Nasal versus oral route for placing feeding tubes in preterm or low birth weight infants
Hawes J, McEwan P, McGuire W
Cover sheet
Title
Nasal versus oral route for placing feeding tubes in preterm or low birth weight infantsReviewers
Hawes J, McEwan P, McGuire W
Dates
Date edited: 26/05/2004
Date of last substantive update: 27/04/2004
Date of last minor update: / /
Date next stage expected 30/10/2005
Protocol first published: Issue 1, 2003
Review first published: Issue 3, 2004
Contact reviewer
Ms Judith Hawes
Clinical Nurse Specialist
Pediatrics
The Hospital for Sick Children
555 University Avenue
Toronto
Ontario CANADA
M5G 1X8
Telephone 1: 1 416 813 7931
Facsimile: 1 416 813 6866
E-mail: judith.hawes@sickkids.ca
Contribution of reviewers
Judith Hawes (JH), Peter McEwan (PM), and William McGuire (WM) developed the protocol
for this review. WM and PM screened the title and abstract of all studies
identified by the above search strategy. JH and WM screened the full text
of the report of each study identified as of potential relevance. JH and
WM extracted the data separately, compared data, and resolved differences
by consensus. JH and WM completed the final review.
Internal sources of support
Tayside Institute of Child Health, Ninewells Hospital and Medical School, Dundee, UK
The Hospital for Sick Children, Toronto, CANADA
External sources of support
None
What's new
Dates
Date review re-formatted: / /
Date new studies sought but none found: / /
Date new studies found but not yet included/excluded: / /
Date new studies found and included/excluded: / /
Date reviewers' conclusions section amended: / /
Date comment/criticism added: / /
Date response to comment/criticisms added: / /
Text of review
Synopsis
Synopsis pending.
Abstract
Background
Enteral feeding tubes for preterm or low birth
weight infants may be placed via either the nose or mouth. Nasal placement
may compromise respiration. However, orally placed tubes may be more prone
to displacement, local irritation, and vagal stimulation.
Objectives
To assess the available evidence from randomised controlled
trials concerning the effects of nasally placed compared with orally placed
feeding tubes on growth and development, and the incidence of adverse consequences
in preterm or low birth weight infants.
Search strategy
We used the standard search strategy of
the Cochrane Neonatal Review Group, including electronic searches of the
Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library,
Issue 2, 2004), MEDLINE (1966 - April 2004), EMBASE (1988 - April 2004),
and CINAHL (1982- April 2004), conference proceedings, and previous reviews.
Selection criteria
Randomised or quasi-randomised controlled
trials that compared the use of the nasal versus oral route for placing feeding
tubes in preterm or low birth weight infants.
Data collection & analysis
We extracted data using the
standard methods of the Cochrane Neonatal Review Group, with separate evaluation
of trial quality and data extraction by each author, and analysis of data
using relative risk, risk difference and mean difference. Main results
We found only one eligible trial. Forty-two
infants participated in the study. This primary aim of the trial was to assess
the effect of oral versus nasal placement of feeding tubes on the incidence
of apnea and periodic breathing in preterm infants. The trial did not report
data on the pre-specified primary outcomes for this review (growth and development).
Reviewers' conclusions
There are insufficient data available
to inform practice. A large randomised controlled trial is required to determine
if the use of nasally placed feeding tubes compared with orally placed feeding
tubes improves growth and development, without increasing adverse consequences
in preterm or low birth weight infants. Background
The establishment of
safe oral feeding in preterm infants may be delayed because of poor co-ordination
of sucking and swallowing, neurological immaturity and respiratory compromise.
In such instances, enteral feeds may be delivered through a catheter passed
via the nose or via the mouth into the stomach or upper small intestine.
Gastric feeds may be delivered by bolus or continuous infusion, whereas feeds
are usually delivered into the upper small intestine by continuous infusion.
Current practice with regard to the route used for placement of enteral feeding
tubes varies among neonatal units (Shiao 1996).
Neonates are obligate nose breathers. Feeding tubes placed via the nasal
route can cause partial nasal obstruction, increased airway resistance, and
increased work of breathing (Stocks 1980; Greenspan 1990).
This increase in energy expenditure may affect growth and development. The
feeding catheter diameter determines the degree of airway obstruction. The
size of feeding tube placed is based on the current weight of the infant,
for example; 5 French gauge catheter for infants weighing less than 1500
grams, 8 French gauge for infants above 1500 grams. However, airway resistance
may differ between infants of similar weights due to differences in nasal
size and structure (Stocks 1980). Other factors
also contribute to the overall pattern of airway resistance. For example,
nasogastric intubation through the larger nare may increase airway resistance
as the infant is forced to breath through an airway of smaller calibre. In
addition, individual differences in nasal size may be acquired secondary
to the effects of nasally placed endotracheal tubes (Gowdar 1980).
Incorrect placement, or subsequent displacement, of feeding tubes
into the lower esophagus or into the lung can lead to aspiration, respiratory
compromise, and increased energy expenditure. These effects are potentially
detrimental to growth and development. Enteral feeding tubes passed via the
nose may be easier to secure to the face than orally placed tubes. In children,
orally placed enteral tubes are more frequently malpositioned compared to
nasally placed tubes (Ellett 1998). Furthermore,
orally placed tubes may be easier to displace as they can loop inside the
mouth. Repetitive movement of the orally placed tube may result in mucosal
trauma and may increase the incidence of apnea and bradycardia due to vagal
stimulation. Similarly, orally placed duodenal and jejunal tubes may be easier
to displace proximally, potentially increasing the risk of aspiration and
respiratory compromise. However, the number of duodenal or jejunal feeding
tubes passed via the oral route is expected to be very small.
The potential adverse consequences of feeding tube displacement
may vary depending upon whether the milk feed is delivered by bolus or by
continuous infusion. In the former case, the clinical effects of delivery
of milk to an inappropriate site may be immediately apparent, for example
acute cough, apnea and cyanosis, and bradycardia. If the feeds are delivered
continuously, especially if of low volume, then the clinical consequences
may not be so immediately apparent, but may be of longer term significance.
For example, silent milk aspiration pneumonitis may contribute to the development
of chronic lung disease.
Given these potential benefits and adverse effects, it is important
to evaluate the available data on nasal versus oral placement of enteral
feeding tubes in preterm infants.
Objectives
In preterm or low birth weight infants who
require enteral tube feeding, does the use of nasally placed feeding tubes
compared with orally placed feeding tubes improve growth and development,
without increasing the adverse consequences? We pre-specified the following subgroup analyses:
1. Very low birth weight (less than 1500 g) and /or infants of gestation
less than 32 weeks versus infants of greater weight or gestational age at
birth
2. Nasogastric versus orogastric enteral tube feeding, and orally versus nasally placed transpyloric tube feeding
3. Studies that compare bolus feeding methods only versus studies that compare continuous feeding methods only
Criteria for considering studies for this review
Types of studies
Controlled trials utilizing either random
or quasi-random patient allocation. The infant had to be the unit of allocation.
Studies that assessed use of the two feeding strategies in the same infant
were not eligible for inclusion. Types of participants
Preterm infants (less than 37 weeks'
gestation) and/or low birth weight infants (less than 2500 g) who require
partial or complete enteral tube feeding. Types of interventions
Trials comparing nasal versus oral
placement of enteral feeding tubes. Feeding tubes could have been in place
either continuously or placed just for the duration of feeding and removed
between feeds. Types of outcome measures
Primary outcomes: Growth and development
1. Short term (from study entry to study end) growth parameters: Weight
gain, linear growth, head growth, and change in skinfold thickness
2. Longer term (following discharge from hospital) growth parameters:
Weight gain, linear growth, head growth, and change in skinfold thickness
3. Neurodevelopmental outcomes during infancy and beyond using validated
assessment tools: Neurological evaluations and classifications of disability,
including auditory and visual, and disability developmental scores, for example,
Bayley Scales of Infant Development: Psychomotor Developmental Index and
Mental Developmental Index Secondary outcomes:
1. Days, from birth, to establish full enteral tube feeds (at least 150
ml/kg/day), independently of parenteral fluids or nutrition
2. Days, from birth, to establish full oral feeds (at least 150 ml/kg/day),
independently of parenteral fluids or nutrition or of enteral tube feeding
3. Days, from birth, to independence from assisted ventilation
4. Days, from birth, to independence from supplemental oxygen
5. Days, from birth, to discharge to home from hospital
6. Adverse events:
a. Episodes of apnea (cessation of breathing for a period of 20 seconds
or more) or bradycardia that required intervention from the caregiver (stimulation,
oronasal suction or toilet, increase in delivery of oxygen, assisted ventilation).
b. Aspiration pneumonia/pneumonitis: Clinical and /or radiological evidence
of lower respiratory tract compromise that has been attributed to covert
or evident aspiration of gastric contents.
c. Chronic lung disease: Additional oxygen requirement at 36 weeks' corrected gestation.
d. Necrotizing enterocolitis: At least two of the following features:
- Pneumatosis coli on abdominal X ray
- Abdominal distension or abdominal X ray with gaseous distension or frothy appearance of bowel lumen (or both)
- Blood in stool
- Lethargy, hypotonia, or apnea (or combination of these)
e. Episodes of gastric or esophageal perforations, intussusception, peritonitis
f. Nasal deformities requiring surgical correction that were attributed to enteral feeding tubes
Search strategy for identification of studies
We used
the standard search strategy of the Cochrane Neonatal Review Group, including
electronic searches of the Cochrane Central Register of Controlled Trials
(CENTRAL, The Cochrane Library, Issue 2, 2004), MEDLINE (1966 - April 2004),
EMBASE (1988 - April 2004), and CINAHL (1982- April 2004). We did not apply
a language restriction. The search strategy used the following text words
and medical subject headings:
1. "Infant-Newborn"/ all subheadings,
2. infan*,
3. neonat*,
4. newborn,
5. prematur*,
6. preterm,
7. explode "Intubation, Gastrointestinal"/ all subheadings,
8. nasal*,
9. oral*,
10. gastric,
11. nasogastric,
12. orogastric,
13. 1 or 2 or 3 or 4 or 5 or 6,
14. 7 or 8 or 9 or 10 or 11 or 12,
15. 13 and 14.
The search outputs were limited with the relevant search filters for clinical trials.
We examined references in studies identified as potentially relevant.
We hand searched the abstracts presented at Society for Pediatric Research
and European Society for Pediatric Research, published in the journal Pediatric
Research between 1990 and 2002 inclusive.
Methods of the review
1. William McGuire (WM) screened the title and abstract of the studies identified
by the above search strategy. WM and Judith Hawes (JH) re-screened the full
text of the report of each study identified as of potential relevance. Only
studies that met all of the pre-specified criteria were eligible for inclusion.
The reviewers resolved any disagreements by discussion. 2. We used the criteria and standard methods of the Cochrane Neonatal
Review Group to assess the methodological quality of the included trial.
We evaluated trial quality in terms of allocation concealment, blinding of
parents or carers and assessors to intervention, and completeness of assessment
in all randomised individuals. We planned to request additional information
from the report authors if there was a need to clarify methodology and results.
3. We used a data collection form to aid extraction of relevant information
and data from the included study. Two reviewers extracted the data separately,
compared data, and resolved any differences by consensus.
4. We used the standard methods of the Cochrane Neonatal Review Group
to analyse and synthesize the data. The Cochrane Neonatal Review Group advises:
a. estimate the treatment effects of individual trials and examine heterogeneity
between trial results by inspecting the forest plots and quantifying the
impact of heterogeneity in any meta-analysis using a measure of the degree
of inconsistency in the studies' results (I- squared statistic).
b. if there is evidence of statistical heterogeneity, explore the possible
causes and perform sensitivity analyses as appropriate.
c. use a fixed effects model for meta-analyses.
d. for categorical data, express the effects as relative risk, risk difference,
and number needed to treat, with respective 95% confidence intervals.
e. for continuous data, express the effects as weighted mean difference and 95% confidence interval.
Description of studies
We identified only two studies which appeared relevant after the first round of screening (van Someren 1984; Daga 1999). Only van Someren 1984
fulfilled the inclusion criteria (see table 'Characteristics of Included
Studies'). This study was undertaken in the early 1980's in a tertiary neonatal
centre in the United Kingdom. Forty-four preterm infants were enrolled in
the study. The birthweight of the infants ranged from 1280 g to 1760 g, and
gestational ages ranged from 30 to 34 completed weeks. Twenty-two infants
were randomised to receive nasoenteric feeding, and 22 infants to oroenteric
feeding. Some of the infants in each group received transpyloric feeds, but
the report of the trial does not state how many. The oral feeding tube was
secured to the palate with a grooved orthodontic appliance (Sullivan 1981).
The trial investigators excluded two infants who had been randomly allocated
to the oroenteric feeding group as parental consent was not obtained to allow
the palatal device to be applied. Infants were recruited to the trial at a postnatal age of between one
and 12 days and remained in the study until breast or bottle-feeding had
been established. It is not clear whether the intervention continued until
full (rather than partial) breast or bottle-feeding was established. The
primary outcome of the trial was the incidence of episodes of periodic breathing
and central apnea assessed by respiratory and polygraphic monitoring on the
third and seventh days after randomisation. The investigators also assessed
weight gain during the first two weeks of participation, the incidence of
local complications such as oral ulceration, and a composite "sickness score"
(mainly a score of the need for and duration of respiratory support).
We did not include a second study (Daga 1999)
as the unit of allocation was not the patient. Instead, infants (term and
preterm) were studied during consecutive nasogastric and orogastric feeds.
(see table 'Characteristics of Excluded Studies').
Methodological quality of included studies
(See table: Characteristics of Included Studies). van Someren 1984:
The method of randomisation used was not stated. The primary outcomes, respiratory
monitoring data recorded either on the third or seventh day, were reported
for only 29 of 42 participating infants. Results
Primary outcomes:
1. Short term (from study entry to study end) growth parameters: van Someren 1984
did not report data on any growth parameters from study entry until study
end. However, the investigators did report weight gain (g/kg/day) for two
periods within the trial (0-7 days, and 8-14 days after randomisation) in
the 37 infants who remained in the trial until at least 14 days post randomisation.
There was a statistically significantly higher rate of weight gain in the
first week after randomisation in the infants fed via an orally placed enteric
feeding tube: nasal: 0.6 g/kg/day versus oral: 8.3 g/kg/day. In the second
week after randomisation there was not a statistically significant difference
in the rate of weight gain: 13.6 g/kg/day versus 12.3 g/kg/day. However,
variance estimators were not reported. There were no reported data on other
growth parameters. 2. Longer term growth: Not assessed/reported.
3. Neurodevelopmental outcomes: Not assessed/reported.
Secondary outcomes:
The only other outcomes reported were episodes of apnea or bradycardia.
These were assessed with respiratory and polygraphic monitoring in a total
of 29 infants on day three or day seven after randomisation. The trial did
not find any statistically significant differences in the frequency of episodes
of apnea between the groups on the third day post randomisation, but on the
seventh day the nasal placement group had statistically significantly more
recorded episodes of apnea. However, the definition of apnea applied was
cessation of breathing for five seconds or more, rather than the more commonly
used definition (cessation of breathing for a period of 20 seconds or more)
that we pre-specified for this review (NIH 1987).
Discussion
We have found one small randomised controlled
trial that compared the nasal versus the oral route for placing feeding tubes
in preterm or low birth weight infants. In this trial the oral tube was secured
to an palatal appliance in order to limit displacement or looping inside
the mouth. The trial assessed short term outcomes only and found very limited
evidence that the route of enteral feeding tube placement affected growth
or the incidence of adverse events. The trial findings are limited by several
methodological issues. The method of randomisation used was not stated in
the published report so it is possible that allocation was not concealed
and therefore the assignment of infants to one or other feeding route could
have been predicted. This may have allowed bias in allocation of infants
that could have affected the outcomes independently of the intervention.
The average postnatal age of entry into the study was two days for the nasal
group compared to six days for the oral group. This difference may have been
a factor in the lower rate of weight gain in the nasal group during the first
seven days of assessment. More infants in the oral group would have already
transitioned through the normal postnatal weight loss that occurs during
the first week of postnatal life, whereas many infants in the nasal group
were still in this postnatal weight loss phase. Furthermore, the difference
in weight gain was not sustained in the 8-14 days postnatal study period.
The finding of a difference in the frequency of apnea identified on the seventh
day after entry into the trial should also be interpreted cautiously. Follow
up assessment was incomplete and the definition of apnea used in the trial
was different from that of consensus agreements of the definition of clinically
significant apnea. Finally, the method of oral placement of the feeding tube
relied on the use of a palatal appliance to secure the tube, thus limiting
the applicability of the study findings to the more common practice of securing
orally placed tubes at the lips rather than intraorally. Reviewers' conclusions
Implications for practice
The data recovered in this review
do not provide sufficient evidence to inform practice regarding whether the
nasal versus the oral route of enteral feeding tube placement is preferable
for preterm or low birth weight infants. Implications for research
A large randomised controlled
trial is needed to determine if the use of nasally placed feeding tubes compared
with orally placed feeding tubes improves growth and development without
increasing adverse consequences in preterm or low birth weight infants who
require enteral tube feeding. Acknowledgements
Potential conflict of interest
None
Characteristics of included studies
| Study | Methods | Participants | Interventions | Outcomes | Notes | Allocation concealment |
| van Someren 1984 | Blinding of randomisation: Can't tell Blinding of intervention: No Complete follow-up: Yes Blinding of outcome measurement: No
| 42 preterm infants who required feeding via an enteral feeding tube.
Neonatal Research Unit, The London Hospital Medical College, London. Early 1980's. | 22 infants allocated to feeding via an oroenteric tube, 20 infants via a nasoenteric tube. | Episodes
of apnea and periodic breathing assessed with respiratory and polygraphic
monitoring on day 3 and day 7 after randomisation. |
| B |
Characteristics of excluded studies
| Study | Reason for exclusion |
| Daga 1999 | Infants
(term and preterm) were studied during consecutive nasogastric and orogastric
feeds. As the unit of allocation was not the patient, the study was ineligible
for inclusion in this review. |
References to studies
References to included studies
van Someren 1984 {published data only}van
Someren V, Linnett SJ, Stothers JK, Sullivan PG. An investigation into the
benefits of resiting nasoenteric feeding tubes. Pediatrics 1984;74:379-83.
References to excluded studies
Daga 1999 {published data only}Daga SR, Lunkad NG, Daga AS, Ahuja VK. Orogastric versus nasogastric feeding of newborn babies. Tropical Doctor 1999;29:242-3.
* indicates the primary reference for the study
Other references
Additional references
Ellett 1998Ellett
ML, Maahs J, Forsee S. Prevalence of feeding tube placement errors and associated
risk factors in children. MCN. The American Journal of Maternal Child Nursing
1998;23:234-9.
Gowdar 1980
Gowdar
K, Bull MJ, Schreiner RL, Lemons JA, Gresham EL. Nasal deformities in neonates.
Their occurrence in those treated with nasal continuous positive airway pressure
and nasal endotracheal tubes. American Journal of Diseases of Children 1980;134:954-7.
Greenspan 1990
Greenspan
JS, Wolfson MR, Holt WJ, Shaffer TH. Neonatal gastric intubation: differential
respiratory effects between nasogastric and orogastric tubes. Pediatric Pulmonology
1990;8:254-8.
NIH 1987
National
Institutes of Health Consensus Development Panel on Infantile Apnea and Home
Monitoring. Consensus statement. Pediatrics 1987;79:292-299.
Shiao 1996
Shiao
SY, DiFiore TE. A survey of gastric tube practices in level II and level
III nurseries. Issues in Comprehensive Pediatric Nursing 1996;19:209-20.
Stocks 1980
Stocks J. Effect of nasogastric tubes on nasal resistance during infancy. Archives of Disease in Childhood 1980;55:17-21.
Sullivan 1981
Sullivan PG, Haringman H. An intra-oral appliance to stabilise orogastric tubes in premature infants. Lancet 1981;1:416-7.
Notes
Published notes
Amended sections
Cover sheet
Synopsis
Abstract
Background
Objectives
Criteria for considering studies for this review
Search strategy for identification of studies
Methods of the review
Description of studies
Methodological quality of included studies
Results
Discussion
Reviewers' conclusions
References to studies
Other references
Characteristics of included studies
Characteristics of excluded studies
Comparisons, data or analyses
Contact details for co-reviewers
Dr Peter McEwan, MRCPCH
Specialist Registrar
Department of Paediatrics
Tayside University Trust Hospitals
University of Dundee
Ninewells Hospital and Medical Centre
Dundee
Scotland UK
DD6 8DL
Telephone 1: +44 1382 633942
Facsimile: +44 1382 632597Dr William McGuire
Senior Lecturer
Tayside Institute of Child Health
University of Dundee
Tayside Institute of Child Health
Ninewells Hospital and Medical School
Dundee
Scotland UK
DD6 8DL
Telephone 1: 0044 1382 633942
Facsimile: 0044 1382 632597
E-mail: w.mcguire@dundee.ac.uk
Secondary contact person's name: Tom Fahey
This review is published as a Cochrane review in The
Cochrane Library 2004, Issue 3, 2004 (see www.CochraneLibrary.net for information).
Cochrane reviews are regularly updated as new evidence emerges and in response
to comments and criticisms, and The Cochrane Library should be consulted
for the most recent version of the Review.
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