(Received September 8, 1969; revision accepted for publication January 15, 1970.) ADDRESS: (J.W.R.) Aramco Box 2438, Dhahran, Saudi Arabia.
PEDIATRICS, Vol. 46, No. 1, July 1970
A
NASOJEJUNAL
TUBE
FOR
INFANT
FEEDING
James
W. Rhea, M.D., andJohn 0.
Kilby,
M.B., F.R.C.S.From the Pediatric Service, Dhahran Health Center, Arabian American Oil Company, Dhahran, Saudi Arabia; and Department of Surgery, Bristol Royal Infirmary, Bristol, England
ABSTRACT. Nasojejunal feeding was used in 48
infants and found to be a practical and useful
means of feeding premature and otherwise ill in-fants in whom conventional feeding was judged hazardous. A limp, polyvinyl tube with an outside diameter of 1.5 mm and a .9 mm bore was passed from the stomach through the pylorus. A tiny, reusable gold bead helped weight-direct the tip of the tube.
Full enteral infant feeding can be accomplished
nonsurgically for a period of weeks with less regur-gitation, aspiration, and gastric distention than seen with gastric tube, gavage, or gastrostomy feeding. In order to avoid the potential dangers in-herent in bypassing the pylorus, the need for close attention to the amount, the type, and, especially, the osmolarity of the jejunal feeding is stressed.
Pediatrics, 45:36, 1970, JEJUNAL FEEDING, JEJU-NM. INTUBATION, INFANT FEEDING, PREMATURE IN-FANTS, NEWBORN INFANTS.
W
HETHER by nasogastric tube,intermit-tent gavage, or medicine dropper,
feeding premature and otherwise ill
new-born infants via conventional methods
poses several problems which, apparently,
are not always solved by resorting to
gastrostomy.’ The purpose of this paper is
to present, as an alternative feeding
method, nasojejunal intubation. We have
found this method to be a safe, effective,
relatively simple, nonsurgical means of
pro-viding enteral feeding for prolonged
peri-ods. We developed the technique initially
to feed newborn infants brought to us with
tetanus. These patients, many of whom are
also premature, have high caloric
require-ments and an enormous propensity for
re-gurgitation
and aspiration, since theirab-dominal muscles convulsively force gastric
contents into their mouths, which are
blocked by locked jaws.
Some
years
ago we found
that aspirationwas minimized when we were able to
by-pass the stomach, advance a feeding tube
through the pylorus, and thus deposit the
food in the jejunum.2 More recently, we
have also used the technique given here for
nontetanus premature infants and newborn
infants in whom conventional feeding was
judged hazardous.
METHOD
Since a stiff feeding tube is unlikely to
find its way through the pylorus, we used a
24-in. length of surgical, nontoxic,
transpar-ent vinyl tubing with an outside diameter
of 1.52 mm and a 0.91 mm bore (Portex
NT/2) with a shore hardness of 75, which
is quite limp. As a direction weight, we
used a small, cylindrical, gold bead 3.0 or
3.5 mm in outside diameter with a central
canal which expands from L5 mm
proxi-mally,
to
2 mm at the distal end( Fig.
1).The beads are designed and cast in a dental
laboratory, and a simple, overhand knot in
the end of the tube slides inside the bead
and retains it. Lead might be used but it is
toxic. Steel beads proved hard to drill and
too light. Densities of iron, lead, and gold
are 7.9, 11.3, and 19.3 gm/cm3. The
cylindri-cal shape of the bead adds weight and
seems to facilitate passage.
We cut two or three small feeding holes
in the tube in the inch nearest the bead
with a small, sharp scissors, taking care to
space
and
cut
the openings properly andtangentially without weakening the tube.
Insertion is accomplished by using a
10-in. length of a 10 Fr nasotracheal tube or a
plastic catheter from which the tip has
dry tubing so that the cut end abuts the
bead. The lubricated bead and catheter are
then gently passed through the naris,
phar-ynx,
and
esophagus
into
the stomach, atwhich point the resistance of the inferior
gastric wall is often felt. The infant is then
turned on the right side and the
introduc-ing catheter is gently withdrawn from the
stomach and over the feeding tube, which
is “fed” into the outcoming catheter. After
the catheter has been withdrawn a distance
of 3 in. over the tube, it is again advanced,
carrying more of the tube into the stomach.
This is repeated two or three times
( to
pro-vide adequate slack for pyloric passage),
after which the catheter is completely
with-drawn. Rubbing the feeding tube with
sili-cone treated lens paper and running a wad
through the catheter will reduce the
inter-nal drag and facilitate withdrawal. For
small premature infants we often use a
catheter slit lengthwise to introduce a 2.0
to 2.5 mm bead on a 12-in. silastic cut-down tube with a connector
(
Silon #356; outsidediameter, 1.40 mm; bore, 0.81 mm). The
slit allows the catheter to be taken out and
from around the tube without retaining the
connector and permits using a shorter tube.
The insertion of the beaded tube into the
stomach usually takes only a few minutes.
The infant is then kept on his right side
with hips slightly elevated for a period of 4
to 6 hours; turns to back and abdomen (but
not left side) are permitted. A blunt,
19-gauge needle is inserted into the nasal end
of the tube for gentle feeding from a
sy-ringe barrel.
The combination of the tiny, limp tube
with
the
passable
weight,
directed
by
placement, pius gastric peristalsis, usually
results in a jejunal position of the tube tip.
This can be confirmed by radiography with
0.5 ml contrast media in the tube or by bile
or pH determination of the aspirate if
ob-tainable (Fig. 2). A radiopaque polyvinyl
chloride tube (Portex R/ 1) has proved
quite satisfactory, although it is less limp
(shore hardness, 85) and the bore is
smaller
(0.75 ml) than that ofnonradio-0
1
mm_1IIiTIiiflillffl
F1i
0
Fic. 1. 2.9 mm and 2.5 mm, 18 kt gold direction beads attached to 1.5 mm polyvinyl and 1.4 mm
silastic tubes for nasojejunal feeding. End on bead
shows tapered canal for knot.
paque tubing of like diameter
(
1.52 mm).The length of tube initially inserted will
vary from 10 to 14 in. in a large newborn
in-fant to less than 8 ill. in a small premature
infant. Efforts to advance the limp tube
into the naris after removal of the catheter
usually lead to coiling or packing and are
not needed if one insures enough slack in
the gastric portion of the tul)e to allow
py-loric passage, after which the tube ‘ill
straighten and advance until restrained.
\Ve have not found stylets helpful. They
are dangerous and difficult to withdraw
after the tube is inserted into the stomach.
\Ve had some early success in directing the
tube by moving a large magnet across the
abdominal val1 to attract a row of iron
beads on the tube tip; but, the single gold
bead technique is simpler, does not require
fluoroscopy, and is usually successful well
within the initial intravenous feeding
pe-riod. The tube vill pass, spaghetti fashion,
into the duodenum without a directing
weight, but, the bead helps prevent
slip-ping back, doubling, and tangling, and it
facilitates the initial nasogastric insertion.
We prefer nasojejunal to orojejunal
intuba-tion. Although the oral route is easier
FIG. 2. Contrast medium injected through naso-jejunal tube in a 1,500 gm premature infant. Note
competence of pyloric valve.
breathing, the continuous oral stimulation
increases sucking, salivation, air
swallow-ing, and regurgitation. All but the smallest
infants can “breathe around” a 1.4 mm
na-sojejunal tube.
In some premature infants the nasal
canal will not accept even a 2 mm bead. A
2-stage approach is used for these patients.
If we wish to save a connector, we carry
the tube through the nose and out of the
mouth in a nasotracheal or regular feeding
tube, picking up the tip with a small Magill
forceps, then attaching the bead and
insert-ing it via a slit catheter through the mouth
into the stomach with slack provided as
be-fore. However, it is usually easier to use an
intact catheter to introduce the bead
through the mouth into the stomach, and
then carry the proximal plain end of the
tube from the mouth, retrograde, through
the nasal canal and out of the naris via a
catheter previously passed nasally.
Sometimes during introduction the bead
lodges in the end of the catheter. If the
catheter is intact, the bead can usually be
popped out hydraulically and then
success-fully advanced if one syringes 1 or 2 ml of
water into the catheter after knotting the
proximal end of the tube. These maneuvers
are safe but call for the gentle, nonforcing,
and considerate approach every premature
infant deserves.
Daily volumes of 150 ml milk per
kilo-gram in small but frequent jejunal feedings
are usually well tolerated. We give from 10
to 15 ml of milk per kilogram every 1% to 2
hours. With this schedule, using low solute
milk (SMA ), we have seen no signs or
symptoms during or after eating which
sug-gest the dumping syndromes (while many
adult patients manifest) following
gastrec-tomy or surgical pyloric bypass, significant
intestinal and/or vasomotor disturbances
(
such as epigastric pain, cramps, bloating,nausea, vomiting, diarrhea, and/or
sweat-ing ), pallor, tachycardia, vertigo, desire to
lie down, and so forth. Our jejunally fed
infants are probably spared this syndrome
complex because of the small, low osmolar
feedings and their recumbent position.
Stud-ies before and 30 minutes after our routine
nasojejunal feedings indicate an essentially
steady state with no rise in hematocrit and
no EKG or serum potassium changes. Stools
seem unaffected.
However, one must consider bypassing
the pylorus to be as potentially dangerous
as is starting an intravenous infusion, hence
the amount, frequency (rate), osmolarity,
type and concentration of the fluid given by
tube must be just as carefully chosen as in-travenous fluids would. In a 1 kg premature
infant, a relatively small amount of any
high osmolar jejunal feeding could lead to
diarrhea and/or hypovolemic shock as fluid
is mobilized in the gut. This could also
hap-pen if the tip of a regular nasogastric tube
should slip through the pylorus. On the
other hand, hypotonic salt and sugar
solu-tions are rapidly absorbed from the
nose breathers but they also seem to cause
newborn infants with tetanus, we have
added 2 gm of corn oil to 100 ml of the
je-jimal milk feedings and find that the extra
fat is handled quite well.
We routinely aspirate before giving the
jejunal feed but usually
get nothing
or anoccasional bile-stained drop 2 hours after
the feeding. One or 2 ml of distilled water
following
the
milk servesto
rinse the tube.Gastric distention has been seen less with
jejunal than with gastric tube feeding and
far less with jejunal than with gastrostomy
feeding. This is probably related to the
competence of the normal infant pyloric
valve. The competence of the normal
(un-scarred) pyloric
valve
has been
previously
demonstrated in adults.5
COMMENT
Our present “special feeding” protocol
calls for jejunostomy if jejunal intubation
has not been effected within 72 hours but,
even though pyloric passage is
peristalsis-dependent, surgery is seldom required. In
the few newborn infants we have had to
feed surgically, we have found gastrostomy
feeding far inferior to jejunostomy, in
which our surgeons, by means of a left
par-amedian incision under local anesthesia,
simply insert, pursestring, then bury, a
length of feeding tube in a serosal tunnel in
a
loop
of proximal
jejunum. In onenew-born infant who underwent gastrostomy on
admission, a nasojejunal tube allowed
feed-ing
while the infected gastrostomy woundhealed.
In more than 60 insertions in 48 infants
during the past 3 years, we have seen no
morbidity attributable to nasojejunal
intu-bation. The infants were newborn and
pre-mature with feeding problems alone or
with tetanus, pneumonia, meningitis,
respi-ratory distress syndrome, congenital heart
disease, pertussis syndrome, achalasia, birth
injuries, or other congenital and acquired
disorders.
The small, inert tubes not only interfere
less with ventilation in these obligatory
no nasal irritation. Occasionally, a tube has
become blocked and has to be reinserted.
This complication occurred with insufficient
rinsing. Sometimes the tube “gets away”
and advances so far down the jejunum that
it cannot be safely retrieved and must be
allowed to pass per anum. The tubes tend
to lose some of their distal limpness a few
days following insertion; but, even after 3
or 4 weeks in the jejunum, this has been no
problem. If too little tube is initially
in-serted, the bead may be positioned at the
cardia instead of at the pylorus; or, with
too much tube, gastric coiling may result.
Sometimes the silicone-treated lens paper
rubbing does not completely eliminate
sticking, which makes advancing the tube
and withdrawing the catheter difficult.
Rinsing tube and catheter in an aqueous
so-lution with a very low concentration of
sili-cone defoamer ( Antifoam A ) will usually
prevent the difficulty. An active infant hand
may pull out the tube before the tip passes
the pylorus, but we prefer to correct these
minor delays than to resort to surgery.
SPECULATION
At present the polyvinyl and silastic
tubes appear to cause much less tissue
reac-tion than do those of polyethylene.
How-ever, medical technology should be able to
produce an inert tube with an outside
di-ameter of 1.0 mm and a bore of .8 mm,
tip-weighted (lead in plastic?), fenestrated,
length marked, radiopaque, and with a heat
responsive shore hardness that would
re-duce from pliable when cold to extremely
limp after insertion.
One might further speculate on the
util-ity of a small double lumen tube in which a
longer, limp, beaded limb for jejunal
feed-ing is combined with a short, pliable tube
fenestrated for gastric suction.
SUMMARY
Nasojejunal feeding was used in 48
in-fants and found to be a practical and useful
means of feeding premature and otherwise
NASOJEJUNAL TUBE
was judged hazardous. A limp, polyvinyl
tube with an outside diameter of 1.5 mm
and a .9 mm bore was passed from the
stomach through the pylorus. A tiny,
reus-able gold bead helped weight-direct the tip
of the tube. Full enteral feeding can be
ac-complished nonsurgically for a period of
weeks with less regurgitation, aspiration,
and gastric distention than noted with
gas-tric tube, gavage, or gastrostomy feeding.
In order to avoid the potential dangers
in-herent in bypassing the pylorus, the need
for close attention to the amount, the type
and, especially, the osmolarity of the
jeju-nal feeding is stressed.
REFERENCES
1. Vengusamy, S., Pildes, R. S., Raffensperger,
J. F., Levine, H. D., and Cornblath, M.: A
controlled study of feeding gastrostomy in low birth weight infants. PEDIATRICS, 43:815,
1969.
2. Rhea, J. W., Graham, A. W., Akhnoukh, F. Z.,
and Parthew, C. T.: Effect of hyperbaric
oxy-genation on neonatal tetanus.
J.
Pediat.,71:33. 1967.
3. Silver, D., McGregor, F. H., Jr., Porter,
J.
M.,and Anlyan, W. C.: The mechanism of the dumping syndrome. Surg. Clin. N. Amer.,
46:425, 1966.
4. Torres-Pinedo, R., Rivera, C. L., and Fernandes, S.: Studies on infant diarrhea. IL Absorption
of glucose and net fluxes of water and sodium
chloride in a segment of the jejunum.
J.
Clin. Invest., 45:1916, 1966.5. Capper, W. M., Airth, C. R., and Kilby, J. 0.:
A test for pyloric regurgitation. Lancet,
2:621, 1966.
6. Polgar, C., and Kong, C. P.: The nasal resis-tance of newborn infants. J. Pediat., 67:557, 1985.
Acknowledgment
The authors thank Dr. B.J. Eggerman, Mr. J. A.
Blackburn, and Mr. D. E. Navratil of the
AR-AMCO Dental Division for their creative and