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(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., and

John 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 their

ab-dominal muscles convulsively force gastric

contents into their mouths, which are

blocked by locked jaws.

Some

years

ago we found

that aspiration

was 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 and

tangentially 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

(2)

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, at

which 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; outside

diameter, 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 of

nonradio-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

(3)

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

(4)

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 an

occasional bile-stained drop 2 hours after

the feeding. One or 2 ml of distilled water

following

the

milk serves

to

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 one

new-born infant who underwent gastrostomy on

admission, a nasojejunal tube allowed

feed-ing

while the infected gastrostomy wound

healed.

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

(5)

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

(6)

1970;46;36

Pediatrics

James W. Rhea and John O. Kilby

A NASOJEJUNAL TUBE FOR INFANT FEEDING

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(7)

1970;46;36

Pediatrics

James W. Rhea and John O. Kilby

A NASOJEJUNAL TUBE FOR INFANT FEEDING

http://pediatrics.aappublications.org/content/46/1/36

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