Randomised trial of continuous nasogastric, bolus nasogastric, and transpyloric feeding in infants of birth weight under 1400 g

Oxygenation Instability during Bolus versus Continuous Feeding among Very Low Birth Weight Premature Infants, Supported by Noninvasive Ventilation: A Randomized Prospective Study

OBJECTIVE

 This study aimed to compare oxygenation instability, as documented by the oxygen saturation (SpO2) histograms, during bolus (over 30 minutes) versus continuous (over 2 hours) feeding among very low birth weight (VLBW) premature infants, supported with noninvasive ventilation (NIV).

STUDY DESIGN

 This was a randomized prospective study. VLBW infants supported with NIV received three consecutive feeds in a random order of bolus-continuous-bolus or continuous-bolus-continuous. During each feed, 30 minutes and 2 hours histograms were documented.

RESULTS

 Twenty-four infants (birth weight [mean ± standard deviation, SD] 820 ± 168 g, gestational age [mean ± SD] 27.0 ± 1.6 weeks) were included in our study (12 infants started with bolus feeding and 12 with continuous feeding) and 72 histograms were obtained (36 during bolus feeding and 36 during continuous feeding). No differences in mean fraction of inspired oxygen (FiO2), and number of apnea events were observed between the two feeding modes. Oxygenation instability as assessed by time spent in different SpO2 ranges and histogram types (stable or unstable) was comparable during bolus and continuous feedings. Changing feeding mode from bolus to continuous or vice versa did not significantly change the oxygenation instability of the group, though individual infants did show a consistence response to feeding length changes.

CONCLUSION

 Among VLBW infants supported with NIV, oxygenation instability, as documented by SpO2 histograms, was comparable between bolus and continuous feedings. Individual infants may benefit from specific feeding length, and this can be easily demonstrated by the SpO2 histograms.

KEY POINTS

· Feeding length did not affect oxygenation instability of preterm infants on noninvasive respiratory Support.. · Oxygen saturation histograms allow objective quantification of oxygenation instability at the bedside.. · Individual infants benefit from specific feeding length, as demonstrated by SpO2 histograms..

Continuous versus Bolus Gastric Tube Feeding in Very Low Birth Weight Infants Supported with Noninvasive Respiratory Support: A Randomized, Pilot Study

OBJECTIVES

 This study aimed to compare time to full feeding (TFF) between continuous gastric feeding (CGF) and bolus feeding (BF) in very low birth weight (VLBW) infants supported with noninvasive ventilation (NIV) and to evaluate feasibility and identify methodological pitfalls for future large-scale studies.

STUDY DESIGN

 This study is a randomized controlled, prospective, pilot study. VLBW premature infants, supported with NIV, were randomized while still on trophic feeding <20 mL/kg/day to receive feeding over 2 hours of CGF or over 15- to 30-minute BF. The primary outcome was TFF. Analysis was done by intention to treat.

RESULTS

 Overall, 32 infants were included in this analysis, 17 in the CGF group and 15 in the BF group. Infants in the CGF group were significantly younger than the BF group (mean ± standard deviation [SD] gestational age [GA] 26.9 ± 1.2 vs. 28.9 ± 1.5 weeks, respectively). TFF was comparable with median (interquartile range [IQR]) for the two groups, 10.0 (10.0, 19.0) days in the BF group versus 12.0 (9.0, 13.0) days in the CGF group (p = 0.59). Feeding length was not found to significantly affect TFF in multivariate analysis correcting for GA. Groups were comparable in weight gain, gastrointestinal complications, length of NIV, bronchopulmonary dysplasia incidence, and age at discharge. Most infants from both groups (60% of BF and 70% of CGF) required changes in feeding length.

CONCLUSION

 In this pilot study, among VLBW infants supported with NIV, TFF was comparable between the BF and CGF groups. These results should be interpreted with caution due to the small sample size and despite the multivariate analysis correcting for the different GA. Interestingly, most infants required changes in feeding length regardless of their allocation. This feasibility study emphasizes the need for careful attention to randomization and strict feeding protocols including criteria for switching allocation in future large-scale studies aimed at determining the preferred feeding length during NIV in VLBW infants.

KEY POINTS

· Among infants supported with NIV, length of feeding affects gastric venting.. · BF might increase gastrointestinal reflux, while continuous feeding hinders gastric decompression.. · Among infants supported by NIV, feeding tolerance was comparable between bolus and continuous groups..

Comparison of Three Modalities of Feeding in Preterm Infants ≤32 Weeks and ≤1,250 G: A Randomized Controlled Trial

OBJECTIVE

 Early establishment of enteral feeds is desirable in very preterm infants, but it may be associated with feeding intolerance. Several feeding methods have been studied with no strong evidence to suggest the preferred feeding method to establish early full enteral feeds. We studied three modalities of feeding in preterm infants ≤32 weeks and ≤1,250 g: continuous infusion (CI), intermittent bolus by infusion (IBI), and intermittent bolus by gravity (IBG) for their effect on time to reach full enteral feeds of 180 mL/kg/d.

STUDY DESIGN

 We randomized 146 infants, 49 infants in each CI and IBI group and 48 infants in the IBG group. In the CI group, feeds were delivered by an infusion pump continuously over 24 hours. In the IBI group, feeds were given every 2 hours and infused over 15 minutes by an infusion pump. In the IBG group, feeds were delivered by gravity over 10 to 30 minutes. The intervention was continued till infants reached direct breast/cup feeds.

RESULTS

 The mean (standard deviation) gestation in CI, IBI, and IBG groups were 28.4 (2.2), 28.5(1.9), and 28.6 (1.8) weeks, respectively. The time to reach full feeds in CI, IBI, and IBG were not significantly different (median [interquartile range]: 13 [10-16], 11.5 [9-17], and 13 [9.5-14.2] d, respectively, p = 0.71). The proportions of infants who developed feeding intolerance in CI, IBI, and IBG were similar (n [%]: 21 [51.2%], 20 [52.6%], and 22 [64.7%], respectively, p = 0.45). There was no difference in necrotizing enterocolitis ≥2 (p = 0.80), bronchopulmonary dysplasia (p = 0.86), intraventricular hemorrhage ≥2 (p = 0.35), patent ductus arteriosus requiring treatment (p = 0.44), retinopathy of prematurity requiring treatment (p = 0.51), and growth parameters at discharge.

CONCLUSION

 In preterm infants, ≤32 weeks of gestation and birth weight ≤1,250 g, there was no difference in time to reach full enteral feeds in the three modalities of feeding. This study is registered with Clinical Trials Registry India (CTRI) and the registration number is CTRI/2017/06/008792.

KEY POINTS

· Gavage feeding in preterm infants is either continuous or intermittent bolus feeding.. · Intermittent bolus feeding was evaluated in a controlled time by infusion over 15 minutes.. · The time to reach full feeds was comparable for all three methods..

Continuous versus Intermittent Enteral Feeding in Critically Ill Children: A Systematic Review

Administration of enteral nutrition (EN) in critically ill pediatric patients admitted to the pediatric intensive care unit (PICU) constitutes a major challenge due to the increased risk of complications, as well as the lack of well-trained healthcare professionals. EN is usually delivered via cyclic, continuous, or intermittent feeding; however, a number of potential barriers have been reported in the literature regarding different feeding regimens. The purpose of this review was to assess the effectiveness of continuous and intermittent bolus feeding on critically ill children. A systematic search was conducted in PubMed, Scopus Cochrane Central Register of Controlled Trials (CENTRAL) and a clinical trial registry up to September 2022, including randomized controlled trials (RCTs) published in the English language. Four studies met the inclusion criteria with a total population of 288 patients admitted to the PICU. Three studies were rated with a high risk of bias and one with some concerns. There was high heterogeneity between the studies in regard to the reporting of outcomes. Three studies measured the total time needed to reach prescribed caloric intake with conflicting results, while two studies evaluated the length of stay (LOS) in PICU with no difference between the two arms. One study assessed the time weaning from mechanical ventilation, favoring the bolus group. No data were provided for gastric residual volume (GRV), anthropometric measurements, and biochemical markers. Additional randomized trials with better methodology are needed to assess the efficacy of the two enteral feeding regimens in critically ill PICU patients.

Transpyloric Feeding is Associated With Improved Oxygenation Compared With Gastric Feeding Among Nonintubated Extremely Low Birth Weight Infants

OBJECTIVE

To study the impact of transpyloric (TP) feed initiation on short-term oxygenation and manual oxygen blender titration among extremely low birth weight infants.

STUDY DESIGN

This retrospective study evaluated several measures of oxygenation among extremely low birth weight infants receiving positive pressure respiratory support for 96 hours before and after TP tube placement in a single neonatal intensive care unit during the years 2017- 2020. The measures included the achieved oxygen saturation (SpO₂), the baseline fraction of inspired oxygen (FiO₂), the SpO₂/FiO₂ ratio, the number and severity of hypoxemic episodes and the frequency of manual oxygen titrations (titration index) and were analyzed using an interrupted time series regression approach.

RESULTS

A total of 56 infants were evaluated. No significant differences were observed in any oxygenation measures during TP vs gastric feeding among 14 intubated infants. However, among 42 nonintubated patients, significant improvements were observed in the median SpO₂/FiO₂ ratios (P = .001), median titration index (P = .05), median number of hypoxemic episodes (P = .02), and median severity of hypoxemic episodes (P = .008) after TP tube placement.

CONCLUSIONS

The transition from gastric to TP tube feeding was temporally associated with acute improvement in oxygenation for nonintubated infants, but not for intubated infants.

Continuous nasogastric milk feeding versus intermittent bolus milk feeding for preterm infants less than 1500 grams

BACKGROUND

Milk feedings can be given via nasogastric tube either intermittently, typically over 10 to 20 minutes every two or three hours, or continuously, using an infusion pump. Although the theoretical benefits and risks of each method have been proposed, their effects on clinically important outcomes remain uncertain.  OBJECTIVES: To examine the evidence regarding the effectiveness of continuous versus intermittent bolus tube feeding of milk in preterm infants less than 1500 grams.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to run comprehensive searches in the Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 7) in the Cochrane Library; Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions; and CINAHL (Cumulative Index to Nursing and Allied Health Literature) on 17 July 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs.

SELECTION CRITERIA

We included RCTs and quasi-RCTs comparing continuous versus intermittent bolus nasogastric milk feeding in preterm infants less than 1500 grams.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all trials for relevance and risk of bias. We used the standard methods of Cochrane Neonatal to extract data. We used the GRADE approach to assess the certainty of evidence. Primary outcomes were: age at full enteral feedings; feeding intolerance; days to regain birth weight; rate of gain in weight, length and head circumference; and risk of necrotising enterocolitis (NEC).

MAIN RESULTS

We included nine randomised trials (919 infants) in this updated Cochrane Review. One study is awaiting classification. Seven of the nine included trials reported data from infants with a maximum weight of between 1000 grams and 1400 grams. Two of the nine trials included infants weighing up to 1500 grams. Type(s) of milk feeds varied, including human milk (either mother's own milk or pasteurised donor human milk), preterm formula, or mixed feeding regimens. In some instances, preterm formula was initially diluted. Earlier studies also used water to initiate feedings. We judged six trials as unclear or high risk of bias for random sequence generation. We judged four trials as unclear for allocation concealment. We judged all trials as high risk of bias for blinding of care givers, and seven as unclear or high risk of bias for blinding of outcome assessors. We downgraded the certainty of evidence for imprecision, due to low numbers of participants in the trials, and/or wide 95% confidence intervals, and/or for risk of bias. Continuous compared to intermittent bolus (nasogastric and orogastric tube) milk feeding Babies receiving continuous feeding may reach full enteral feeding almost one day later than babies receiving intermittent feeding (mean difference (MD) 0.84 days, 95% confidence interval (CI) -0.13 to 1.81; 7 studies, 628 infants; low-certainty evidence).  It is uncertain if there is any difference between continuous feeding and intermittent feeding in terms of number of days of feeding interruptions (MD -3.00 days, 95% CI -9.50 to 3.50; 1 study, 171 infants; very low-certainty evidence). It is uncertain if continuous feeding has any effect on days to regain birth weight (MD -0.38 days, 95% CI -1.16 to 0.41; 6 studies, 610 infants; low-certainty evidence). The certainty of evidence is low and the 95% confidence interval is consistent with possible benefit and possible harm. It is uncertain if continuous feeding has any effect on rate of gain in weight compared with intermittent feeding (standardised mean difference (SMD) 0.09, 95% CI -0.27 to 0.46; 5 studies, 433 infants; very low-certainty evidence). Continuous feeding may result in little to no difference in rate of gain in length compared with intermittent feeding (MD 0.02 cm/week, 95% CI -0.04 to 0.08; 5 studies, 433 infants; low-certainty evidence). Continuous feeding may result in little to no difference in rate of gain in head circumference compared with intermittent feeding (MD 0.01 cm/week, 95% CI -0.03 to 0.05; 5 studies, 433 infants; low-certainty evidence). It is uncertain if continuous feeding has any effect on the risk of NEC compared with intermittent feeding (RR 1.19, 95% CI 0.67 to 2.11; 4 studies, 372 infants; low-certainty evidence). The certainty of evidence is low and the 95% confidence interval is consistent with possible benefit and possible harm.

AUTHORS' CONCLUSIONS

Although babies receiving continuous feeding may reach full enteral feeding slightly later than babies receiving intermittent feeding, the evidence is of low certainty. However, the clinical risks and benefits of continuous and intermittent nasogastric tube milk feeding cannot be reliably discerned from current available randomised trials. Further research is needed to determine if either feeding method is more appropriate for the initiation of feeds. A rigorous methodology should be adopted, defining feeding protocols and feeding intolerance consistently for all infants. Infants should be stratified according to birth weight and gestation, and possibly according to illness.

Continuous versus intermittent bolus milk feeding in preterm infants: a meta-analysis

Objectives

To analyze the evidence comparing the benefits and risks of continuous versus intermittent milk feeding in low birth weight (LBW) infants.

Methods

Three electronic databases were searched and screened to identify randomized controlled trials of continuous and intermittent milk feeding of LBW infants up to October 2016.

Results

Eight trials were included in this meta-analysis. Continuous feeding had no effect on days to full feeds and time to regain birth weight. There were no significant differences in the number of apneas, invasive ventilation, changes in body length, occipitofrontal circumference, skinfold thickness, and total protein, and in the number of stools between the two feeding strategies. Continuous feeding was associated with higher gastric residual volume, noninvasive ventilation, weight gain, increase in bilirubin, and longer nil by mouth. There were no significant differences in adverse events and confounders between the two feeding strategies.

Conclusions

Continuous milk feeding was superior to intermittent feeding in LBW infants in terms of weight gain. However, continuous feeding was also associated with increased nil by mouth duration, increased bilirubin, increased noninvasive support, and increased gastric residuals. Continuous feeding thus confers advantages in terms of weight gain, but also has disadvantages compared with bolus feeding.

Gastro-oesophageal reflux disease in infancy: a review based on international guidelines

Gastro-oesophageal reflux (GOR) in infancy is common, physiological and self-limiting; it is distinguished from gastro-oesophageal reflux disease (GORD) by the presence of organic complications and/or troublesome symptomatology. GORD is more common in infants with certain comorbidities, including history of prematurity, neurological impairment, repaired oesophageal atresia, repaired diaphragmatic hernia, and cystic fibrosis. The diagnosis of GORD in infants relies almost exclusively on clinical history and examination findings; the role of invasive testing and empirical trials of therapy remains unclear. The assessment of infants with vomiting and regurgitation should seek out red flags and not be attributed to GOR or GORD without considered evaluation. Investigations should be considered to exclude other pathology in infants referred with suspected GORD, and occasionally to confirm the diagnosis. Management of GORD should follow a step-wise approach that uses non-pharmacological options where possible and pharmacological interventions only where necessary.

Continuous feeding versus intermittent bolus feeding for premature infants with low birth weight: a meta-analysis of randomized controlled trials

Background/objectives

Clinical risks and advantages of both continuous feeding and intermittent feeding for preterm infants have been presented in previous studies. To determine the most appropriate feeding method for low-birth-weight infants, a meta-analysis was conducted.

Subjects/methods

Articles related to this topic were searched in PubMed, EMBASE, and Cochrane Library electronic database from the onset to May 2019. Heterogeneity analysis was performed with Chi-square and I² test. Pooled analysis was based on fixed effects model, if heterogeneity between the eligible studies was negligible (I² < 50%, P > 0.05). In contrast, a random effects model was carried out. The quality of including studies were evaluated by Cochrane assessment tool.

Results

A total of 1030 articles identified. Altogether, eight articles including 707 infants were included in final analysis based on eligibility criteria. In continuous feeding infants, time to achieving full feeds was longer (weight mean difference 0.98 (95% CI 0.26–1.71, P = 0.008) days) compared with intermittent feeding infants. Pooled analysis indicated there were no significant difference in other variables such as feeding intolerance, duration of hospitalization, days to regain birth weight, days to first successful oral feeding, duration of parenteral feeding, weight growth, length increment, head circumference growth, proven necrotizing enterocolitis, and probable necrotizing enterocolitis. In subgroup analysis for birth weight (<1000 g and >1000 g), we did not identify significant difference in time to full feeds, time to regain birth weight, and duration of hospitalization.

Conclusions

Intermittent feeding may be more beneficial for low-birth weight infants, However, well-designed studies and evidenced-based clinical practice are required to determine the most appropriate feeding method for premature infants with low birth weight.

Early transpyloric vs gastric feeding in preterm infants: a retrospective cohort study

BACKGROUND

Neonatal transpyloric feeding (TPF) has not been rigorously studied since the 1980s. Our objective was to evaluate early TPF, defined as TPF initiated within the first week after birth, among preterm infants in the setting of modern neonatal practice.

STUDY DESIGN

A retrospective cohort study was conducted between 2013 and 2017 for all extremely low birth weight (ELBW) infants born in a tertiary neonatal intensive care unit where early TPF is a common practice. Infants were excluded if they did not receive enteral feeding within the first week after birth or if they died prior to initiation of enteral feeding. The primary outcome was death or bronchopulmonary dysplasia (BPD). The association between early TPF and the primary outcome was assessed using multivariable logistic regression, with adjustment for gestational age, birth weight, and intubation status.

RESULT

The study sample included 368 ELBW infants. Twenty-seven percent received early TPF. Death or BPD occurred in 58% of infants who received early TPF compared with 67% of infants who received gastric feeding, adjusted odds ratio 0.6, 95% confidence interval 0.3-0.9. Growth and adverse gastrointestinal outcomes did not differ between the two groups.

CONCLUSION

Early TPF is associated with reduced risk of death or BPD among ELBW infants. Further investigation in the form of a randomized controlled trial is required to confirm a causal association between early TPF and improved clinical outcomes.

Intermittent bolus feeding promotes greater lean growth than continuous feeding in a neonatal piglet model

Background

Orogastric tube feeding is indicated in neonates with an impaired ability to ingest food normally and can be administered with an intermittent bolus or continuous feeding schedule.

Objectives

The objectives were to 1) compare the long-term effect of continuous with intermittent feeding on growth using the newborn pig as a model, 2) determine whether feeding frequency alters lean tissue and fat mass gain, and 3) identify the signaling mechanisms by which protein deposition is controlled in skeletal muscle in response to feeding frequency.

Design

Neonatal pigs were fed the same amount of a balanced formula by orogastric tube either as an intermittent bolus meal every 4 h (INT) or as a continuous infusion (CON). Body composition was assessed at the start and end of the study by dual-energy X-ray absorptiometry, and hormone and substrate profiles, muscle mass, protein synthesis, and indexes of nutrient and insulin signaling were measured after 21 d.

Results

Body weight, lean mass, spine length, and skeletal muscle mass were greater in the INT group than in the CON group. Skeletal muscle fractional protein synthesis rates were greater in the INT group after a meal than in the CON group and were associated with higher circulating branched-chain amino acid and insulin concentrations. Skeletal muscle protein kinase B (PKB) and ribosomal protein S6 kinase phosphorylation and eukaryotic initiation factor (eIF) 4E-eIF4G complex formation were higher, whereas eIF2α phosphorylation was lower in the INT group than in the CON group, indicating enhanced activation of insulin and amino acid signaling to translation initiation.

Conclusions

These results suggest that when neonates are fed the same amounts of nutrients as intermittent meals rather than continuously there is greater lean growth. This response can be ascribed, in part, to the pulsatile pattern of amino acids, insulin, or both induced by INT, which enables the responsiveness of anabolic pathways to feeding to be sustained chronically in skeletal muscle.

Feeding Intervals in Premature Infants ≤1750 g: An Integrative Review

BACKGROUND

The timely establishment of enteral feeds and a reduction in the number of feeding interruptions are key to achieving optimal nutrition in premature infants. Nutritional guidelines vary widely regarding feeding regimens and there is not a widely accepted consensus on the optimal feeding interval.

PURPOSE

To critically examine the evidence to determine whether there is a relationship to feeding intervals and feeding outcomes in premature infants.

METHODS

A systematic review of the literature in the following databases: PubMed, CINAHL, Embase and the Cochrane Library. The search strategy used the terms infant premature, low birth weight, enteral feeding, feed tolerance and feed intervals.

RESULTS

Search results yielded 10 studies involving 1269 infants (birth weight ≤1750 g). No significant differences in feed intolerance, growth, or incidence of necrotizing enterocolitis were observed. Evidence suggests that infants fed at 2 hourly intervals reached full feeds faster than at 3 hourly intervals, had fewer days on parenteral nutrition, and fewer days in which feedings were withheld. Decrease in the volume of gastric residuals and feeding interruptions were observed in the infants fed at 3 hourly intervals than those who were continuously fed.

IMPLICATIONS FOR PRACTICE

Reducing the feed interval from 3 to 2 hourly increases nurse workload, yet may improve feeding outcomes by reducing the time to achieve full enteral feeding.

IMPLICATIONS FOR RESEARCH

Studies varied greatly in the definition and management of feeding intolerance and in how outcomes were measured, analyzed, and reported. The term "intermittent" is used widely but can refer to a 2 or 3 hourly interval.

Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition

This document serves as an update of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) 2009 clinical guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD) in infants and children and is intended to be applied in daily practice and as a basis for clinical trials. Eight clinical questions addressing diagnostic, therapeutic and prognostic topics were formulated. A systematic literature search was performed from October 1, 2008 (if the question was addressed by 2009 guidelines) or from inception to June 1, 2015 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Clinical Trials. The approach of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to define and prioritize outcomes. For therapeutic questions, the quality of evidence was also assessed using GRADE. Grading the quality of evidence for other questions was performed according to the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) and Quality in Prognostic Studies (QUIPS) tools. During a 3-day consensus meeting, all recommendations were discussed and finalized. In cases where no randomized controlled trials (RCT; therapeutic questions) or diagnostic accuracy studies were available to support the recommendations, expert opinion was used. The group members voted on each recommendation, using the nominal voting technique. With this approach, recommendations regarding evaluation and management of infants and children with GERD to standardize and improve quality of care were formulated. Additionally, 2 algorithms were developed, 1 for infants <12 months of age and the other for older infants and children.

Near-infrared spectroscopy measurements of splanchnic tissue oxygenation during continuous versus intermittent feeding method in preterm infants

OBJECTIVES

The aim of the present study was to compare the effects of continuous and intermittent bolus milk feeding on splanchnic regional oxygenation (rSO₂S) in small-for-gestational age (SGA) and appropriate-for-gestational age (AGA) preterm infants.

METHODS

Infants with gestational age <32 weeks were prospectively studied by near-infrared spectroscopy. Each infant was given a milk bolus in ~10 minutes (intermittent feeding) followed after 3 hours by a 3-hour continuous feeding. rO₂S and splanchnic fractional oxygen extraction ratio (FOES [S = splanchnic]) were recorded 30 minutes before (T₀) and 30 minutes after the beginning of bolus feeding (T₁), 30 minutes before (T₂), at the end (T₃), and 30 minutes after the continuous feeding period (T₄).

RESULTS

rSO2S increased at T₁ in both AGA and SGA groups, whereas FOES did not vary during the study period. Moreover, we found that rSO2S was higher and FOES was lower at T₁ and T₃ in the AGA than in the SGA group.

CONCLUSIONS

Bolus milk feeding increases splanchnic oxygenation in both AGA and SGA infants, whereas continuous feeding does not. Splanchnic oxygenation is higher in AGA than in SGA infants both during bolus and continuous feeding. Continuous enteral feeding could help to limit the risk of hypoxic-ischemic gut damage in preterm infants in critical condition, especially in AGA infants.

Transpyloric versus gastric tube feeding for preterm infants

BACKGROUND

Enteral feeding tubes for preterm infants may be placed in the stomach (gastric tube feeding) or in the upper small bowel (transpyloric tube feeding). There are potential advantages and disadvantages to both routes.

OBJECTIVES

To determine the effect of feeding via the transpyloric route versus feeding via the gastric route on feeding tolerance, growth and development, and adverse consequences (death, gastro-intestinal disturbance including necrotising enterocolitis, aspiration pneumonia, chronic lung disease, pyloric stenosis) in preterm infants.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 3), MEDLINE, EMBASE, and CINAHL (to June 2012), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing transpyloric with gastric tube feeding in preterm infants.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Review Group with separate evaluation of trial quality and data extraction by two review authors. We synthesised data using a fixed-effect model and reported typical risk ratio (RR), risk difference (RD), and mean difference (MD).

MAIN RESULTS

We found nine eligible trials in which a total of 359 preterm infants participated. All of the trials contained methodological weaknesses with lack of allocation concealment, absence of blinding of caregivers or assessors, and incomplete follow-up being the major potential sources of bias. The included trials did not detect any statistically significant effects on feeding tolerance or in-hospital growth rates. Meta-analyses found that infants allocated to receive transpyloric feeding had a higher risk of gastro-intestinal disturbance (typical RR 1.48 (95% confidence interval (CI) 1.05 to 2.09); typical RD 0.09 (95% CI 0.02 to 0.17); number needed to treat for an additional harmful outcome (NNTH) 10 (95% CI 6 to 50); six studies, 245 infants) and all-case mortality (typical RR 2.46 (95% CI 1.36 to 4.46); typical RD 0.16 (95% CI 0.07 to 0.26); NNTH 6 (95% CI 4 to 14); six studies, 217 infants). However, the trial that contributed most weight to these findings was likely to have been affected by selective allocation of the less mature and sicker infants to transpyloric feeding. We did not find any statistically significant differences in the incidence of other adverse events, including necrotising enterocolitis, intestinal perforation, and aspiration pneumonia.

AUTHORS' CONCLUSIONS

The available data do not provide evidence of any beneficial effect of transpyloric feeding for preterm infants. Some evidence of harm exists, including a higher risk of gastrointestinal disturbance and mortality, but these findings should be interpreted and applied cautiously because of methodological weaknesses in the included trials.

Anabolic signaling and protein deposition are enhanced by intermittent compared with continuous feeding in skeletal muscle of neonates

Orogastric tube feeding is indicated for neonates with impaired ability to ingest and can be administered by intermittent bolus or continuous schedule. Our aim was to determine whether feeding modalities affect muscle protein deposition and to identify mechanisms involved. Neonatal pigs were overnight fasted (FAS) or fed the same amount of food continuously (CON) or intermittently (INT; 7 × 4 h meals) for 29 h. For 8 h, between hours 20 and 28, pigs were infused with [(2)H(5)]phenylalanine and [(2)H(2)]tyrosine, and amino acid (AA) net balances were measured across the hindquarters. Insulin, branched-chain AA, phenylalanine, and tyrosine arterial concentrations and whole body phenylalanine and tyrosine fluxes were greater for INT after the meal than for CON or FAS. The activation of signaling proteins leading to initiation of mRNA translation, including eukaryotic initiation factor (eIF)4E·eIF4G complex formation in muscle, was enhanced by INT compared with CON feeding or FAS. Signaling proteins of protein degradation were not affected by feeding modalities except for microtubule-associated protein light chain 3-II, which was highest in the FAS. Across the hindquarters, AA net removal increased for INT but not for CON or FAS, with protein deposition greater for INT. This was because protein synthesis increased following feeding for INT but remained unchanged for CON and FAS, whereas there was no change in protein degradation across any dietary treatment. These results suggest that muscle protein accretion in neonates is enhanced with intermittent bolus to a greater extent than continuous feeding, mainly by increased protein synthesis.

Continuous nasogastric milk feeding versus intermittent bolus milk feeding for premature infants less than 1500 grams

BACKGROUND

Milk feedings can be given via nasogastric tube either intermittently, typically over 10 to 20 minutes every two or three hours, or continuously, using an infusion pump. Although theoretical benefits and risks of each method have been proposed, effects on clinically important outcomes remain uncertain.

OBJECTIVES

To examine the evidence regarding the effectiveness of continuous versus intermittent bolus nasogastric milk feeding in premature infants less than 1500 grams.

SEARCH METHODS

Searches were performed of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2011), MEDLINE, CINAHL and HealthSTAR up to July 2011.

SELECTION CRITERIA

Randomised and quasi-randomised clinical trials comparing continuous versus intermittent bolus nasogastric milk feeding in premature infants less than 1500 grams.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all trials for relevance and methodologic quality. The standard methods of the Cochrane Neonatal Review Group were used to extract data.

MAIN RESULTS

Overall, the seven included trials, involving 511 infants, found no differences in time to achieve full enteral feeds between feeding methods (weighted mean difference (WMD) 2 days; 95% CI -0.3 to 3.9) . In the subgroup analysis of those studies comparing continuous nasogastric versus intermittent bolus nasogastric milk feedings the findings remained unchanged (WMD 2 days, 95% CI -0.4 to 4.1). There was no significant difference in somatic growth and incidence of NEC between feeding methods irrespective of tube placement. One study noted a trend toward more apneas during the study period in infants fed by the continuous tube feeding method compared to those fed by intermittent feedings delivered predominantly by orogastric tube placements [mean difference (MD) 14.0 apneas during study period; 95% CI -0.2 to 28.2]. In subgroup analysis based on weight groups, one study suggested that infants less than 1000 grams and 1000 to 1250 grams birth weight gained weight faster when fed by the continuous nasogastric tube feeding method compared to intermittent nasogastric tube feeding method (MD 2.0 g/day; 95% CI 0.5 to 3.5; MD 2.0 g/day; 95% CI 0.2 to 3.8, respectively). A trend toward earlier discharge for infants less than 1000 grams birth weight fed by the continuous tube feeding method compared to intermittent nasogastric tube feeding method (MD -11 days; 95% CI -21.8 to -0.2).

AUTHORS' CONCLUSIONS

Small sample sizes, methodologic limitations, inconsistencies in controlling variables that may affect outcomes, and conflicting results of the studies to date make it difficult to make universal recommendations regarding the best tube feeding method for premature infants less than 1500 grams. The clinical benefits and risks of continuous versus intermittent nasogastric tube milk feeding cannot be reliably discerned from the limited information available from randomised trials to date.

Transpyloric versus gastric tube feeding for preterm infants

BACKGROUND

Enteral feeding tubes for preterm infants may be placed in the stomach (gastric tube feeding) or in the upper small bowel (transpyloric tube feeding). There are potential advantages and disadvantages to both routes.

OBJECTIVES

To determine the effect of feeding via the transpyloric route versus feeding via the gastric route on feeding tolerance, growth and development and adverse consequences in preterm infants who require enteral tube feeding.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group was used. This included electronic searches of MEDLINE and EMBASE (up to March 2007) and of The Cochrane Controlled Trials Register in The Cochrane Library (Issue 1, 2007), and searches of the references in previous reviews including cross references.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing transpyloric with gastric tube feeding in preterm infants.

DATA COLLECTION AND ANALYSIS

Data were extracted using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author and synthesis of data using relative risk (RR) and weighted mean difference (WMD).

MAIN RESULTS

Data from nine trials were available. No evidence of an effect on short term growth rates was found: weight: WMD -0.7 g/week (95% confidence interval (CI) -25.2, 23.8); crown heel length: WMD -0.7 mm/week (95% CI -2.4, 1.0); head circumference: WMD 0.6 mm/week (95% CI -0.9, 2.1). Longer term growth was reported in one study. There were not any statistically significant differences between the groups in the mean body weight or occipitofrontal head circumference at three months or at six months corrected age. None of the included studies provided data on neurodevelopmental outcomes. Transpyloric feeding was associated with a greater incidence of gastro-intestinal disturbance (RR 1.45, 95% CI 1.05, 2.09). There was some evidence that feeding via the transpyloric route increased mortality (RR 2.46, 95% CI 1.36, 4.46). However, the outcomes of the study that contributed most to this finding were likely to have been affected by selective allocation of the less mature and sicker infants to transpyloric feeding. No statistically significant differences in the incidence of other adverse events, including necrotising enterocolitis, intestinal perforation, and aspiration pneumonia was found.

AUTHORS' CONCLUSIONS

No evidence of any beneficial effect of transpyloric feeding in preterm infants was found. However, evidence of adverse effects was noted. Feeding via the transpyloric route cannot be recommended for preterm infants.

Continuous feeding promotes gastrointestinal tolerance and growth in very low birth weight infants

OBJECTIVE

To compare the effects of continuous versus intermittent feeding on gastrointestinal tolerance and growth in very low birth weight (VLBW) infants.

STUDY DESIGN

In a randomized, controlled trial conducted at 3 neonatal units, 70 premature infants with a gestational age 24 to 29 weeks and birth weight < 1200 g were assigned to 1 of 3 feeding methods: continuous nasogastric feeding, intermittent nasogastric feeding, or intermittent orogastric feeding. Feeding was initiated within 30 hours of birth. Daily enteral and parenteral volumes, caloric and protein intakes, growth, enteral intolerance, and clinical complications were recorded. Cox regression analysis was used to determine primary outcome, the time to achieve full enteral feeding.

RESULTS

The continuously fed infants achieved full enteral feeding significantly faster than the intermittently fed infants (hazard ratio [HR] = 1.86; 95% confidence interval [CI] = 1.07 to 3.22). In stratified analysis according to birth weight, the improvement was even more pronounced in the smallest infants, those with birth weight < or = 850 g (adjusted HR = 4.13; 95% CI = 1.48 to 11.53). Growth rate was significantly faster in the continuously fed infants ( P = .002).

CONCLUSION

In VLBW infants, continuous feeding seems to be better than intermittent feeding with regard to gastrointestinal tolerance and growth.

Systematic review of transpyloric versus gastric tube feeding for preterm infants

AIM

To determine if enteral tube feeding by the transpyloric versus the gastric route improves feeding tolerance, and growth and development, without increasing adverse events, in preterm infants.

METHODS

Systematic review of randomised controlled trials. A search was made of the Cochrane Controlled Trials Register (CCTR; 2003, issue 1), Medline (1966 to April 2003), and Embase (1980 to April 2003), and references in previous reviews. The data were extracted, analysed, and synthesised using the standard methods of the Cochrane Neonatal Collaborative Review Group.

RESULTS

Data were found from eight trials. No evidence of an effect on growth or development was found, but transpyloric feeding was associated with a greater incidence of gastrointestinal disturbance: relative risk (RR) 1.45, 95% confidence interval (CI) 1.05 to 2.09. Transpyloric feeding was also associated with increased mortality: RR 2.46, 95% CI 1.36 to 4.46. However, the trial that contributed most to this finding may have been affected by allocation bias. No significant differences were detected in the incidence of other adverse events, including necrotising enterocolitis, intestinal perforation, and aspiration pneumonia.

CONCLUSIONS

No evidence of benefit was found, but evidence of harm was found. Feeding by the transpyloric route cannot be recommended for preterm infants.

Gastric Feeding in Critically Ill Children: A Randomized Controlled Trial

• Background Provision of enteral nutrition via the gastric route is a common nursing procedure in pediatric intensive care units. Little research, however, has focused on children’s tolerance of different types of gastric feeding regimens.

• Objectives To examine the relationship between 2 gastric feeding regimens, continuous and intermittent, and children’s tolerance as measured by the number of stools and prevalences of diarrhea and vomiting.

• Methods A randomized controlled trial was conducted in an Australian pediatric intensive care unit; 45 children were randomly assigned to either the continuous or the intermittent gastric feeding groups. Participants remained in the assigned feeding group for the duration of the study, and values of variables used to monitor patients’ tolerance were recorded.

• Results Both feeding groups were similar with respect to Pediatric Index Mortality score, age, weight, sex, diagnosis, and use of pharmacological agents known to affect the gastrointestinal tract. Additionally, the 2 groups did not differ in study duration or the daily volume of administered enteral formula per kilogram of body weight. The number of stools per day and the prevalences of diarrhea and vomiting did not differ significantly between the 2 groups.

• Discussion Continuous and intermittent gastric feeding regimens have similar outcomes with respect to the number of stools per day and the prevalence of diarrhea and vomiting in pediatric intensive care patients. Further gastric feeding studies and the development of enteral feeding guidelines for critically ill children are needed.

Continuous nasogastric milk feeding versus intermittent bolus milk feeding for premature infants less than 1500 grams

BACKGROUND

Most premature infants less than 1500 grams birth weight must be fed initially by tube because of their inablity to suck effectively, or to coordinate sucking, swallowing and breathing. Milk feedings can be given by tube either intermittently, typically over 10-20 minutes every two or three hours, or continuously, using an infusion pump. Although theoretical benefits and risks of each method have been proposed, effects on clinically important outcomes remain uncertain.

OBJECTIVES

To examine the evidence from randomized trials regarding the effectiveness of continuous versus intermittent bolus nasogastric milk feeding in premature infants less than 1500 grams. The primary outcomes reviewed included feeding tolerance, days to reach full enteral feeding, somatic growth, days to discharge and incidence of necrotizing enterocolitis (NEC).

SEARCH STRATEGY

Searches were performed of MEDLINE, CINAHL, and HealthSTAR, each up to February 2002, and the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2002). As well, studies identified from abstracts and conference proceedings and references from relevant publications were retrieved.

SELECTION CRITERIA

Randomized and quasi-randomized clinical trials that met the following criteria for relevance: a) Enrollment of infants < 1500 grams birth weight with no major congenital anomalies which might interfere with feeding tolerance b) Comparison of continuous nasogastric versus intermittent bolus tube feedings using breastmilk or formula c) Assessment of relevant outcomes including feeding tolerance, days to full feeds, somatic growth, days to discharge, and complications such as NEC or apnea

DATA COLLECTION AND ANALYSIS

All articles retrieved from the complete search were assessed independently by the two reviewers for relevance (see selection criteria), and for methodologic quality using the following criteria: blinding of randomization, blinding of intervention, complete follow-up and blinding of outcome measurement. Only those articles judged by both reviewers to be relevant and to have appropriate methodologic quality were included in the analysis. Differences were resolved through discussion and consensus of the reviewers.

MAIN RESULTS

Infants fed by continuous tube feeding method took longer to reach full enteral feeds (weighted mean difference 3.0 days; 95% CI 0.7, 5.2). Although there was no evidence of a difference in the days to discharge overall, one study suggested a trend toward earlier discharge for infants less than 1000 grams birth weight fed by the continuous tube feeding method (mean difference (MD) -11 days; 95% CI -21.8, -0.2). Overall, there was no evidence of a difference in somatic growth (weight, length, head circumference or skinfold thickness) between the two groups, but subgroup analyses in one study suggested that infants less than 1000 grams and 1000 - 1250 grams birthweight gained weight faster when fed by the continuous tube feeding method (MD 2.0 g/day; 95% CI 0.5, 3.5; MD 2.0 g/day; 95% CI 0.2, 3.8, respectively). There was no evidence of a difference in the incidence of NEC. One study showed a trend toward more apneas during the study period in infants fed by the continuous tube feeding method (MD 14.0 apneas during study period; 95% CI -0.2, 28.2).

REVIEWER'S CONCLUSIONS

Infants fed by the continuous tube feeding method took longer to reach full feeds, but there was no significant difference in somatic growth, days to discharge, or the incidence of NEC for infants fed by continuous versus intermittent bolus tube feeds. Small sample sizes, methodologic limitations and conflicting results of the studies to date, together with inconsistencies in controlling variables that may affect outcomes, make it difficult to make universal recommendations regarding the best tube feeding method for premature infants less than 1500 grams. The clinical benefits and risks of continuous versus intermittent nasogastric tube milk feeding cannot be reliably discerned from the limited information available from randomized trials to date.

Transpyloric versus gastric tube feeding for preterm infants

BACKGROUND

Enteral feeding tubes for preterm infants may be placed in the stomach (gastric tube feeding) or in the upper small bowel (transpyloric tube feeding). There are potential advantages and disadvantages to both routes.

OBJECTIVES

In preterm infants who require enteral tube feeding, does feeding via the transpyloric route versus the gastric route improve feeding tolerance, and growth and development, without increasing adverse consequences?

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group was used. This included electronic searches of MEDLINE and EMBASE (up to December 2001) and of The Cochrane Controlled Trials Register in The Cochrane Library (Issue 3, 2001), and searches of the references in previous reviews including cross references.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing transpyloric with gastric tube feeding in preterm infants.

DATA COLLECTION AND ANALYSIS

Data were extracted using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author and synthesis of data using relative risk and weighted mean difference.

MAIN RESULTS

Data from eight trials were available. We did not find any evidence of an effect on growth rates: short term weight gain, weighted mean difference -0.7 g/week (95% confidence interval -25.2, 23.8); short term increase in crown heel length, weighted mean difference -0.7 mm/week (95% confidence interval -2.4, 1.0); short term increase in head circumference, weighted mean difference 0.6 mm/wk (95% confidence interval -0.9, 2.1). Longer term growth was reported in one study. There were not any statistically significant differences between the groups in the mean body weight or occipitofrontal head circumference at three months or at six months corrected age. None of the included studies provided data on neurodevelopmental outcomes during infancy or beyond. Transpyloric feeding was associated with a greater incidence of gastro-intestinal disturbance, RR 1.45, 95% CI 1.05, 2.09. There was some evidence that feeding via the transpyloric route increased mortality, RR 2.46, 95% CI 1.36, 4.46; however, the outcomes of the study that contributed most to this finding were likely to have been affected by selective allocation of the less mature and sicker infants to transpyloric feeding. We did not detect any statistically significant differences in the incidence of other adverse events, including necrotising enterocolitis, intestinal perforation, and aspiration pneumonia.

REVIEWER'S CONCLUSIONS

We did not find any evidence of benefit, but did find evidence of adverse effects, of transpyloric feeding in preterm infants. Feeding via the transpyloric route cannot be recommended for preterm infants.

Feeding methods for the preterm infant

As more very immature preterm infants survive, provision of enteral feedings has become a major focus of concern. Although many aspects of gastrointestinal function are immature in the preterm infant, the ability of the preterm neonate to process and absorb enteral nutrients appears to be adequate enough to sustain nutritional needs. Few prospective randomized trials have compared the efficacy of different feeding methods. However, some studies have compared differing routes of feeding, rates of feeding, and volume of feeding. The ability to successfully digest enteral feedings may be inhibited or enhanced by pharmacological agents. The need to modify a feeding strategy can be monitored by tracking several measurements prospectively. Finally, there is a need to assess ongoing dietary needs of preterm infants for discharge planning.

Early aggressive nutrition in preterm infants

Increasingly, neonatologists are realizing that current feeding practices for preterm infants are insufficient to produce reasonable rates of growth, and earlier and larger quantities of both parenteral and enteral feeding should be provided to these infants. Unfortunately, there is very little outcome data to recommend any particular nutritional strategy to achieve better growth. Instead, the rationale for feeding regimens in many nurseries has been quite variably extrapolated from animal data and human studies conducted in gestationally more mature and/or stable neonates. Additionally, there are no well-controlled, prospective studies that validate any nutritional regimen for the very preterm and or sick, unstable neonate. The goal of this review is to present available data to help define the risks and benefits of early parenteral and enteral nutrition, particularly in very preterm neonates, concluding with a more aggressive approach to feeding these infants than has been customary practice.

Feeding tolerance in preterm infants: randomized trial of bolus and continuous feeding

OBJECTIVE

To test the hypothesis that continuous gastric infusion (CGI) is better tolerated than intermittent gastric bolus (IGB) in small very low birth weight (VLBW) infants.

DESIGN

Two-center, prospective, randomized, unmasked clinical trial.

PATIENTS

28 VLBW infants (birth weight <1250 g). A strict feeding protocol was followed.

INTERVENTION

Patients were randomized to IGB or CGI.

MAIN OUTCOME MEASURES

Time to reach full feeds (160 cc/kg/d)(by design and real), daily weight, caloric intake, residual gastric volume and type of feeding (formula vs. human milk vs. both).

RESULTS

Five infants failed to complete the study because of death (n = 4) or protocol violation (n = 1). The two groups did not differ by birth weight or gestational age; infants fed via IGB reached full feeds earlier (p = 0.03) and had less delay in reaching full feeds than infants fed via CGI.

CONCLUSION

Contrary to our hypothesis, gravity IGB is more effective than CGI in improving feeding tolerance in small VLBW infants.

Upper gastrointestinal tract bleeding in critically ill pediatric patients

Similar to adults, children under physiologic stress can develop an imbalance in defensive (mucosal layer, motility) and aggressive (gastric acid, bile salts, enzymes) factors responsible for maintaining a healthy gastrointestinal tract. Hypoxia in the gastrointestinal tract likely disrupts the defensive factors, thereby permitting damage by aggressive factors to upper gastrointestinal epithelium that may progress to stress ulceration and acute upper gastrointestinal tract bleeding (UGIB). The basic pathophysiology may be similar in children and adults; however, differences in the time to developing ulceration, ulcer location, and number of ulcers have been reported. Functional development of the gastrointestinal tract is influenced by disease, gestational and postnatal age, and exposure to and type of enteral feedings, thereby confounding the development and prophylaxis of UGIB in neonates and infants. In addition, pharmacotherapy decisions are often complicated by drug administration issues and adverse effects.

Transpyloric enteral feeding in critically ill children

BACKGROUND

Nutrition is important in childhood because the child has a lower energy reserve than the adult and a higher demand for calories because of ongoing growth. In this study, the utility of transpyloric enteral feeding (TEF) in critically ill children was evaluated.

METHODS

A prospective, descriptive study was made in a pediatric intensive care unit of a tertiary pediatric center of 41 critically ill children, 30 after surgical procedures and 11 with nonsurgical illness, aged 8 days to 12 years, who received transpyloric enteral feeding with 8- or 10-Fr weighted feeding tubes. Analysis was made of tolerance and complications (vomiting, abdominal distension, excessive gastric residual, diarrhea, and pulmonary aspiration) of TEF.

RESULTS

The mean duration of TEF was 19.5 +/- 26.8 days (range, 1-120 days). The administration of sedative agents or inotropic drugs did not alter toleration of TEF. Eight of 12 patients treated with continuous infusion of vecuronium tolerated TEF without complications. Eleven gastrointestinal complications occurred in 10 patients, abdominal distension and excessive gastric residual in 7 (17%), and diarrhea in 4 (9.7%). In 7 patients gastrointestinal complications improved, with decreasing use or transitory interruption of TEF, but in 4 patients (9.7%), TEF had to be withdrawn. Gastrointestinal complications were more frequent in postsurgical than in nonsurgical patients (p < 0.001). No patients suffered from pulmonary aspiration, and the incidence of pulmonary infection and hepatic dysfunction diminished during TEF.

CONCLUSIONS

Transpyloric enteral feeding is a good method of nutritional support in critically ill children and can be used in patients treated with neuromuscular blocking agents. The frequency and severity of complications and the risks of pulmonary infection and hepatic dysfunction related to TEF are low.

A survey of gastric tube practices in level II and level III nurseries

Gastric tube placement practices were identified by a telephone survey of 113 Level II and Level III nurseries in five states (Indiana, Kentucky, Michigan, Ohio, and Pennsylvania). The purpose was to examine current practice and the rationale for practice with fragile preterm infants. Twenty-one percent of the nurseries inserted only orogastric (OG) tubes, 13% used only nasogastric (NG) tubes, and 66% used both NG and OG tubes. Of those that placed an NG or OG tube, 50% did so continuously, 5% placed it intermittently, and 45% placed the tube both continuously and intermittently, for different reasons. The average time interval to change a tube was 47.81 hr (+/-36.37), and the range was 8 to 168 hr. To calculate the length of tube insertion. 98% of nurseries measured from nose or mouth to earlobe then to the xiphoid process. To validate tube placement, 82% used an auscultation technique, and 60% had rules about replacing gastric aspirates. These findings indicate a great variability of practices in gastric tube placements and a reliance on tradition of practitioners working with preterm infants. The findings point to the need for further research on the most efficient practices and the importance of using research findings in nurseries.

A prospective randomized trial comparing continuous versus intermittent feeding methods in very low birth weight neonates

OBJECTIVE

To compare the effects of continuous versus intermittent feedings on physical growth, gastrointestinal tolerance, and macronutrient retention in very low birth weight infants ( < 1500 gm).

STUDY DESIGN

Very low birth weight neonates stratified by birth weight were randomly assigned to either continuous (24-hour) or intermittent (every 3 hours) nasogastric feedings. Feedings with half-strength Similac Special Care formula were initiated between day 2 and 3 and were advanced isoenergetically to goal. Daily weights, volume/caloric intakes, weekly anthropometric and dynamic skin-fold thickness measurements, and data on feeding milestones and clinical complications were collected. Nitrogen, carbohydrate, and fat balance studies were performed on a subset of male subjects.

RESULTS

Eighty-two neonates with birth weights between 750 and 1500 gm who were born between 27 and 34 weeks of gestation were randomly assigned to continuous (n = 42) and intermittent (n = 40) feeding groups. There were no significant differences in baseline demographics and severity of respiratory distress between groups. There were no significant differences in days to regain birth weight, days to full enteral feedings, days to discharge, and discharge anthropometric measurements between continuously fed and intermittently fed infants, both when evaluated together and according to 250 gm weight intervals. Retention rates of nitrogen, fat, total carbohydrate, and lactose were comparable in the continuously fed (n = 17) and intermittently fed (n = 13) male neonates. Very low birth weight neonates who were fed continuously did not have feeding-related complications.

CONCLUSION

Very low birth weight infants achieve similar growth and macronutrient retention rates and have comparable lengths of hospital stay whether they are fed with continuous or intermittent feedings.