Nasoduodenal Versus Nasogastric Feeding in the Very Low Birthweight Infant

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Nasoduodenal

Versus

Nasogastric

Feeding

in the

Very

Low Birthweight

Infant

Micheline Van Caillie, M.D., and Geraldine K. Powell, M.D.

From the Department of Pediatrics, University of Texas Medical Branch, Galveston

ABSTRACT. The practicality, effectiveness, and safety of feeding very low birthweight infants (less than 1,300 gm) by continuous nasoduodenal infusion was assessed by compari-son with continuous nasogastric feeding. The nasoduodenal group appeared to have a clear advantage over the naso-gastric group for the overall period in terms of caloric in-take (131 cal/kg/day vs. 106 cal/kg/day), average weight gain (16 gm/day vs. 10 gm/day), and safety. This advantage was even more striking in the first two weeks of life. A ca-loric intake of 120 cal/kg/day could be reached within 48 to 72 hours after tube placement in the nasoduodenal group but only after a week in the nasogastric group.

Nasoduodenal feeding resulted in faster weight gain than comparable published data on conventional feeding, pe-ripheral intravenous alimentation, and parenteral alimenta-tion.

There were no cases of aspiration associated with tubes placed in the duodenum whereas two cases of aspiration pneumonia were associated with tubes placed in the stom-ach. With the tip of the catheter in the duodenum, none of the complications reported with nasojejunal tubes (intussus-ception, perforation, or necrotizing enterocolitis) were seen, either in the initial pilot study reported here or in 50 additional infants. Pediatrics, 56:1,065-1,072, 1975, LOW-BIRTHWEIGHT INFANTS, NASOGASTRIC FEEDING, CALORIC IN-TAKE, PREMATURE INFANTS.

Providing the very low birthweight infant (less

than 1,300 gm) with sufficient calories to sustain

optimum growth and brain development is a

ma-jon concern.’2

Provision of adequate calories by conventional

techniques is limited by the relatively small

stomach, lax cardia, and very competent pylorus

of these infants. As a result, the volumes required

to feed these small infants with formulas in a safe

osmolar range canny a large risk of aspiration.

Recent approaches developed to safely

in-crease the caloric intake include parentenal

au-mentation,3’ supplementation of oral feedings by

peripheral alimentation,6 continuous nasogastnic

drip,7’8 and nasojejunal infusion.9

To assess the practicality and safety of

intesti-nal feeding, we compared two groups of very low

binthweight infants (less than 1,300 gm). Both

groups were fed the same commercial formula by

continuous drip, one group through a nasogastric

tube and the other through a nasoduodenal tube.

The

duodenum was chosen as the infusion site

rather than the jejunum for physiological reasons

(

discussed later), and because previous

expeni-ence indicated that tubes placed in the

duode-num have less tendency towards aboral

move-ment and are less likely to serve as a lead point

for intussusception than those placed beyond the

ligament of Treitz.

METHODS

Patients

Eleven infants with bmrthweights less than

1,300 gm and gestational ages between 26 and 36

weeks form the basis of this report. Infants with

severe respiratory distress (blood pH less than 7.2

or Pco, greater than 65 mm Hg) were excluded.

Otherwise, all infants in the very low birthweight

category who were admitted during the period of

this study and who lived for 24 hours after birth

were included and allocated alternately to the

(Received November 15, 1974; revision accepted for publi-cation January 17, 1975.)

ADDRESS FOR REPRINTS: (G.K.P.) Department of Pedi-atrics, University of Texas Medical Branch, Galveston,

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TABLE I

SUMMARY OF CLINICAL DATA

Case

Birthweigbt (gm)

Estimated

Gestational Age (wk)

Weight

Classification#{176} Clinical Problems

1 950 28

Nasoduodenal

AGA Traumatic diverticulum (post tracheal intubation),

recurrent apnea, aspiration pneumonia

2 975 26 AGA Immaturity

3 1,050 26 AGA Meconium plug syndrome, recurrent apnea,

sepsis, diarrhea

4t 1,145 32 SGA Twin birth

5t 1,110 30 SGA Recurrent apnea, omphalitis

6t 1,300 32 SGA Twin birth, respiratory distress

At 1,005 27

Nasogastrict

AGA Wilson-Mikety syndrome

B 920 30 SGA Recurrent apnea, hyperbilirubinemia, aspiration

pneumonia

C

995 36 SGA Triplet

Dt 1,065 26 AGA Respiratory distress, recurrent apnea

Et 1,250 33 SGA

SGA = small for

Hyperbilirubinemia

gestational age.

Feeding

Program

#{176}AGA = appropriate for gestational age; fTransferred from other hospitals.

tJnfant A by conventional lavage; infants B, C, D, and

nasoduodenal or nasogastnic group. One infant

died of pulmonary hemorrhage at 3 days of age

(

30 hours after placement of the tube) and,

there-fore, is not included in the calculations of daily

caloric intake or weight gain. He is included,

however, under complications. Gestational age

was estimated on the basis of historical, physical,

and neurological data.” Table I summarizes the

clinical data.

Each infant was fed the same commercial

for-mula#{176}infused at a constant rate using a perfusion

pump,

f

either through a nasoduodenal catheter

or through a nasogastnic feeding tube. An

at-tempt was made to increase the rate of infusion

as quickly as possible in each case, so that the

in-fants would receive at least 120 cal/kg/day.

Re-gurgitation was the limiting factor in the

naso-gastric group. Fluid balance was maintained by

intravenous administration of 10% dextrose until

enteral fluid intake reached 80 to 100 ml/kg/day.

The period of study was initiated with the

place-ment of the feeding tube and was discontinued

when an infant was able to spontaneously suck

0 Enfamil, 24 calories per ounce.

f Ivac Company.

E by continuous drip.

any small amount of formula. Infants were

weighed daily.

Placement of Feeding Tube

A

polyvinyl tube with a gold bead, as

de-scribed by Rhea and Kilby,9 was used in our first

patient, since this was the method described in

most detail at the time of initiation of our study.

However, because of the difficulties encountered

in placement of this tube, the delay in passage of

the tube into the duodenum, and the problem of

visualizing its exact position radiologically

with-out the use of contrast material, another type of

tubing was utilized thereafter. This tubes was

slightly stiffer and radioopaque and could

rou-tinely be placed directly in the duodenum,

usu-ally with the first attempt. It required no weight

(such as a gold bead) and therefore had less

tend-ency than tubes with weighted ends to continue

aboral movement with peristalsis. After nasal

in-tubation, the tube was gently placed first in the

stomach and then into the duodenum with the

in-fant lying on its right side. Backilow of bile

mdi-cated its passage through the pylorus. The

posi-tion of the tube was checked radiologically and

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FIG. 1. Optimal positioning of the duodenal feeding tube.

First Week of Tube Feeding

(cal/ kg/day)

Overall Period of Tube Feeding (cal/ kg/day)

Nasoduodenal Nasogastric Nasoduodenal Nasogastric

126 69 147 116

128 48 154 117

111 76 120 78

112 59 135 124

112 86 112 94

118 . . 118 ..

118 ± 16#{176} 68 ± 13#{176} 131 ± 14t 106 ± 17+

was considered optimal if its tip lay in the

duode-num somewhere between the second portion and

the ligament of Treitz (Fig. 1). The tube was

Se-cured as follows: a piece of cotton umbilical tape

was tied around the tubing as it entered the nanes

and attached with adhesive to the tubing. The

umbilical tape was then secured to the infant’s

cheeks bilaterally. A small dot (indelible marker)

was placed on the tubing, 1 inch from the nose,

so that any displacement of the tube from its

original position would be immediately

appan-ent. For the first three infants, a small bolus

(ap-proximately 5 cc) of contrast material was

in-jected just before the abdominal x-ray was taken

to check for gastric reflux. No reflux was seen and

this practice was discontinued. The nasogastnic

tube was placed in the stomach and its position

secured in the same way.

Fecal Fat

Fat absorption was assessed by 72-hour stool

collections on four of the infants with

nasoduode-nal tubes at an average age of 38 days. Stools

were analyzed for fat by a modification of the

method of Cohen et al.’3 Percent absorption was

calculated as follows:

Fat intake-fat excretion (gm/day)

Fat intake (gm/day)

x

100 = % absorption.

RESULTS

The two groups were similar in regard to

binthweight, estimated gestational age, age at

on-set of tube feeding, and general medical

prob-lems unassociated with feeding (Table I).

Caloric Intake

There was a significant difference between the

two groups for average enteral caloric intake.

Infants with nasoduodenal tubes averaged 131

cal/kg/day and infants with nasogastric tubes

106 cal/kg/day. This difference was more

strik-ing over the first week of feeding (nasoduodenal,

118 cal/kg/day vs. nasogastnic, 68 cal/kg/day)

(Table II). As can be seen in Figure 2, an intake

in the range of 120 cal/kg/day could be reached

as early as 48 to 72 hours after placement of the

TABLE II

ENTERAL INTAKE

Mean ± SD

(4)

80-

60-

40-

20-too

-

80-

60-

40- 20->1

0 U

0

C Iii

#{149}ANaso duodsnol

#{149}BNoso gastric

- I I- U I I I

0 I a 3456

Feeding Days

FIG. 2. An intake in the range of 120 cal/kg/day can be

reached in 48 to 72 hours after placement of the duodenal tube.

tube in the duodenum and initiation of feeding.

In the

group fed by nasogastnic tube, this amount

could only be reached after a week of feeding.

TABLE III

CHANGE IN BODY WEIGHT DURING ENTERAL ALIMENTATION

The patients fed by continuous nasogastric

infu-#{174}

sion had a gradual increase in their ability to

to!-erate a larger volume of feeding, and the

differ-ence in caloric intake became less striking after

two weeks of feeding.

Weight Gain

The

initial weight was very similar for both

groups (Table III). The nasoduodena! group

re-gained their birthweight at 13.5 days of age

(

average). When calculated from the onset of

feeding, this actually required an average of 9.5

days for this group. Once feedings were initiated,

U I 1 -r-- weight loss ceased and the average time to regain

7 8 9 10 initial weight was 1.3 days.

The nasogastnic group regained their

birth-weight at the mean age of 17.8 days. From the

onset of feedings, the average length of time

re-quired was 13.6 days for this group. These infants

continued to lose weight during the first one to

two days of feeding and the average time to

re-gain initial weight in this group was 3.4 days.

The average daily weight gain for the overall

period of study was 16 gm/day for the

naso-duodenal group as compared to 10 gm/day for

the patients in the nasogastnic group. This

differ-ence was statistically significant (P= .05). The

in-dividual growth curves (weight) during the

pe-Onset of Feeding .

Duratton of Tube Feeding

. .

Age Bzrthwezght

Was Regained

.

Average Galfl During Tube Feeding

,-Age Weight

Case (days) (gm) (days)

Nasoduodenal

(days) (gm/day)

1 12#{176} 825 40 18 15

2 2 955 38 6 17

3 3 900 47 20 12t

4 6 1,000 24 14 19

5 4 1,035 7 9 14

6 4 1,125 7 14 18

Mean 5.2 970 27 ± 16 14 ± 5 16 ± 3

A 6 860

Nasogastric

36 24 14

B 7 850 34 21 13

C

2 995 8 8 2

D 4 880 38 26 10

E 2 1,195 10 10 10

Mean 4.2 956 25 ± 13 18 ± 3 10 ± 4

#{176}Feeding prior to passage of tube into duodenum was complicated by aspiration pneumonia. tlncludes two days when the infant received nothing by mouth (diarrhea).

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WEIGHT 750#{149} 750

-

1500-250

-000

-

750-500

-oJ

750

0 5 0 5 20 25 30 35 40

DAYS

FIG. 3. Weight gain plotted on standard premature growth chart during nasoduodenal feeding.

5-, 500

0 r , . . . . . .

0 5 0 IS 20 25 30 35 40

DAYS

FIG. 4. Weight gain plotted on standard premature growth charts during nasogastnc feeding.

TABLE IV

COMPLICATIONS OBSERVED DURING TUBE FEEDING WEIGHT

nod of study are plotted on a standard premature

growth chart’4 in Figures 3 (nasoduodenal) and 4

(nasogastnic).

The efficiency of 100 calories ingested as

ex-pressed by the mean weight gain in grams per

kilogram per 24 hours per 100 calories was 8 gm

for the infants fed by continuous nasogastnic

feed-ing as compared to 11 gm for the infants on a

nasoduodenal feeding.

Fat absorption in the four infants studied in

the nasoduodenal group averaged 89% (range,

87.5%

to 91%).

The nasoduodenal group required postnatal

panenteral fluid support for an average of three

days less than the nasogastnic group.

Complications (Table IV)

There was no mortality related to the feeding

technique. One infant died within 30 hours of

tube placement of pulmonary hemorrhage, and is

not included in the caloric intake and weight

gain figures as the period of feeding was too short

to enter the calculations. Otherwise, there were

no deaths in this series.

There were two cases of aspiration

pneu-monia. Both occurred in relationship to tubes

placed in the stomach, one in an infant from the

nasogastnic group, the other in an infant from the

nasoduodenal group (case 1) prior to passage of

the tube from the stomach to the duodenum (soft

tube with gold bead). There were no cases of

as-piration associated with tubes actually placed in

the duodenum. Some degree of regurgitation was

seen in most of the patients fed by nasogastric

tube. This was usually easily corrected by

de-creasing the volume intake. The plateau in the

curve from day 6 through 9 in Figure 2 reflects

this problem.

Diarrhea occurred in three of the patients with

nasoduodenal tubes and in one of the patients

with a nasogastnic tube. In two of the

nasoduode-nal cases, the diarrhea was directly related to the

forward displacement of the catheter into the

jejunum.

It

ceased abruptly six to eight hours

af-ten the tip of the catheter was replaced in its

mi-tial duodenal position.

One patient developed diarrhea, vomiting, and

shock. The stools were positive for reducing

sub-stance (clinitest) but were negative for blood.

On

culture, no entenic pathogens were isolated.

None of the radiological findings of pneumatosis

intestinalis were seen and the nasoduodenal

feed-ing was safely resumed after 48 hours of

par-Complication Nasoduodenal Nasogastric

Mortality 10 0

Aspiration pneumonia 0 2

Bilirubin > 15 mg/100 ml 0 2

Diarrhea 3 1

Necrotizing enterocolitis 0 0

Jejunal perforation 0 0

Intussusception 0 0

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TABLE V

RESULTS OF ALTERNATIVE FEEDING TECHNIQUES IN VERY Low BIRTHWEIGHT INFANTS

Metho(l No.’

Acerage

Birth-weight (gm)

Duration of Feeding (days)

Days Needed To Achieve 100 cal/

kg/day

Weight Gain (gm/day)t

Days Needed To Regain

initial Weight Deaths

Conventional” 12 1,120 28 NS 4 21.0 . . .

Conventional’4 NS 1,000 26 NS 8 18.0 . . .

Peripheral plus

nasogastrict 10 1,083 14 8 9 14.5 0

Parenteral’ 9 899 18 6 7 8.9 4

Parenteral’ 13 1,219k 20 NS 15 NS 5

Nasogastnic7# 16 1,773 21 5 17 NS NS

Nasojejunal” 36 1,624 20 NS 17 NS 5

Present series

Nasogastric 5 1,047 25 7 10 3.4 0

Nasoduodenal 6 1,088 27 3 16 1.3 0

Intrauterine

growth160#{176} NS 1,000 28 . . . 16 . . . ...

#{176}NS= not stated.

tUnless otherwise stated, averaged over duration of specified type of feeding.

*Study included only survivors without complications or neurological damage. §No weight gain was observed for first 14 days; averaged over 28 days.

Includes only infants who survived long enough to enter calculations (No. 10). #Group fed similar formula (SMA S-26) chosen for comparison.

0#{176}Weight gain from 27 to 31 weeks’ duration; 50th percentile curves from Lubchenko et al. 16

enteral fluid therapy. There were no cases of

intussusception, perforation, or necrotizing

enter-ocolitis seen.

Since completion of the pilot study reported in

detail here, an additional 50 infants with

birth-weights under 2,000 gm have been fed utilizing

the nasoduodenal technique without any one of

these complications. In approximately one half of

these infants, the tube described above was used.

This type of tube has a tendency to become stiff

with time and requires frequent changing.

There-fore, an effort was made to find a more pliable

tubing which could still be easily placed in the

duodenum. A No. 5 or 8 French feeding tube,

readily available commercially, met these

cnite-na and has been used on the last 25 infants fed

nasoduodenally with equally good results.

DISCUSSION

All the infants gained weight satisfactorily as

determined by traditional standards (Figs. 3 and

4), whether fed by nasogastnic or by

nasoduode-nal tube. For comparison purposes, a

represent-ative sample of data published on different

feed-Argyle, length 15 or 42 inches with sentinel line (x-ray opaque), Sherwood Medical Industries, Inc.

ing techniques has been assembled in Table V.

There is no published data on the use of

naso-duodenal feeding. The only published data on

nasogastric7 and nasojejunal” feeding concerns

the utilization of these techniques in larger

in-fants, but they are included for completeness. All

of the other studies chosen involve very low

bmnthweight infants, comparable in size to those

in the present study.

The average weight gain of our infants fed by

constant nasogastnic drip was better than the

weight gain of infants fed conventionally’4 and

those fed by peripheral alimentation6 and also

exceeded the average weight gain of one of the

groups3 fed by parenteral alimentation (Table V).

The infants fed by constant nasoduodenal

infu-sion gained weight faster than any other reported

group of infants of comparable birthweight,

in-eluding those fed by parenteral alimentation.

In-deed, their weight gain was similar to the

ex-pected intrauterine weight gain calculated from

Lubchenco et a!. ‘s16 curves for infants of 1,000

gm over the same period of time (Table V).

In

addition to proving at least as effective as

any other present method of feeding very low

birthweight infants, this method was attended

with fewer complications and a fan lower

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weight gain (parenteral alimentation’). There

were no deaths in our series related to

naso-duodenal feedings, whereas three of the deaths in

the two series of parenterally alimented infants35

were considered to be related to the central

venous catheter (sepsis, thrombosis). No episodes

of perforation’7 or intussusception’8 were noted

in this series and two of the three problems with

diarrhea were associated with forward

dis-placement of the catheter to the jejunum.

Functionally, the duodenum occupies a

posi-tion midway between the stomach and small

in-testine, serving a very important churning and

mixing function. In our experience, tubes placed

in the duodenum have far less tendency toward

aboral movement than those placed beyond the

ligament of Treitz. It is for these reasons that

placement of the tube in the duodenum rather

than the jejunum would seem more reasonable

physiologically, and far less likely to produce

in-tussusception or diarrhea. Nasoduodenal feeding

has been in use continuously in our nursery since

this pilot study was done. An additional 50

in-fants have been fed by this means without the

oc-currence of a single case of intussusception,

per-foration, or necrotizing enterocolitis.

The duodenum serves an important function in

digestion. Cholecystokinmn is released from the

mucosa of the duodenum, and pancreatic and

bile ducts have their entry points there. The fat

absorption data on the infants with nasoduodenal

tubes studied are quite comparable to data on

in-fants of similar size and age fed conventionally,’9

suggesting that duodenal infusion was as efficient

from an absorption standpoint as nasogastnic or

oral feeding at the same age.

Duodenal placement was not associated with

regurgitation nor could we demonstrate reflux

into the stomach. Whether this position would be

equally safe in infants on respirators is unknown

at present.

None of the infants fed with a continuous

naso-duodenal drip developed significant

hyperbili-rubinemia, while two of five infants fed by

continuous nasogastnic milk feedings required

ex-change transfusion. It has been repeatedly shown

that fasting significantly affects the bilirubin

level in infants.’0 A larger series would be

re-quired to demonstrate whether early adequate

caloric intake can also reduce the incidence and

the severity of the physiologic

hyper-bilirubinemia of very low birthweight infants.

The danger of perforation remains, since the

more easily placed tubes tend to become stiff

with time. Therefore, the following precautions

should be routinely observed: (1) frequent

chang-ing of tubing (once a week if the stiff intracath

tubing is utilized); (2) careful anchorage of tube,

once it is properly positioned; (3) cotton mitts on

infants to decrease accidental removal; (4)

fre-quent observation of tube position; and (5) clear

instructions to nursing personnel not to attempt

to replace or advance a tube that has been

par-tially or completely removed.

SUMMARY

Nasoduodenal tube feeding of very low

birth-weight infants seems to be a practical means of

administering total caloric and fluid

require-ments as soon as 48 to 72 hours after placement

of the tube. The calories administered are

effec-tively utilized, as evidenced by normal fat

ab-sorption for age and satisfactory weight gain,

close to projected intrauterine growth rates. The

technique seems to be a safe one if meticulous

precautions are observed; these include care of

the tube as described above and careful

observa-tion of frequency and character of stools.

With placement of the tube in the duodenum

and careful monitoring, none of the

complica-tions described with nasojejunal tubes have been

seen, either in the pilot study reported here or in

50 additional infants fed by this method since

then.

In the

very low binthweight infants, this

tech-nique is most useful in the first two to three

weeks of life. After this time, continuous

naso-gastric infusion appears to be an equally effective

alternative.

REFERENCES

1. Dobbing J: Later growth of the brain: Its vulnerability.

Pediatrics 53:2, 1974.

2. Winick M, Rosso P: The effect of severe early malnutri-tion on cellular growth of human brain. Pediatr Res 3:181, 1969.

3. Driscoll JM, Heird WC, Schullinger JN, et a!: Total in-travenous alimentation in low birth weight in-fants: A preliminary report. J Pediatr 81:145, 1973.

4. Brans YW, Sumners JE, Dweck HS, Cassady C: Feed-ing the low-birthweight infant: Orally or paren-terally? Preliminary results of a comparative study. Pediatrics 54: 15, 1974.

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8. Valman HB, Heath CD, Brown RJK: Continuous intra-gastric milk feedings in infants of low birth weight. Br Med J 3:547, 1972.

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feed-ing. Pediatrics 46:36, 1970.

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ACKNOWLEDGMENT

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1975;56;1065

Pediatrics

Micheline Van Caillie and Geraldine K. Powell