Legal Briefs: Aggressive Gavage Feeding and Gastric Perforation

Abstract

Twins at 341/7 weeks’ gestation were born to a 33-year-old healthy mother with a pregnancy remarkable for in vitro fertilization, diamniotic, dichorionic twins, and preterm labor. After a full course of antenatal corticosteroids, the twins were born by cesarean delivery. Twin A was a 2,410-g male infant with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. His examination findings were normal, and his complete blood count was unremarkable. On day 1 an order was written to begin feeding the infant with either breast milk or premature formula (20 calories per ounce). The feedings were to be initiated by gavage or nipple feeding at 5 mL every 3 hours for two times and subsequently to increase by 3 mL every 3 hours to a maximum feed of 20 mL/kg every 3 hours; a concomitant order to decrease the intravenous fluid rate was written as the oral feeds increased. On day 1 the infant fed well, taking each feed by nipple within 20 minutes. By the end of day 1, he was nippling 17 mL. The mean heart rate (HR) was 131 beats per minute. The abdominal girth, measured 4 times, was 28 cm. Instead of losing weight at this point, he gained 60 g. On day 2 the infant was initially nippling his feeds well, but when the amount reached 30 mL, he began feeding poorly; he needed stimulation to suck, was sleepy, needed chin support, and required an increasing time to nipple feed. At this point the nurse decided to gavage feed the infant to keep up with the feeding schedule of an increase of 3 mL every feed. The nurse inserted a nasogastric tube. She did not document the depth of insertion. The nurse maintained at her deposition that she inserted the …