Feeding challenges of the very low birth weight infant

Abstract

A baby boy was born at 25 weeks’ gestation. He was placed on a ventilator and received the standard of care for very low birth weight infants. At 29 weeks, he was diagnosed with a grade IV intraventricular hemorrhage and cystic periventricular leukomalacia. He was started on total parenteral nutrition and progressed to enteral feeding by gavage. Nipple feedings were initiated at 35 weeks. During the first attempt at nipple feeding, the baby experienced significant apnea with associated bradycardia. During the second attempt at nipple feeding (1 day later), he required chest compressions caused by apnea, which was followed by cardiac arrest. A third nipple feeding was attempted 2 days later. For the third feeding, the infant was placed on a recording system for the purpose of electronically documenting the sequence of any physiological changes during the nipple feeding. The recording system collected respiration rate, respiratory wave, raw electrocardiogram data, heart rate, and oxygen saturation. Within 30 seconds of the initiation of nipple feeding, his respiratory rate was 0, the heart rate decreased to 30 beats per minute, and the arterial oxygen saturation dropped below 75%. The attending physician reviewed the data to evaluate the extent of feeding dysfunction. A gastrointestinal consult was conducted and a gastrostomy tube (GT) was inserted. Discharge teaching for the infant’s parents, both aged 15, included GT feeding and the precaution to not bottle-feed the infant for the time being. All feedings were to be given at home via the GT. At the 4-month high-risk neonatal follow-up appointment, the mother admitted she had been exclusively feeding the infant via the bottle. The neonatologist conducted a nipple feeding during the clinic appointment. The infant was electronically monitored and data recorded during this feeding. The physiologic difference between this feeding and the one in the hospital was dramatic. The nipple feeding was completed without apnea. Arterial oxygen saturation and pulse rate were also monitored. Both remained within normal limits. The GT was permanently removed the next week. The cause of the initial feeding dysfunction was never determined.