birth-weight in-
10 9 6
Letters to the Editor
fants during the past 12 years. If human milk or a low protein adapted cow's milk preparation (e.g., S.M.A. $26) is used, we found that 300 ml. per kilogram per 24 hours is usually tolerated by the ninth day. This results in considerably larger weight gains than those reported by Cheek and Staub.
H. B. Valman, M.B., M.R.C.P. Consultant Paediatrician Northwick Park Hospital and Clinical Research Centre Harrow, Middlesex, England R. ]. K. Brown, M.B., F.R.C.P. Consultant Paediatrician The Middlesex Hospital London, W.1., England
REFERENCES 1. Cheek, J. A., and Staub, G. F.: Nasojejunal alimentation for premature and full-term newborn infants, J. PEDIATR. 82" 955, 1973. 2. Valman, H. B., Heath, C. D., and Brown, R. J. K.: Continuous intragastric milk feeds in infants of low birth weight, Br. Med. J. 3: 547, 1972.
Reply To the Editor: In 1955, Holmdahl 1 first described the use of continuous milk drip gastric feedings in 72 premature infants; however, when he compared the method to gavage feedings, he found that emesis and attacks of cyanosis occurred in approximately the same frequency. The recent articles by Valman and associates 2 and Landwirth s revive the technique with satisfactory results. However, their method was used mainly in healthy premature infants and no calorie per kilogram per day values were given. This differs from our use of the nasojejunal method in two respects. The first important difference is that all of our infants were critically ill newborns, with 33 of the 36 premature infants having respiratory distress syndrome. Second, we agree with the recent study of Schain and associates 4 which demonstrated that even a relatively brief period of undernutrition in the newborn period may often retard brain growth. By our method, we were able to provide 72 calories per kilogram per day by the first 24 hours of life. It remains to be answered whether this ability to provide early adequate
The Journal o[ Pediatrics December 1973
calories is important in the human newborn; however, we feel that it does make a difference. By using the continuous nasogastric method of Valman and associates, similar calorie values were not obtained until 3 to 4 days of life. As Valman and associates points out, whichever method one chooses it is imperative that it be technically easy and safe in the hands of the user. Since regurgitation, aspiration, stomach dilatation, and vagal stimulation with bradycardia remain a significant possibility when feeding into the stomach and our method has a slight to no possibility of these occurrences, then we will continue to use what is comfortable in our hands, namely, transpyloric feedings. Except for the unscientific recommendations by Pierog and Ferrarc, 5 the actual capacity of the premature and full-term infants' stomach is unknown. Therefore, one is taking a "calculated" chance when infusing volumes similar to those suggested by Valman and associates. We are neither condemning nor condoning their method. However, as we pointed out in our article, the nasojejunal method of alimentation should be considered as a new tool for the physician caring for the newborn to properly evaluate. Proper evaluation of any of these methods would hopefully involve controlled studies testing several methods against our method. Only after these studies can anyone expound one method or the other.
f. Allan Cheek, ]r., M.D. Associate Director, Newborn Nurseries Rock[ord Memorial Hospital 2400 N. Rockton Ave. Rockford, Ill. 61103
REFERENCES 1. Holmdahl, K.: Milk drip via an indwelling nasogastric rubber tube for feeding premature infants, Acta Paediatr. 44: 330, 1955. 2. Valman, H. B., Heath, C. D., and Brown, R. J. K.: Continuous intragastric milk feeding in infants of low birth weight, Br. Med. J. 3: 547, 1972. 3. Landwirth, J.: Continuous nasogastric infusion versus total intravenous atimentation, J. PEDIATR. 81: 1037, 1972. 4. Schain, R. J., Watanabe, K., and Harel, S.: Effects of brief postnatal fasting upon brain development of rabbits, Pediatrics 51: 240, 1973. 5. Pierog, S. H., and Ferrarc, A.: Approach to the medical care of the sick newborn. St. Louis, 1971, The C. V. Mosby Company, p. 203.
Letters to the Editor
10 9 5
garding insensible water loss were not made by us. However, comparison among the various groups of infants of body weight gain at 14 days of age did not show significant differences. Since all infants in our study received early feedings, within 6 to 12 hours, either parenterally or orally, it is possible that excess of water losses may have been minimized. More detailed water-balance studies are needed in order to evaluate the effects of a radiant heater on the insensible water loss in the small, immature infant.
found greater deceleration of skeletal age than of height. We have described 3 the same phenomenon after treatment of congenital adrenal hyperplasia with corticoids, a matter previously recognized but perhaps not sufficiently emphasized.
Forrest H. Adams, M.D. George C. Emmanouilides, M.D. UCLA School o[ Medicine Los Angeles, Cali[ornia 90024
1. Guthrie, R. D., Smith, D. W., and Graham, C. B.: Testosterone treatment for mlcropenis during early childhood, J. PEDrATm 83: 247, 1973. 2. van Gelderen, H. H., and van Gemund, J. J.: Repair after abnormally rapid growth. Helv. Paediatr. Acta 25: 280, 1970. 3. Bongiovanni, A. M., Moshang, T., and Parks, J. S." Maturational deceleration after treatment of congenital adrenal hyperplasia, Helv. Paediatr. Acta 28: 127, 1973.
REFERENCES 1. Fanaroff, A. A., Wald, M., Gruber, H. S., and Klaus, M. H.: Insensible water loss in low birth weight infants, Pediatrics 50: 236, 1972. 2. Oh, W.,, and Kareeki, H.: Phototherapy and insensible water loss in the newborn infant, Am. J. Dis. Child. 124: 120, 1972.
AI[red M. Bongiovanni, M.D. The Children's Hospital o[ Philadelphia 1740 Bainbridge St. Philadelphia 46, Pa. REFERENCES
Reply To the Editor:
M a t u r a t i o n a l deceleration f o l l o w i n g
We thank Bongiovanni for his additional pertinent comments.
Robert Guthri'e, M.D. David W. Smith, M.D. Pro[essor in Pediatrics School o] Medicine Dept. o/Pediatrics RR234 Health Sciences RD-20 University o[ Washington Seattle, Wash. 98105
t r e a t m e n t w i t h testosterone To the Editor: In the August issue of the JOURNAL, Guthrie and co-workers 1 describe their results with testosterone treatment for micropenis. They consider the question of general growth and maturation in connection with this treatment and in Fig. 4 show the change in linear growth velocity during and after treatment. In two of the four cases there is an actual deceleration of velocity below that of the pretreatment baseline. In 1970 van Gelderen and van Gemund 2 describe what they termed "repair" after abnormally rapid growth. They show that "the reverse of catch-up growth . . . has not received much attention" and they describe seven children unduly advanced in growth and skeletal age because of prior administration of androgens or the presence of virilizing tumor. Following removal of such androgenic stimulation, they found significant deceleration of skeletal age and height, which tended to restore these children to their original channels. It would seem that there may be control mechanisms, the converse of those described in "catch-up growth" and these authors
I n t r a g a s t r i c rersus n a s o j e j u n a l f e e d i n g o f low-birth-weight i n f a n t s To the Editor: We were pleased to see the paper of Cheek and Staub, 1 which has confirmed our observation of the safety of continuous alimentation with milk feeds in infants of low birth weight. 2 In our series the tube was in the stomach, which is technically easier than the jejunal site and in our hands proved to be quite safe. We should like to mention that one of us (R. J. K. B.) has used this method routinely in feeding low-birth-weight in-
10 9 6
Letters to the Editor
fants during the past 12 years. If human milk or a low protein adapted cow's milk preparation (e.g., S.M.A. $26) is used, we found that 300 ml. per kilogram per 24 hours is usually tolerated by the ninth day. This results in considerably larger weight gains than those reported by Cheek and Staub.
H. B. Valman, M.B., M.R.C.P. Consultant Paediatrician Northwick Park Hospital and Clinical Research Centre Harrow, Middlesex, England R. ]. K. Brown, M.B., F.R.C.P. Consultant Paediatrician The Middlesex Hospital London, W.1., England
REFERENCES 1. Cheek, J. A., and Staub, G. F.: Nasojejunal alimentation for premature and full-term newborn infants, J. PEDIATR. 82" 955, 1973. 2. Valman, H. B., Heath, C. D., and Brown, R. J. K.: Continuous intragastric milk feeds in infants of low birth weight, Br. Med. J. 3: 547, 1972.
Reply To the Editor: In 1955, Holmdahl 1 first described the use of continuous milk drip gastric feedings in 72 premature infants; however, when he compared the method to gavage feedings, he found that emesis and attacks of cyanosis occurred in approximately the same frequency. The recent articles by Valman and associates 2 and Landwirth s revive the technique with satisfactory results. However, their method was used mainly in healthy premature infants and no calorie per kilogram per day values were given. This differs from our use of the nasojejunal method in two respects. The first important difference is that all of our infants were critically ill newborns, with 33 of the 36 premature infants having respiratory distress syndrome. Second, we agree with the recent study of Schain and associates 4 which demonstrated that even a relatively brief period of undernutrition in the newborn period may often retard brain growth. By our method, we were able to provide 72 calories per kilogram per day by the first 24 hours of life. It remains to be answered whether this ability to provide early adequate
The Journal o[ Pediatrics December 1973
calories is important in the human newborn; however, we feel that it does make a difference. By using the continuous nasogastric method of Valman and associates, similar calorie values were not obtained until 3 to 4 days of life. As Valman and associates points out, whichever method one chooses it is imperative that it be technically easy and safe in the hands of the user. Since regurgitation, aspiration, stomach dilatation, and vagal stimulation with bradycardia remain a significant possibility when feeding into the stomach and our method has a slight to no possibility of these occurrences, then we will continue to use what is comfortable in our hands, namely, transpyloric feedings. Except for the unscientific recommendations by Pierog and Ferrarc, 5 the actual capacity of the premature and full-term infants' stomach is unknown. Therefore, one is taking a "calculated" chance when infusing volumes similar to those suggested by Valman and associates. We are neither condemning nor condoning their method. However, as we pointed out in our article, the nasojejunal method of alimentation should be considered as a new tool for the physician caring for the newborn to properly evaluate. Proper evaluation of any of these methods would hopefully involve controlled studies testing several methods against our method. Only after these studies can anyone expound one method or the other.
f. Allan Cheek, ]r., M.D. Associate Director, Newborn Nurseries Rock[ord Memorial Hospital 2400 N. Rockton Ave. Rockford, Ill. 61103
REFERENCES 1. Holmdahl, K.: Milk drip via an indwelling nasogastric rubber tube for feeding premature infants, Acta Paediatr. 44: 330, 1955. 2. Valman, H. B., Heath, C. D., and Brown, R. J. K.: Continuous intragastric milk feeding in infants of low birth weight, Br. Med. J. 3: 547, 1972. 3. Landwirth, J.: Continuous nasogastric infusion versus total intravenous atimentation, J. PEDIATR. 81: 1037, 1972. 4. Schain, R. J., Watanabe, K., and Harel, S.: Effects of brief postnatal fasting upon brain development of rabbits, Pediatrics 51: 240, 1973. 5. Pierog, S. H., and Ferrarc, A.: Approach to the medical care of the sick newborn. St. Louis, 1971, The C. V. Mosby Company, p. 203.