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Nasojejunal feeding: A commentary
July 1974 The Journal o f P E D I A T R I C S
111
Nasojejunalfeeding: A commentary William C. Heird, M.D.,* New York, N. Y.
THE LIKELIHOOD of a r e l a t i o n s h i p b e t w e e n early malnutrition and permanent retardation of brain growth, TM coupled with the observation that early feeding o f t h e p r e m a t u r e i n f a n t was a s s o c i a t e d w i t h decreased morbidity, 5 has r e s u l t e d i n an enhanced interest in i m p r o v e m e n t of nutrition o f the low-birthweight infant. Since there is little evidence to indicate that currently available nutritional mixtures (i.e., various prepared formulas) are inadequate, and since delivery of nutrients to premature infants has been a long-standing problem, most of the work in this area has centered on methods of delivering nutrients. One of the most recently advocated methods is continuous n a s o j e j u n a l i n f u s i o n s of various formulas. 68 This method was described initially by Rhea and colleagues.6, 7 More recently, its successful use in management of a large number of infants was reported by Cheek and Staub. 8 Since their enthusiastic endorsement of the method, it has been adopted by many institutions for delivering nutrients to premature infants. This issue of THE JOURNAL contains three articles and one letter concerning continuous nasojejunal feeding. The first reports an improvement of the method. 9 Two subsequent articles describe complications associated with it; one describes intestinal perforation resulting apparently from the nasojejunal tube ~~and the other rep o r t s various g a s t r o i n t e s t i n a l complications. 1~ Dr. Challacombe's lz observations as outlined in his Letter to t h e Editor, although not related directly to nasojejunal feeding, raise several interesting theoretical aspects of this feeding method. It is disturbing that three of the communications report actual or potential complications of the method. In
From the Department o f Pediatrics, Columbia University College o f Physicians & Surgeons, and Babies Hospital, Columbia-Presbyterian Medical Center. *Reprintaddress:Department of Pediatrics. 630 W. 168thSt., New York,N. Y. 10032
a d d i t i o n , the fact that an " i m p r o v e d " m e t h o d was needed suggests that difficulties with the described approach have been encountered. It can be argued that the complications of duodenal perforation m, ll did not result specifically from the method of feeding but rather from a technical mistake in m a n i p u l a t i o n of the feeding tube. M o r e o v e r , it is unlikely that this "mistake" would have resulted in perforation were it not for the fact that the tubes currently used for continuous nasojejunal feeding become more rigid after a short period of use. Although few of the complications reported by Chen and Wong can be related absolutely to the method of n a s o j e j u n a l feeding, a c a u s e - a n d - e f f e c t r e l a t i o n s h i p seems likely. Our experience with nasojejunal feeding in very small infants further supports the likelihood of such a relationship. Four of the first 30 patients in whom this method of feeding was used developed necrotizing enterocolitis and a number of other infants developed abdominal distention, vomiting, and/or diarrhea (sometimes containing blood) which resolved after withdrawal of the nasojejunal tube and discontinuation of feedings. 13 Dr. C h a l l a c o m b e ' s o b s e r v a t i o n of a change in the small intestinal flora following insertion of an indwelling tube may explain the increased incidence of gastrointestinal complications that has been observed. A quantitative, and probably a qualitative, change in the flora of the g a s t r o i n t e s t i n a l tract has several possible conseq u e n c e s - e . g . , deconjugation of the bile acids; hydroxylation of fatty acids; metabolism o f ingested (or infused) nutrients. 14 All of these could result in the gastrointestinal sYmptoms that have been described. In addition, the presence o f a b n o r m a l o r g a n i s m s in the upper gastrointestinal tract poses an interesting theoretic question of an entirely different nature. Does this situation make the infant more vulnerable to systemic infection as may be the case with abnormal nasopharygeal flora15? It is likely that the articles reporting complications of
Vol. 85, No. 1, pp. 111-112
112
Heird
nasojejunal feeding have greater significance than merely to make those using the method aware of its possible hazards. Possibly they are the forerunners of many such reports that will appear over the next few months. If so, it is likely that this method of feeding will be abandoned and its potential usefulness will be jeopardized. Such a situation might be unfortunate. It should be recalled that the majority of patients in both earlier series of nasojejunal feeding weighed more than 1,500 gm. 68 The complications, on the other hand, seem to be more prevalent in smaller infants. Thus, it can be speculated that continuous nasojejunal feeding, although not solving all the difficulties of providing nutrients to all low-birth-weight infants, is one of the methods by which better nutrition of this group of patients can be achieved. The key to its future role in nutrition of low-birth-weight infants, as with other clinical procedures, will be patient selection. Perhaps the greatest significance of the fact that the latest "panacea" for feeding premature infants is associated with more complications than initially observed is to raise two very important questions: (1) How critically should new feeding techniques for low-birth-weight infants be evaluated before their use becomes widespread, as has occurred with nasojejunal feedings? (2) Should the reasons for concern about adequate nutrition for lowbirth-weight infants be re-evaluated? Neither of these questions can be answered completely at the present time. As has been mentioned previously, evaluation of feeding methods is very difficult and probably requires the collaborative efforts of several institutions.16 The need for an answer to the second question, perhaps, is more crucial; in fact, the answer to this question is the probable key to answering the first question. The importance of some nutrition in terms of immediate survival cannot be questioned, but is maintenance of the intrauterine growth rate necessary? Or is there evidence that a short period of suboptimal nutrition is associated with deleterious effects? Recent studies indicate that cellular proliferation of the human central nervous system continues for up to 18 m o n t h s or longer. 17 Furthermore, it is not clear that poor nutrition during a brief portion of this period will alter subsequent brain development. Indeed, it has been shown that "catch-up" growth of various animal organs occurs following a period of poor nutrition, provided adequate nutrition is reinstituted while the capability of cell division still exists. 18
The Journal o f Pediatrics July 1974
Thus the present state of knowledge regarding this area suggests that perhaps it would be safer to exercise more caution in acceptance of new feeding methods for premature infants, especially very small premature infants. REFERENCES
1. Winick, M., and Noble, A.: Cellular response in rats during malnutrition at various ages, J. Nutr, 89: 3, 1966. 2. Winick, M.: Malnutrition and brain development, J. PEDIATR.74: 667,1969. 3. Winick, M., and Rosso, P.: Head circumference and cellular growth of the brain in normal and marasmic children, J. PED1ATR.74: 774, 1969. 4. Hertzig, M. E., Birch, H. G., Richardson, S. A., and Tizard, J.: Intellectual levels of school children severely malnour ished during the first two years of life, Pediatrics 49: 814, 1972. 5. Auld, P. A. M., Bhangananda, P., and Mehta, S.: The influence of early caloric intake with IV glucose on catabolism of premature infants, Pediatrics 37: 592, 1966. 6. Rhea, J. W., and Kilby, J. O.: A nasojejunal tube for infant feeding, Pediatrics 46: 36, 1970. 7. Rhea, J. W., Ghazzawi, O., and Weidman, W.: Nasojejunal feeding: An improved device and intubation technique, J. PEDIATR.82: 951, 1973. 8. Cheek, J. A., Jr., and Staub, G. F.: Nasojejunal alimentation for premature and full-term newborn infants, J. PEDIATR.82: 955, 1973. 9. LOO, S.W.H., Gross, J., and Warshaw, J. B.: Improved method of nasojejunal feeding in low-birth-weight infants, J. PEDIATR.85: 104, 1974. 10. Boros,S. J., and Reynolds, J. W.: Duodenal perforation: A complication of neonatal transpyloric tube feeding, J. PEDIATR. 85: 107, 1974. 11. Chert, J. W., and Wong, P. W. K.: Intestinal complications of nasojejunal feeding in low-birth-weight infants, J. PED1ATR.85: 109, 1974. 12. ChaUacombe, D. N.: Bacterial microflora in infants receiving nasojejunal tube feeding (Letter to the Editor), J. PEDIATR.85: 113, 1974. 13. Meier, W. A., and Heird, W. C.: Unpublished observations. 14. Phillips, S. F.: Diarrhea: A current view of the pathophysiology, Gastroenterology 63: 495, 1972. 15. Sprunt, K., Leidy, G., and Redman, W.: Risk of infection and role of antibiotics in development of infection in a neonatal ICU (Abstract). Program of Thirteenth Inter science Conference on Antimicrobial Agents and Chemotherapy, Sept. 1973. 16. Heird, W.C.: Improved methods of non-oral neonatal feeding: Commentary, J. PEDIATR.82: 963, 1973. 17. Dobbing, J.: Later growth of the brain: Its vulnerability, Pediatrics 53: 2, 1974. 18. Winick, M., Fish, I., and Rosso, P.: Cellular recovery in rat tissues after a brief period of neonatal malnutrition, J. Nutr. 95: 623, 1968.
111
Nasojejunalfeeding: A commentary William C. Heird, M.D.,* New York, N. Y.
THE LIKELIHOOD of a r e l a t i o n s h i p b e t w e e n early malnutrition and permanent retardation of brain growth, TM coupled with the observation that early feeding o f t h e p r e m a t u r e i n f a n t was a s s o c i a t e d w i t h decreased morbidity, 5 has r e s u l t e d i n an enhanced interest in i m p r o v e m e n t of nutrition o f the low-birthweight infant. Since there is little evidence to indicate that currently available nutritional mixtures (i.e., various prepared formulas) are inadequate, and since delivery of nutrients to premature infants has been a long-standing problem, most of the work in this area has centered on methods of delivering nutrients. One of the most recently advocated methods is continuous n a s o j e j u n a l i n f u s i o n s of various formulas. 68 This method was described initially by Rhea and colleagues.6, 7 More recently, its successful use in management of a large number of infants was reported by Cheek and Staub. 8 Since their enthusiastic endorsement of the method, it has been adopted by many institutions for delivering nutrients to premature infants. This issue of THE JOURNAL contains three articles and one letter concerning continuous nasojejunal feeding. The first reports an improvement of the method. 9 Two subsequent articles describe complications associated with it; one describes intestinal perforation resulting apparently from the nasojejunal tube ~~and the other rep o r t s various g a s t r o i n t e s t i n a l complications. 1~ Dr. Challacombe's lz observations as outlined in his Letter to t h e Editor, although not related directly to nasojejunal feeding, raise several interesting theoretical aspects of this feeding method. It is disturbing that three of the communications report actual or potential complications of the method. In
From the Department o f Pediatrics, Columbia University College o f Physicians & Surgeons, and Babies Hospital, Columbia-Presbyterian Medical Center. *Reprintaddress:Department of Pediatrics. 630 W. 168thSt., New York,N. Y. 10032
a d d i t i o n , the fact that an " i m p r o v e d " m e t h o d was needed suggests that difficulties with the described approach have been encountered. It can be argued that the complications of duodenal perforation m, ll did not result specifically from the method of feeding but rather from a technical mistake in m a n i p u l a t i o n of the feeding tube. M o r e o v e r , it is unlikely that this "mistake" would have resulted in perforation were it not for the fact that the tubes currently used for continuous nasojejunal feeding become more rigid after a short period of use. Although few of the complications reported by Chen and Wong can be related absolutely to the method of n a s o j e j u n a l feeding, a c a u s e - a n d - e f f e c t r e l a t i o n s h i p seems likely. Our experience with nasojejunal feeding in very small infants further supports the likelihood of such a relationship. Four of the first 30 patients in whom this method of feeding was used developed necrotizing enterocolitis and a number of other infants developed abdominal distention, vomiting, and/or diarrhea (sometimes containing blood) which resolved after withdrawal of the nasojejunal tube and discontinuation of feedings. 13 Dr. C h a l l a c o m b e ' s o b s e r v a t i o n of a change in the small intestinal flora following insertion of an indwelling tube may explain the increased incidence of gastrointestinal complications that has been observed. A quantitative, and probably a qualitative, change in the flora of the g a s t r o i n t e s t i n a l tract has several possible conseq u e n c e s - e . g . , deconjugation of the bile acids; hydroxylation of fatty acids; metabolism o f ingested (or infused) nutrients. 14 All of these could result in the gastrointestinal sYmptoms that have been described. In addition, the presence o f a b n o r m a l o r g a n i s m s in the upper gastrointestinal tract poses an interesting theoretic question of an entirely different nature. Does this situation make the infant more vulnerable to systemic infection as may be the case with abnormal nasopharygeal flora15? It is likely that the articles reporting complications of
Vol. 85, No. 1, pp. 111-112
112
Heird
nasojejunal feeding have greater significance than merely to make those using the method aware of its possible hazards. Possibly they are the forerunners of many such reports that will appear over the next few months. If so, it is likely that this method of feeding will be abandoned and its potential usefulness will be jeopardized. Such a situation might be unfortunate. It should be recalled that the majority of patients in both earlier series of nasojejunal feeding weighed more than 1,500 gm. 68 The complications, on the other hand, seem to be more prevalent in smaller infants. Thus, it can be speculated that continuous nasojejunal feeding, although not solving all the difficulties of providing nutrients to all low-birth-weight infants, is one of the methods by which better nutrition of this group of patients can be achieved. The key to its future role in nutrition of low-birth-weight infants, as with other clinical procedures, will be patient selection. Perhaps the greatest significance of the fact that the latest "panacea" for feeding premature infants is associated with more complications than initially observed is to raise two very important questions: (1) How critically should new feeding techniques for low-birth-weight infants be evaluated before their use becomes widespread, as has occurred with nasojejunal feedings? (2) Should the reasons for concern about adequate nutrition for lowbirth-weight infants be re-evaluated? Neither of these questions can be answered completely at the present time. As has been mentioned previously, evaluation of feeding methods is very difficult and probably requires the collaborative efforts of several institutions.16 The need for an answer to the second question, perhaps, is more crucial; in fact, the answer to this question is the probable key to answering the first question. The importance of some nutrition in terms of immediate survival cannot be questioned, but is maintenance of the intrauterine growth rate necessary? Or is there evidence that a short period of suboptimal nutrition is associated with deleterious effects? Recent studies indicate that cellular proliferation of the human central nervous system continues for up to 18 m o n t h s or longer. 17 Furthermore, it is not clear that poor nutrition during a brief portion of this period will alter subsequent brain development. Indeed, it has been shown that "catch-up" growth of various animal organs occurs following a period of poor nutrition, provided adequate nutrition is reinstituted while the capability of cell division still exists. 18
The Journal o f Pediatrics July 1974
Thus the present state of knowledge regarding this area suggests that perhaps it would be safer to exercise more caution in acceptance of new feeding methods for premature infants, especially very small premature infants. REFERENCES
1. Winick, M., and Noble, A.: Cellular response in rats during malnutrition at various ages, J. Nutr, 89: 3, 1966. 2. Winick, M.: Malnutrition and brain development, J. PEDIATR.74: 667,1969. 3. Winick, M., and Rosso, P.: Head circumference and cellular growth of the brain in normal and marasmic children, J. PED1ATR.74: 774, 1969. 4. Hertzig, M. E., Birch, H. G., Richardson, S. A., and Tizard, J.: Intellectual levels of school children severely malnour ished during the first two years of life, Pediatrics 49: 814, 1972. 5. Auld, P. A. M., Bhangananda, P., and Mehta, S.: The influence of early caloric intake with IV glucose on catabolism of premature infants, Pediatrics 37: 592, 1966. 6. Rhea, J. W., and Kilby, J. O.: A nasojejunal tube for infant feeding, Pediatrics 46: 36, 1970. 7. Rhea, J. W., Ghazzawi, O., and Weidman, W.: Nasojejunal feeding: An improved device and intubation technique, J. PEDIATR.82: 951, 1973. 8. Cheek, J. A., Jr., and Staub, G. F.: Nasojejunal alimentation for premature and full-term newborn infants, J. PEDIATR.82: 955, 1973. 9. LOO, S.W.H., Gross, J., and Warshaw, J. B.: Improved method of nasojejunal feeding in low-birth-weight infants, J. PEDIATR.85: 104, 1974. 10. Boros,S. J., and Reynolds, J. W.: Duodenal perforation: A complication of neonatal transpyloric tube feeding, J. PEDIATR. 85: 107, 1974. 11. Chert, J. W., and Wong, P. W. K.: Intestinal complications of nasojejunal feeding in low-birth-weight infants, J. PED1ATR.85: 109, 1974. 12. ChaUacombe, D. N.: Bacterial microflora in infants receiving nasojejunal tube feeding (Letter to the Editor), J. PEDIATR.85: 113, 1974. 13. Meier, W. A., and Heird, W. C.: Unpublished observations. 14. Phillips, S. F.: Diarrhea: A current view of the pathophysiology, Gastroenterology 63: 495, 1972. 15. Sprunt, K., Leidy, G., and Redman, W.: Risk of infection and role of antibiotics in development of infection in a neonatal ICU (Abstract). Program of Thirteenth Inter science Conference on Antimicrobial Agents and Chemotherapy, Sept. 1973. 16. Heird, W.C.: Improved methods of non-oral neonatal feeding: Commentary, J. PEDIATR.82: 963, 1973. 17. Dobbing, J.: Later growth of the brain: Its vulnerability, Pediatrics 53: 2, 1974. 18. Winick, M., Fish, I., and Rosso, P.: Cellular recovery in rat tissues after a brief period of neonatal malnutrition, J. Nutr. 95: 623, 1968.