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Nasojejunal alimentation for premature and full-term newborn infants
]une, 1973 T h e Journal o[ P E D I A T R I C S
955
Nasol'ejunal alimentation for premature and full-term newborn infants Thirty-six ill premature (mean gestation 32.8 weeks, mean birth weight 1,624 Gin.) and 10 sick, lull-term, newborn in/ants received continuous infusions of formula by nasojejunal aIimentation as a means of total nutritional support for periods of 2 to 75 days. In the premature infants the mean duration of nasojejunal feedings was 20.1 days, and the mean weight gain was 17.3 Gin. per day. The mean of the maximum rate of infusion was 145.8 ml. per kilogram per day with corresponding mean caloric intake of 113.6 cal. per kilogram per day and protein intake of 2.9 Gin. per kilogram per day. Only 3 of 46 infants (6.5 per cent) failed to gain weight while receiving sole nutritional support by jejunal alimentation; 2 of them died within 72 hours of age with hyaline membrane disease and intraventricular cerebral hemorrhages, and the third infant died at age 13 days (birth weight 680 Gin.) with hya!ine membrane disease. The mean duration of infusion for the sick full-term infants was 10.8 days; their mean weight gain was 18.3 Gin. per day. No significant alterations were observed in serial determinations of blood glucose, of serum calcium, sodium, potassium, blood urea nitrogen, and osmolaIity, or of hemogram during jejunal infusion. No abnormalities were noted in urinary or fecal output and analysis.
j . Allan Cheek, Jr., M.D., ~ a n d G e r a l d F. Staub, M.D., R o c k f o r d , lll.
R H EA and associates, 1 in 1967, first rep o r t e d the use of nasojejunal feedings as a means of nutritional support in newborn infants with tetanus; in 1970, R h e a a n d K i l b y 2 described their method. W e have employed a modification of their m e t h o d for From the Rockford Regional Neonatal Center, Division of Neonatology, Department of Pediatrics, Rockford Memorial Hospital, and the University of Illinois Rockford School of Medicine. ~'Address: Rockford Regional Neonatal Center, 2400 N. Rockton Ave., Rockford, III. 61103.
the nasojejunal feeding of sick p r e m a t u r e a n d term newborn infants. O u r experience using this m e t h o d in 46 infants is detailed in this paper. ~' MATERIALS
AND
METHODS
All of the infants in this study were critically ill shortly after birth and were a d m i t ted to the high-risk unit from either the ~Detailed clinical data will be furnished upon request by Dr. Cheek. Vol. 82, No. 6, pp. 955-962
956
Cheek and Staub
The Journal of Pediatrics June 1973
Fig. 1. A, Case 17 (lowest weight 1,106 Gin.) demonstrating nasojejunal system. Arrows point to Soluset reservoir filled with formula and Holter pump with feeding line to patient. Note cotton gauze mittens. B, Same patient at 54 days of age (weight 1,573 Gm.). C, Maternal-infant eye-to-eye contact while on nasojejunal alimentation.
Rockford Memorial Hospital delivery room or regional hospitals. Thirty-six premature infants with gestational ages of less than 37 weeks (calculated from the first day of the mother's last menstrual period rounded to the nearest week and by physical examination of the infant 3) and ten full-term infants were selected for nasojejunal feeding because they were unable to tolerate oral feedings for at least one of the following conditions: (l) respiratory distress syndrome, (2) neonatal asphyxia with an Apgar score of less than 7 and requiring resuscitation at birth, (3) neonatal seizures with inability to coordinate sucking and swallowing, (4) clinical a n d / o r laboratory evidence of sepsis, or (5) congenital heart disease. Immediately after the initial clinical evaluation and emergency procedures were performed, a cardiotach monitor (V. MuellerMM2100) was connected to the patient for continuous monitoring of heart rate. The length of insertion of the nasojejunal tube was then estimated by measuring the distance from the glabella to the stretched-out heel; this spot was marked on a radiopaque polyvinyl chloride Argyle No. 5 French 36 inch feeding tube (inside diameter 0.037 inch, outside diameter 0.063 inch). The tube was then inserted through the nostril into the
stomach while the monitor was observed for bradycardia. The following criteria were used to indicate that the tube had not entered the trachea: (1) no exacerbation of existing respiratory difficulty, and (2) auscultation over the stomach area while 3 to 5 c.c. of air was injected with a syringe. After being certain that the stomach had been entered, it was aspirated and, if conditions permitted, the patient was placed on his right side to facilitate passage of the tube through the pylorus. The feeding tube was inserted until the previously measured mark was reached. The protruding end of it was secured to the face with adhesive tape in such a way so as not to cause pressure necrosis or irritation or block the nasal canal. Finally, it was strapped to the cheek or forehead by plastic adhesive tape. Occasionally, soft cotton gauze mittens were placed over the infant's hands to prevent him from dislodging the tube. When bile was obtained through the feeding tube and the fluid had a p H of 5 to 7, abdominal and chest posteroanterior and lateral roentgenograms were obtained to insure that the tube was at the ligament of Treitz before feedings were begun. Either a 250 c.c. Soluset (Abbott P-250) or a 30 c.c. plastic disposable Luer-Lok syringe (Becton-Dickerson) was used as the
Volume 82 Number 6
Nasojejunal feeding
957
Table I. Summary of outcome of infants receiving nasojejunal feeding Birth weight (Gin.)
Gestation (wk.)
No. of patients
No. survived
Per cent survival
26-30 29-35 34-36 36 Totals
6 13 15 2 36
3 11 15 2 31
50 84.6 100 100 86.1
> 36 > 36 Totals
1 9 10
1 8 9
100 88.8 90
Premature infants
567-992 1,021-1,500 1,55'9-2,381 > 2,500 Full-term infants
< 2,500 > 2,500
Table II. Summary of data during the first 72 hours of life on jejunal feeding
Period
No. of patients
Mean gestation (wk.)
First 24 hr. First 72 hr.
15 22
32.3 33
Mean birth weight (Gin.)
Mean weight loss (%)
1,460 1,311
6.0 8.8
reservoir for the fluid. The Soluset or syringe was connected to the p u m p tubing of a Holter pump (Model No. 903, 907, or 912) for continuous infusion. The proximal end of the Holter pump tubing was subsequently connected to a disposable, nonpyrogenic, 3 way T o m a c stopcock (American Hospital Supply K-75). The nasojejunal feeding tube was then connected to the other end of the stopcock. The desired formula or fluid was delivered at room temperature to the infant by continuous infusion at a rate which would provide the desired amounts of fluid and calories. The osmolarity of the infusion fluid ranged from 278 to 369 mOsm. per liter. Similac or SMA, 24 cal. per ounce (osmolarity 369 mOsm. per liter), was used for most premature infants to provide 60 to 180 ml. or 48 to 144 cal. per kilogram per day. However, several very small infants with birth weights of less than 1,200 Gm. and gestational ages of less than 31 weeks were initially given 5 per cent dextrose in water (278 mOsm. per liter) while their jejunal osmolarity tolerance was determined by monitoring the clinical condition and serum osmolality. After establishing their jejunal os-
Mean rate Mean caloric I Mean proof infusion intake ] tein intake (ml./Kg./ (cal./Kg./ ( Gra./ K g./ day) day) day) I
98.3 105.2
72 76.3
1.7 1.9
molarity tolerance, the jejunal feedings were slowly increased to 24 cal. per ounce as tolerated. The Soluset or syringe apparatus was monitored for bacteria and changed at least every fifth day, but the nasojejunal tubes were not changed routinely; one remained in situ for 10 89 weeks without causing any problem. While the feeding tube was in place, our nursing staff and parents stimulated the infant by touching or handling as often as possible (Fig. 1, A, B, and C). Base-line and serial measurements of head circumference, length, body weight, hemoglobin, hematocrit, and white blood ceil count were obtained, as well as microanalysis of serum sodium, potassium and calcium, blood urea nitrogen, capillary serum osmolality, urine osmolality, and blood glucose concentration. Urine studies of pH, sugar, acetone, and protein and microscopic examination for casts, cells, and bacteria were also carried out. Frequent random stool examinations {or occult blood, fat content, and bacterial culture were performed; stool frequency and consistency were recorded by the nurses. All infants were treated appropriately for
958
Cheek and Staub
The Journal of Pediatrics June 1973
Table I I I . General course during nasojejunal feedings in premature and full-term infants Weight In[ants 36 Premature Mean (• S.D.) 10 Full-term Mean (• S.D.)
GestationM age (wk.)
Birth weight (Gin.)
Lowest weight (Gin.)
32.8 (0.5)
1,624.4 (82.5)
1,518.8 (84.1)
I0
20.1 (9.7)
39.0 (0.4)
3,339.8 (202.9)
3,i38.5 (149.3)
6
10.8 (2.3)
their underlying conditions. Umbilical artery or vein catheters were often used during the first 72 to 96 hours of life for monitoring, for blood transfusions, and for antibiotic therapy when indicated. These catheters were not used as a means of nutritional support in any of the infants. A surgical approach was employed to insert the feeding tube into the jejunum of 5 premature infants when attempts to pass the tube through the nasojejunal route were unsuccessful; in 4 of the 5 approaches gastrostomies were performed with insertion of the jejunal tube via the stomach. Upon reaching a postconceptual age of 35 weeks, all premature infants were assessed with respect to feasibility and safety of beginning oral formula feedings by nipple. When the clinical condition improved in ill full-term infants, they were also reevaluated for institution of nipple feedings. When oral feedings were initiated in these infants, the jejunal infusion rate was proportionately decreased and then discontinued when adequate fluid and caloric intake with nipple feedings was possible. The jejunal infusion was stopped for 30 minutes before and after the initiation of each nipple feeding. In order to avoid clogging of the feeding tube during the discontinuation of feeding, the polyvinyl tube was flushed with 1 c.c. of 0.45 per cent saline, and the stopcock toward the patient was closed until jejunal tube feedings were restarted. The stopcock also provided a means of giving medications through the feding tube. When used for this purpose, the tube was flushed as described above after administration of the medication.
lOSS
(%)
Duration (days)
The data listed in this report are limited to the period of jejunal alimentation. RESULTS
Nine of 10 (90 per cent) sick full-term infants survived while receiving nutritional support by jejunal feedings, and 31 of 36 (86 per cent) sick premature infants survived (Table I ) . Autopsies were performed on all patients who died, and no death could be attributed directly to the method used for nutrition. However, one infant with a birth weight of 680 Gm. in whom a jejunostomy was performed for jejunal feeding did have leakage of formula at the surgical site, with generalized peritonitis found at autopsy following death at 13 days of age. After this experience, jejunostomy was abandoned as a surgical approach, and the jejunal feeding tube was placed via a gastrostomy without complications in 4 other patients. In 22 of 36 premature infants (61 per cent) jejunal feedings could be initiated during the first 72 hours of life. Their mean gestational age was 33 weeks and mean birth weight was 1,311 Gm. During the first 72 hours of life these infants received a mean infusion of 105 ml. per kilogram per day providing 76 calories per kilogram per day and 1.9 Gm. of protein per kilogram per day. Their mean lowest weight indicated an average weight loss of 8.8 per cent (Table I I ) . It took only 13 days for these infants to regain their birth weights. Unfortunately nitrogen balance studies were not performed during this early catabolic period. Table I I I summarizes the data for age, birth weight, lowest weight, percentage of total weight loss, duration of feeding, final
Volume 82 .Number 6
NasojejunaI [eeding
Rate o[ infusion (ml./Kg./day)
Caloric intake (cal./Kg./day) Minimum ] Maximum
959
Protein intake (Gm./Kg./day) Minimum I Maximum
Final weight (Gm.)
Weight gain (Gm./day)
1,866.6 (95.6)
17.3 (1.4)
109.1 (4.3)
145.8 (4.2)
79.4 (4.3)
113.6 (3.4)
2.i (0.1)
2.9 (0.1)
3,331.7 (214.8)
18.3 (5.3)
88.0 (6.1)
124.0 (5.5)
67.3 (6.0)
97.0 (4.0)
1.8 (0.2)
2.4 (0.1)
Minimum ]Maximum
weight, weight gain, rate of infusion, and caloric and protein intake during the total duration of jejunal alimentation for the 36 premature and 10 full-term infants. For the premature infants it was possible to give 146 c.c. of formula per kilogram per day providing 114 cal. per kilogram per day and 2.9 Gm. of protein per kilogram per day. Excellent utilization of nutrients is indicated by the mean weight gain of 17.3 Gm. per day in these premature infants. The head circumference and length of these infants also increased during the period of jejunal feedings. Except for initial abnormalities secondary to the underlying critical clinical condition, all laboratory and clinical parameters remained within expected normal ranges for premature and full-term infants during the entire course of nasojejunal alimentation. Loose stools, lethargy, poor muscle tone, gray mottled color, excessive apnea, edema, dehydration, nephropathy, or late metabolic acidosis were not observed in our infants after their initial underlying condition was corrected. COMPLICATIONS None of the 46 infants had nasal infections caused by the in situ nasojejunal tubes; however, 2 infants were found to have Staphylococcus aureus, which was coagulase positive on nasal cultures done at the time the tubes were withdrawn from the nose. Neither of these infants presented problems; both were successfully treated by intranasal instillation of Neosporin. No patient had pressure necrosis or any deterioration in respiratory function attributable to the nasal
tube. Three infants (6.5 per cent) had serious complications during the early refinements of this modified method, all technical in nature. One patient (birth weight 680 Gin.) had generalized peritonitis secondary to leakage of formula from a jejunostomy site; at autopsy hyaline memb r a n e disease and lobar pneumonia were also found. Aspiration of infusing formula caused by a "blast" of fluid occurred in two patients when the tube was not correctly placed back on the Holter pump during a change in apparatus. One of these two patients (birth weight 567 Gin.) died at 9 days of age; autopsy findings included hyaline membrane disease, pulmonary hemorrhage, and pneumonia (Candida albicans). The other patient (birth weight 1,200 Gm.) responded to tracheal lavage and antibiotic therapy and recovered. None of these complications has recurred. Eight of 46 patients' nasojejunal tubes clogged, but in 6 of these 8 the plug was dislodged by applying pressure at the stopcock with a syringe filled with 0.45 per cent saline; however, 2 of the 8 required removal of the tube. Reinsertion of the nasojejunal tube was required, therefore, in 2 of 46 (4.3 per cent) because the tube was clogged. There was no relation between duration of feeding and blockage of the feeding tube. Only 3 of 46 infants (6.5 per cent) failed to gain weight while receiving nutritional support entirely by jejunal alimentation. Two of them died within 72 hours of life, both with hyaline membrane disease and intraventricular cerebral hemorrhage. The third infant, who had a birth weight of 680 Gm., died at 13 days of age with hyaline mem-
960
Cheek and Staub
The Journal o/ Pediatrics June 1973
2000
2000
1750
1750,
.t7 1500 ~ . . . ~
~
~
/
J ~
1500
18s
0 Z_. 1250,
0 z
1250
IOOG
100l~
750j!
750
500i
10
20
500
,.
10
AGE IN DAYS Fig. 2. Dancis graph~ demonstrating weight gain of Cases 7, 8, 10, I8, and 19 begun on nasojejunal alimentation within the first 72 hours of life. Atl had birth weights < 1,500 Gin.
AGE IN DAYS Fig. 3. Dancis graph ~ demonstrating weight gain of Cases 9, 11, and 17. Ali had birth weights 1,500 Gm., required assisted ventilation, and were begun on nasojejunal feedings within the first 72 hours of life.
brane disease, generalized peritonitis (Candida albicans), and Acintobacter anitratus sepsis. All other infants gained weight without evidence of circulatory overload or peripheral edema. Fig. 2 shows examples of the weight gain of 5 infants with birth weights of 1,500 Gin. or less in whom nasojejunal feedings were begun within the first 72 hours of life. 4 Fig. 3 demonstrates the weight gain in 3 other infants with birth weights of 1,500 Gm. or less who required ventilatory support. The weight gain for Case 11 was not as great as the others because of a patent ductus arteriosus which required surgical ligation at 31 days of age. All of these infants were maintained in an anabolic state despite being critically ill, and all survived.
ing an anabolic state 9 and improving later mental function? ~ Peripheral intravenous alimentation, ~1 gavage feedings, 12 and total intravenous alimentation TM 1, are all associated with higher rates of serious complication than is the nasojejunaI method of maintaining adequate nutritional support. Since all of our patients were sick, it is difficult to accurately compare our results with other reports dealing with normal premature or fullterm infants. In addition to the provision of adequate fluid and nutrients by a method relatively free from serious complications, the jejunal feedings offer the following advantages: (1) reduction in the time required by personnel for feeding purposes, (2) reduction in disturbance to the patient, (3) presentation of a greater quantity of calories without danger of gastric distension and vagal stimulation, (4) diminution of the chance of aspiration as compared to that with garage feeding, (5) elimination of the chance of osmotic or volume o v e r l o a d a s seen in the parenteral alimentation methods, (6) ability to increase calories supplied without the risk of patient fatigue, (7) absence of bradycardia caused by feeding, and (8) the economic considera-
COMMENT Most authorities now agree that delay in the administration of adequate fluids and calories to a premature or ill full-term infant decreases the infant's chance of survivaP' 6; if starvation is prolonged, a poorer quality of life probably results even if the patient lives. 7,8 The nasojejunal method of alimentation provides the high nutrient requirements which are important to achiev-
Volume 82 Number 6
tion that the cost of maintaining a patient on formula feedings is much smaller than the cost of parenteral alimentation. Several precautions should be observed when the nasojejunal method is used. Since the osmolarity of the fluid which normally traverses the jejunum is nearly isotonic and the "dumping syndrome" may be observed when hypertonic fluids are infused, 16 it is imperative to maintain the materials infusing the jejunum as nearly isotonic to plasma as possible. Thus in the infants under 1,200 Gm. and with gestational ages of less than 31 weeks, it is advisable to begin jejunal feedings with 13 cal. per ounce of formula or 5 per cent dextrose in water (278 mOsm. per liter) and gradually increase to the higher osmolality formulas (20 cal. per ounce = 300 mOsm. per liter, and 24 cal. per ounce = 369 mOsm. per liter). Reflux of fluid occurs proximal to the infusion site in all areas of the bowel. 17 The mean percentage of reflux decreases from 20.9 per cent for duodenal infusion to 3.6 per cent for upper jejunal infusion? 8 Therefore, the more distal the infusion site is to the pylorus, the less chance there is of reflux of fluid. There is little recycling of refluxed fluid from the stomach back into the duodenum, so placement of a nasogastric tube for intermittent aspiration may become necessary if the feeding tube is in the duodenum when feedings are begun. 19 We suggest employing nasojejunal feedings in premature infants of less than 35 weeks' gestation to minimize the possible risks involved in gavage or parenteral feedings. In addition, the jejunal method should be strongly considered for sick premature infants of 35 weeks or more gestational age and for sick full-term infants who have clinical conditions which would be aggravated by oral, nipple, or gavage feedings. We believe central venous or peripheral parenteral nutrition should only be considered in the treatment of ill newborn infants when it is impossible to provide nutrition by the gastrointestinal route. Since this is a new method, a larger number of controlled clinical trials from other
Nasojejunal /eeding
96 1
units will be needed to confirm our findings. Follow-up studies are planned, but it now appears that since weight, head circumference, and length have increased appropriately while infants are on nasojejunal feedings, the possibility of permanent retardation of brain development due to postnatal malnutrition is unlikely. REFERENCES
1. Rhea, J. W., Graham, A. W., Jr., Akhnoukh, F., and Parthew, C. T.: Effect of hyperbaric oxygenation on neonatal tetanus, J. PXDIATR. 71: 33, 1967. 2. Rhea, J. W., and Kilby, J. O.: A naso-jejunal tube for infant feeding, Pediatrics 46: 36, 1970. 3. Usher, R., Mclean, F., and Scott, K. E.: Judgment of fetal age. II. Clinical significance of gestational age and an objective method for its assessment, Pediatr. Clin. North Am. 13: 835, 1966. 4. Dancis, J., O'Connell, J. R., and Holt, L. E., Jr.: Grid for recording the weight of premature infants, J. PEDIATR.33: 570, 1948. 5. Gleiss, J.: Zum Fruhgeboren enproblem tier Gegenwart. IX. Mitteilung, Z. Kinderheilk. 76: 261, 1955. 6. Auld, P. A. M., Bhangananda, P., and Mehta, S.: The influence of early caloric feeding with intravenous glucose on catabolism of premature infants, Pediatrics 37: 592, I966. 7. Lubchenco, L. O., Delivoria-Papadopoulos, M., Butterfield, L. J., French, J. H., Metealf, D., Hix, I. E., Jr., Danick, J., Dodds, J., Downs, M., and Freeland, M. A.: Long-term follow-up studies of prematurely born infants. I. Relationship of handicaps to nursery routines, J. Pediatr. 80: 501, 1972. 8. Drillen, C. M.: The growth and development of the prematurely born infant, Baltimore, 1963, The Williams & Wilkins Company. 9. Babson, S. G.: Feeding the low-birth-weight infant, J. PEDIATR. 79: 694, 1971. 10. Winick, M.: Malnutrition and brain development, J. PEDIATR.74: 667, 1969. 11. Benda, G. I. M., and Babson, S. G.: Peripheral intravenous allmentation of the small premature infant, J. PI~DIATR.79: 494, 1971. 12. Smallpeice, V., and Davies, P. A.: Immediate feeding of premature infants with undiluted breast-milk, Lancet 2: I349, 1964. 13. Peden, V. H., and Karpel, J. T.: Total parenteral nutrition in premature infants, J. PEDIATR. 81: 137, 1972. 14. DriscolI, J. M., Jr., Heird, W. C., Schullinger, J. N., Gongaware, R. D., and Winters, R. W.: Total intravenous alimentation in low-birthweight infants: A preliminary report, J. PEDIATR. 81: 145, 1972. 15. Fordtan, J. S., and Locklear, T. W.: Ionic
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Cheek and Staub
constituents and osmolality of gastric and small intestinal fluids after eating, Am. J. Dig. Dis. 11: 503, 1966. 16. Roberts, K. E., Randall, H. T., Farr, H. W., Kidwell, A. P., McNeer, G. P., and Pack, G. T.: Cardiovascular and blood volume alteration's resulting from intrajejunal administration of hypertonic solutions to gastrectomized patients: The relationship of these changes to the dumping syndrome, Ann. Surg. 140: 631, I954.
The Journal o/ Pediatrics June 1973
17. Fordtan, J. S.: Segmental perfusion techniques, Gastroenterology 56: 987, 1969. 18. Gustke, R. F., Varma, R. R., and Soergel, K. H.: Gastric reflux during perfusion of the proximal small bowel, Gastroenterology 59: 890, 1970. 19. Go, V. L. H., Hoffman, A. F., and Summerskill, W. H. J.: Simultaneous measurement of total pancreatic, biliary, and gastric outputs in man using a perfusion technique, Gastroenterology 58: 32i, 1870.
955
Nasol'ejunal alimentation for premature and full-term newborn infants Thirty-six ill premature (mean gestation 32.8 weeks, mean birth weight 1,624 Gin.) and 10 sick, lull-term, newborn in/ants received continuous infusions of formula by nasojejunal aIimentation as a means of total nutritional support for periods of 2 to 75 days. In the premature infants the mean duration of nasojejunal feedings was 20.1 days, and the mean weight gain was 17.3 Gin. per day. The mean of the maximum rate of infusion was 145.8 ml. per kilogram per day with corresponding mean caloric intake of 113.6 cal. per kilogram per day and protein intake of 2.9 Gin. per kilogram per day. Only 3 of 46 infants (6.5 per cent) failed to gain weight while receiving sole nutritional support by jejunal alimentation; 2 of them died within 72 hours of age with hyaline membrane disease and intraventricular cerebral hemorrhages, and the third infant died at age 13 days (birth weight 680 Gin.) with hya!ine membrane disease. The mean duration of infusion for the sick full-term infants was 10.8 days; their mean weight gain was 18.3 Gin. per day. No significant alterations were observed in serial determinations of blood glucose, of serum calcium, sodium, potassium, blood urea nitrogen, and osmolaIity, or of hemogram during jejunal infusion. No abnormalities were noted in urinary or fecal output and analysis.
j . Allan Cheek, Jr., M.D., ~ a n d G e r a l d F. Staub, M.D., R o c k f o r d , lll.
R H EA and associates, 1 in 1967, first rep o r t e d the use of nasojejunal feedings as a means of nutritional support in newborn infants with tetanus; in 1970, R h e a a n d K i l b y 2 described their method. W e have employed a modification of their m e t h o d for From the Rockford Regional Neonatal Center, Division of Neonatology, Department of Pediatrics, Rockford Memorial Hospital, and the University of Illinois Rockford School of Medicine. ~'Address: Rockford Regional Neonatal Center, 2400 N. Rockton Ave., Rockford, III. 61103.
the nasojejunal feeding of sick p r e m a t u r e a n d term newborn infants. O u r experience using this m e t h o d in 46 infants is detailed in this paper. ~' MATERIALS
AND
METHODS
All of the infants in this study were critically ill shortly after birth and were a d m i t ted to the high-risk unit from either the ~Detailed clinical data will be furnished upon request by Dr. Cheek. Vol. 82, No. 6, pp. 955-962
956
Cheek and Staub
The Journal of Pediatrics June 1973
Fig. 1. A, Case 17 (lowest weight 1,106 Gin.) demonstrating nasojejunal system. Arrows point to Soluset reservoir filled with formula and Holter pump with feeding line to patient. Note cotton gauze mittens. B, Same patient at 54 days of age (weight 1,573 Gm.). C, Maternal-infant eye-to-eye contact while on nasojejunal alimentation.
Rockford Memorial Hospital delivery room or regional hospitals. Thirty-six premature infants with gestational ages of less than 37 weeks (calculated from the first day of the mother's last menstrual period rounded to the nearest week and by physical examination of the infant 3) and ten full-term infants were selected for nasojejunal feeding because they were unable to tolerate oral feedings for at least one of the following conditions: (l) respiratory distress syndrome, (2) neonatal asphyxia with an Apgar score of less than 7 and requiring resuscitation at birth, (3) neonatal seizures with inability to coordinate sucking and swallowing, (4) clinical a n d / o r laboratory evidence of sepsis, or (5) congenital heart disease. Immediately after the initial clinical evaluation and emergency procedures were performed, a cardiotach monitor (V. MuellerMM2100) was connected to the patient for continuous monitoring of heart rate. The length of insertion of the nasojejunal tube was then estimated by measuring the distance from the glabella to the stretched-out heel; this spot was marked on a radiopaque polyvinyl chloride Argyle No. 5 French 36 inch feeding tube (inside diameter 0.037 inch, outside diameter 0.063 inch). The tube was then inserted through the nostril into the
stomach while the monitor was observed for bradycardia. The following criteria were used to indicate that the tube had not entered the trachea: (1) no exacerbation of existing respiratory difficulty, and (2) auscultation over the stomach area while 3 to 5 c.c. of air was injected with a syringe. After being certain that the stomach had been entered, it was aspirated and, if conditions permitted, the patient was placed on his right side to facilitate passage of the tube through the pylorus. The feeding tube was inserted until the previously measured mark was reached. The protruding end of it was secured to the face with adhesive tape in such a way so as not to cause pressure necrosis or irritation or block the nasal canal. Finally, it was strapped to the cheek or forehead by plastic adhesive tape. Occasionally, soft cotton gauze mittens were placed over the infant's hands to prevent him from dislodging the tube. When bile was obtained through the feeding tube and the fluid had a p H of 5 to 7, abdominal and chest posteroanterior and lateral roentgenograms were obtained to insure that the tube was at the ligament of Treitz before feedings were begun. Either a 250 c.c. Soluset (Abbott P-250) or a 30 c.c. plastic disposable Luer-Lok syringe (Becton-Dickerson) was used as the
Volume 82 Number 6
Nasojejunal feeding
957
Table I. Summary of outcome of infants receiving nasojejunal feeding Birth weight (Gin.)
Gestation (wk.)
No. of patients
No. survived
Per cent survival
26-30 29-35 34-36 36 Totals
6 13 15 2 36
3 11 15 2 31
50 84.6 100 100 86.1
> 36 > 36 Totals
1 9 10
1 8 9
100 88.8 90
Premature infants
567-992 1,021-1,500 1,55'9-2,381 > 2,500 Full-term infants
< 2,500 > 2,500
Table II. Summary of data during the first 72 hours of life on jejunal feeding
Period
No. of patients
Mean gestation (wk.)
First 24 hr. First 72 hr.
15 22
32.3 33
Mean birth weight (Gin.)
Mean weight loss (%)
1,460 1,311
6.0 8.8
reservoir for the fluid. The Soluset or syringe was connected to the p u m p tubing of a Holter pump (Model No. 903, 907, or 912) for continuous infusion. The proximal end of the Holter pump tubing was subsequently connected to a disposable, nonpyrogenic, 3 way T o m a c stopcock (American Hospital Supply K-75). The nasojejunal feeding tube was then connected to the other end of the stopcock. The desired formula or fluid was delivered at room temperature to the infant by continuous infusion at a rate which would provide the desired amounts of fluid and calories. The osmolarity of the infusion fluid ranged from 278 to 369 mOsm. per liter. Similac or SMA, 24 cal. per ounce (osmolarity 369 mOsm. per liter), was used for most premature infants to provide 60 to 180 ml. or 48 to 144 cal. per kilogram per day. However, several very small infants with birth weights of less than 1,200 Gm. and gestational ages of less than 31 weeks were initially given 5 per cent dextrose in water (278 mOsm. per liter) while their jejunal osmolarity tolerance was determined by monitoring the clinical condition and serum osmolality. After establishing their jejunal os-
Mean rate Mean caloric I Mean proof infusion intake ] tein intake (ml./Kg./ (cal./Kg./ ( Gra./ K g./ day) day) day) I
98.3 105.2
72 76.3
1.7 1.9
molarity tolerance, the jejunal feedings were slowly increased to 24 cal. per ounce as tolerated. The Soluset or syringe apparatus was monitored for bacteria and changed at least every fifth day, but the nasojejunal tubes were not changed routinely; one remained in situ for 10 89 weeks without causing any problem. While the feeding tube was in place, our nursing staff and parents stimulated the infant by touching or handling as often as possible (Fig. 1, A, B, and C). Base-line and serial measurements of head circumference, length, body weight, hemoglobin, hematocrit, and white blood ceil count were obtained, as well as microanalysis of serum sodium, potassium and calcium, blood urea nitrogen, capillary serum osmolality, urine osmolality, and blood glucose concentration. Urine studies of pH, sugar, acetone, and protein and microscopic examination for casts, cells, and bacteria were also carried out. Frequent random stool examinations {or occult blood, fat content, and bacterial culture were performed; stool frequency and consistency were recorded by the nurses. All infants were treated appropriately for
958
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The Journal of Pediatrics June 1973
Table I I I . General course during nasojejunal feedings in premature and full-term infants Weight In[ants 36 Premature Mean (• S.D.) 10 Full-term Mean (• S.D.)
GestationM age (wk.)
Birth weight (Gin.)
Lowest weight (Gin.)
32.8 (0.5)
1,624.4 (82.5)
1,518.8 (84.1)
I0
20.1 (9.7)
39.0 (0.4)
3,339.8 (202.9)
3,i38.5 (149.3)
6
10.8 (2.3)
their underlying conditions. Umbilical artery or vein catheters were often used during the first 72 to 96 hours of life for monitoring, for blood transfusions, and for antibiotic therapy when indicated. These catheters were not used as a means of nutritional support in any of the infants. A surgical approach was employed to insert the feeding tube into the jejunum of 5 premature infants when attempts to pass the tube through the nasojejunal route were unsuccessful; in 4 of the 5 approaches gastrostomies were performed with insertion of the jejunal tube via the stomach. Upon reaching a postconceptual age of 35 weeks, all premature infants were assessed with respect to feasibility and safety of beginning oral formula feedings by nipple. When the clinical condition improved in ill full-term infants, they were also reevaluated for institution of nipple feedings. When oral feedings were initiated in these infants, the jejunal infusion rate was proportionately decreased and then discontinued when adequate fluid and caloric intake with nipple feedings was possible. The jejunal infusion was stopped for 30 minutes before and after the initiation of each nipple feeding. In order to avoid clogging of the feeding tube during the discontinuation of feeding, the polyvinyl tube was flushed with 1 c.c. of 0.45 per cent saline, and the stopcock toward the patient was closed until jejunal tube feedings were restarted. The stopcock also provided a means of giving medications through the feding tube. When used for this purpose, the tube was flushed as described above after administration of the medication.
lOSS
(%)
Duration (days)
The data listed in this report are limited to the period of jejunal alimentation. RESULTS
Nine of 10 (90 per cent) sick full-term infants survived while receiving nutritional support by jejunal feedings, and 31 of 36 (86 per cent) sick premature infants survived (Table I ) . Autopsies were performed on all patients who died, and no death could be attributed directly to the method used for nutrition. However, one infant with a birth weight of 680 Gm. in whom a jejunostomy was performed for jejunal feeding did have leakage of formula at the surgical site, with generalized peritonitis found at autopsy following death at 13 days of age. After this experience, jejunostomy was abandoned as a surgical approach, and the jejunal feeding tube was placed via a gastrostomy without complications in 4 other patients. In 22 of 36 premature infants (61 per cent) jejunal feedings could be initiated during the first 72 hours of life. Their mean gestational age was 33 weeks and mean birth weight was 1,311 Gm. During the first 72 hours of life these infants received a mean infusion of 105 ml. per kilogram per day providing 76 calories per kilogram per day and 1.9 Gm. of protein per kilogram per day. Their mean lowest weight indicated an average weight loss of 8.8 per cent (Table I I ) . It took only 13 days for these infants to regain their birth weights. Unfortunately nitrogen balance studies were not performed during this early catabolic period. Table I I I summarizes the data for age, birth weight, lowest weight, percentage of total weight loss, duration of feeding, final
Volume 82 .Number 6
NasojejunaI [eeding
Rate o[ infusion (ml./Kg./day)
Caloric intake (cal./Kg./day) Minimum ] Maximum
959
Protein intake (Gm./Kg./day) Minimum I Maximum
Final weight (Gm.)
Weight gain (Gm./day)
1,866.6 (95.6)
17.3 (1.4)
109.1 (4.3)
145.8 (4.2)
79.4 (4.3)
113.6 (3.4)
2.i (0.1)
2.9 (0.1)
3,331.7 (214.8)
18.3 (5.3)
88.0 (6.1)
124.0 (5.5)
67.3 (6.0)
97.0 (4.0)
1.8 (0.2)
2.4 (0.1)
Minimum ]Maximum
weight, weight gain, rate of infusion, and caloric and protein intake during the total duration of jejunal alimentation for the 36 premature and 10 full-term infants. For the premature infants it was possible to give 146 c.c. of formula per kilogram per day providing 114 cal. per kilogram per day and 2.9 Gm. of protein per kilogram per day. Excellent utilization of nutrients is indicated by the mean weight gain of 17.3 Gm. per day in these premature infants. The head circumference and length of these infants also increased during the period of jejunal feedings. Except for initial abnormalities secondary to the underlying critical clinical condition, all laboratory and clinical parameters remained within expected normal ranges for premature and full-term infants during the entire course of nasojejunal alimentation. Loose stools, lethargy, poor muscle tone, gray mottled color, excessive apnea, edema, dehydration, nephropathy, or late metabolic acidosis were not observed in our infants after their initial underlying condition was corrected. COMPLICATIONS None of the 46 infants had nasal infections caused by the in situ nasojejunal tubes; however, 2 infants were found to have Staphylococcus aureus, which was coagulase positive on nasal cultures done at the time the tubes were withdrawn from the nose. Neither of these infants presented problems; both were successfully treated by intranasal instillation of Neosporin. No patient had pressure necrosis or any deterioration in respiratory function attributable to the nasal
tube. Three infants (6.5 per cent) had serious complications during the early refinements of this modified method, all technical in nature. One patient (birth weight 680 Gin.) had generalized peritonitis secondary to leakage of formula from a jejunostomy site; at autopsy hyaline memb r a n e disease and lobar pneumonia were also found. Aspiration of infusing formula caused by a "blast" of fluid occurred in two patients when the tube was not correctly placed back on the Holter pump during a change in apparatus. One of these two patients (birth weight 567 Gin.) died at 9 days of age; autopsy findings included hyaline membrane disease, pulmonary hemorrhage, and pneumonia (Candida albicans). The other patient (birth weight 1,200 Gm.) responded to tracheal lavage and antibiotic therapy and recovered. None of these complications has recurred. Eight of 46 patients' nasojejunal tubes clogged, but in 6 of these 8 the plug was dislodged by applying pressure at the stopcock with a syringe filled with 0.45 per cent saline; however, 2 of the 8 required removal of the tube. Reinsertion of the nasojejunal tube was required, therefore, in 2 of 46 (4.3 per cent) because the tube was clogged. There was no relation between duration of feeding and blockage of the feeding tube. Only 3 of 46 infants (6.5 per cent) failed to gain weight while receiving nutritional support entirely by jejunal alimentation. Two of them died within 72 hours of life, both with hyaline membrane disease and intraventricular cerebral hemorrhage. The third infant, who had a birth weight of 680 Gm., died at 13 days of age with hyaline mem-
960
Cheek and Staub
The Journal o/ Pediatrics June 1973
2000
2000
1750
1750,
.t7 1500 ~ . . . ~
~
~
/
J ~
1500
18s
0 Z_. 1250,
0 z
1250
IOOG
100l~
750j!
750
500i
10
20
500
,.
10
AGE IN DAYS Fig. 2. Dancis graph~ demonstrating weight gain of Cases 7, 8, 10, I8, and 19 begun on nasojejunal alimentation within the first 72 hours of life. Atl had birth weights < 1,500 Gin.
AGE IN DAYS Fig. 3. Dancis graph ~ demonstrating weight gain of Cases 9, 11, and 17. Ali had birth weights 1,500 Gm., required assisted ventilation, and were begun on nasojejunal feedings within the first 72 hours of life.
brane disease, generalized peritonitis (Candida albicans), and Acintobacter anitratus sepsis. All other infants gained weight without evidence of circulatory overload or peripheral edema. Fig. 2 shows examples of the weight gain of 5 infants with birth weights of 1,500 Gin. or less in whom nasojejunal feedings were begun within the first 72 hours of life. 4 Fig. 3 demonstrates the weight gain in 3 other infants with birth weights of 1,500 Gm. or less who required ventilatory support. The weight gain for Case 11 was not as great as the others because of a patent ductus arteriosus which required surgical ligation at 31 days of age. All of these infants were maintained in an anabolic state despite being critically ill, and all survived.
ing an anabolic state 9 and improving later mental function? ~ Peripheral intravenous alimentation, ~1 gavage feedings, 12 and total intravenous alimentation TM 1, are all associated with higher rates of serious complication than is the nasojejunaI method of maintaining adequate nutritional support. Since all of our patients were sick, it is difficult to accurately compare our results with other reports dealing with normal premature or fullterm infants. In addition to the provision of adequate fluid and nutrients by a method relatively free from serious complications, the jejunal feedings offer the following advantages: (1) reduction in the time required by personnel for feeding purposes, (2) reduction in disturbance to the patient, (3) presentation of a greater quantity of calories without danger of gastric distension and vagal stimulation, (4) diminution of the chance of aspiration as compared to that with garage feeding, (5) elimination of the chance of osmotic or volume o v e r l o a d a s seen in the parenteral alimentation methods, (6) ability to increase calories supplied without the risk of patient fatigue, (7) absence of bradycardia caused by feeding, and (8) the economic considera-
COMMENT Most authorities now agree that delay in the administration of adequate fluids and calories to a premature or ill full-term infant decreases the infant's chance of survivaP' 6; if starvation is prolonged, a poorer quality of life probably results even if the patient lives. 7,8 The nasojejunal method of alimentation provides the high nutrient requirements which are important to achiev-
Volume 82 Number 6
tion that the cost of maintaining a patient on formula feedings is much smaller than the cost of parenteral alimentation. Several precautions should be observed when the nasojejunal method is used. Since the osmolarity of the fluid which normally traverses the jejunum is nearly isotonic and the "dumping syndrome" may be observed when hypertonic fluids are infused, 16 it is imperative to maintain the materials infusing the jejunum as nearly isotonic to plasma as possible. Thus in the infants under 1,200 Gm. and with gestational ages of less than 31 weeks, it is advisable to begin jejunal feedings with 13 cal. per ounce of formula or 5 per cent dextrose in water (278 mOsm. per liter) and gradually increase to the higher osmolality formulas (20 cal. per ounce = 300 mOsm. per liter, and 24 cal. per ounce = 369 mOsm. per liter). Reflux of fluid occurs proximal to the infusion site in all areas of the bowel. 17 The mean percentage of reflux decreases from 20.9 per cent for duodenal infusion to 3.6 per cent for upper jejunal infusion? 8 Therefore, the more distal the infusion site is to the pylorus, the less chance there is of reflux of fluid. There is little recycling of refluxed fluid from the stomach back into the duodenum, so placement of a nasogastric tube for intermittent aspiration may become necessary if the feeding tube is in the duodenum when feedings are begun. 19 We suggest employing nasojejunal feedings in premature infants of less than 35 weeks' gestation to minimize the possible risks involved in gavage or parenteral feedings. In addition, the jejunal method should be strongly considered for sick premature infants of 35 weeks or more gestational age and for sick full-term infants who have clinical conditions which would be aggravated by oral, nipple, or gavage feedings. We believe central venous or peripheral parenteral nutrition should only be considered in the treatment of ill newborn infants when it is impossible to provide nutrition by the gastrointestinal route. Since this is a new method, a larger number of controlled clinical trials from other
Nasojejunal /eeding
96 1
units will be needed to confirm our findings. Follow-up studies are planned, but it now appears that since weight, head circumference, and length have increased appropriately while infants are on nasojejunal feedings, the possibility of permanent retardation of brain development due to postnatal malnutrition is unlikely. REFERENCES
1. Rhea, J. W., Graham, A. W., Jr., Akhnoukh, F., and Parthew, C. T.: Effect of hyperbaric oxygenation on neonatal tetanus, J. PXDIATR. 71: 33, 1967. 2. Rhea, J. W., and Kilby, J. O.: A naso-jejunal tube for infant feeding, Pediatrics 46: 36, 1970. 3. Usher, R., Mclean, F., and Scott, K. E.: Judgment of fetal age. II. Clinical significance of gestational age and an objective method for its assessment, Pediatr. Clin. North Am. 13: 835, 1966. 4. Dancis, J., O'Connell, J. R., and Holt, L. E., Jr.: Grid for recording the weight of premature infants, J. PEDIATR.33: 570, 1948. 5. Gleiss, J.: Zum Fruhgeboren enproblem tier Gegenwart. IX. Mitteilung, Z. Kinderheilk. 76: 261, 1955. 6. Auld, P. A. M., Bhangananda, P., and Mehta, S.: The influence of early caloric feeding with intravenous glucose on catabolism of premature infants, Pediatrics 37: 592, I966. 7. Lubchenco, L. O., Delivoria-Papadopoulos, M., Butterfield, L. J., French, J. H., Metealf, D., Hix, I. E., Jr., Danick, J., Dodds, J., Downs, M., and Freeland, M. A.: Long-term follow-up studies of prematurely born infants. I. Relationship of handicaps to nursery routines, J. Pediatr. 80: 501, 1972. 8. Drillen, C. M.: The growth and development of the prematurely born infant, Baltimore, 1963, The Williams & Wilkins Company. 9. Babson, S. G.: Feeding the low-birth-weight infant, J. PEDIATR. 79: 694, 1971. 10. Winick, M.: Malnutrition and brain development, J. PEDIATR.74: 667, 1969. 11. Benda, G. I. M., and Babson, S. G.: Peripheral intravenous allmentation of the small premature infant, J. PI~DIATR.79: 494, 1971. 12. Smallpeice, V., and Davies, P. A.: Immediate feeding of premature infants with undiluted breast-milk, Lancet 2: I349, 1964. 13. Peden, V. H., and Karpel, J. T.: Total parenteral nutrition in premature infants, J. PEDIATR. 81: 137, 1972. 14. DriscolI, J. M., Jr., Heird, W. C., Schullinger, J. N., Gongaware, R. D., and Winters, R. W.: Total intravenous alimentation in low-birthweight infants: A preliminary report, J. PEDIATR. 81: 145, 1972. 15. Fordtan, J. S., and Locklear, T. W.: Ionic
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constituents and osmolality of gastric and small intestinal fluids after eating, Am. J. Dig. Dis. 11: 503, 1966. 16. Roberts, K. E., Randall, H. T., Farr, H. W., Kidwell, A. P., McNeer, G. P., and Pack, G. T.: Cardiovascular and blood volume alteration's resulting from intrajejunal administration of hypertonic solutions to gastrectomized patients: The relationship of these changes to the dumping syndrome, Ann. Surg. 140: 631, I954.
The Journal o/ Pediatrics June 1973
17. Fordtan, J. S.: Segmental perfusion techniques, Gastroenterology 56: 987, 1969. 18. Gustke, R. F., Varma, R. R., and Soergel, K. H.: Gastric reflux during perfusion of the proximal small bowel, Gastroenterology 59: 890, 1970. 19. Go, V. L. H., Hoffman, A. F., and Summerskill, W. H. J.: Simultaneous measurement of total pancreatic, biliary, and gastric outputs in man using a perfusion technique, Gastroenterology 58: 32i, 1870.