Transpyloric Route Research Articles

Transpyloric versus gastric tube feeding for preterm infants

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

Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Paciente neurocrítico

Neurocritical patients require specialized nutritional support due to their intense catabolism and prolonged fasting. The preferred route of nutrient administration is the gastrointestinal route, especially the gastric route. Alternatives are the transpyloric route or mixed enteralparenteral nutrition if an effective nutritional volume of more than 60% cannot be obtained.Total calore intake ranges from 20–30kcal/kg/day, depending on the period of the clinical course, with protein intake higher than 20% of total calories (hyperproteic diet). Nutritional support should be initiated early.The incidence of gastrointestinal complications is generally higher to other critically-ill patients, the most frequent complicat ion being an increase in gastric residual volume. As in other critically-ill patients, glycemia should be closely monitored and maintained below 150mg/dL.

Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: neurocritical patient.

Neurocritical patients require specialized nutritional support due to their intense catabolism and prolonged fasting. The preferred route of nutrient administration is the gastrointestinal route, especially the gastric route. Alternatives are the transpyloric route or mixed enteral-parenteral nutrition if an effective nutritional volume of more than 60% cannot be obtained. Total calorie intake ranges from 20-30 kcal/kg/day, depending on the period of the clinical course, with protein intake higher than 20% of total calories (hyperproteic diet). Nutritional support should be initiated early. The incidence of gastrointestinal complications is generally higher to other critically-ill patients, the most frequent complication being an increase in gastric residual volume. As in other critically-ill patients, glycemia should be closely monitored and maintained below 150 mg/dL.

Capitulo 16: RECOMENDACIONES PARA EL SOPORTE NUTRICIONAL Y METABÓLICO ESPECIALIZADODEL PACIENTE CRÍTICO. ACTUALIZACIÓN.CONSENSO SEMICYUC-SENPE: PACIENTE NEUROCRÍTICO

Neurocritical patients require specialized nutritional support due to their intense catabolism and prolonged fasting. The preferred route of nutrient administration is the gastrointestinal route, especially the gastric route. Alternatives are the transpyloric route or mixed enteralparenteral nutrition if an effective nutritional volume of more than 60% cannot be obtained. Total calore intake ranges from 20-30 kcal/kg/day, depending on the period of the clinical course, with protein intake higher than 20% of total calories (hyperproteic diet). Nutritional support should be initiated early. The incidence of gastrointestinal complications is gene - rally higher to other critically-ill patients, the most frequent complication being an increase in gastric residual volume. As in other critically-ill patients, glycemia should be closely monitored and maintained below 150 mg/dL.

Gastric versus transpyloric feeding in severe traumatic brain injury: a prospective, randomized trial

To evaluate the efficacy of transpyloric feeding (TPF) compared with gastric feeding (GF) with regard to the incidence of ventilator-associated pneumonia in severe traumatic brain injury patients (TBI). Prospective, open-label, randomized study in an intensive care unit of a university hospital. One hundred and four CHI adult patients admitted for TBI between April 2007 and December 2008. Patients were included within the first 24 h after ICU admission and were followed until discharge or 30 days after admission. Patients were randomized to TPF or GF groups. They received the same diet, with 25 kcal kg(-1) day(-1) of calculated energy requirements and a nitrogen intake of 0.2 g N kg(-1) day(-1). Primary outcome was the incidence of early and ventilatory-associated pneumonia. Secondary outcomes were enteral nutrition-related gastrointestinal complications (GIC), days on mechanical ventilation, length of ICU stay and hospital stay, and sequential organ failure assessment score (SOFA). The TPF group had a lower incidence of pneumonia, OR 0.3 (95% CI 0.1-0.7, P = 0.01). There were no significant differences in other nosocomial infections. The TPF group received higher amounts of diet compared to the GF group (92 vs. 84%, P < 0.01) and had lesser incidence of increased gastric residuals, OR 0.2 (95% CI 0.04-0.6, P = 0.003). Enteral nutrition delivered through the transpyloric route reduces the incidence of overall and late pneumonia and improves nutritional efficacy in severe TBI patients.

How You Can Improve the Delivery of Enteral Nutrition in Your PICU

Dr. Mehta and colleagues 1 have provided an excellent opportunity for those of us who treat critically ill infants and children to examine and improve enteral nutrition (EN) delivery to our patients. Future research aimed at elucidating effective nutrition strategies to improve patient outcomes depends on early initiation and subsequent maintenance of optimal EN. If we are unable to reliably reach and sustain target intakes of EN, we will be unable to determine effects of specific EN therapies on patient outcomes. Many basic research questions in need of answers revolve around enteral feeding in the pediatric intensive care unit (PICU). When should we start EN? How should we administer EN? Are there advantages or disadvantages to specialized enteral formulas? Should initiation of EN be delayed until medical paralytic and vasoactive agents have been discontinued? What is the optimal amount of EN needed for trophic gastrointestinal effects? How is EN tolerance defined, and how can it be improved? When is the transpyloric route indicated? How do we define appropriate enteral intake targets? When should the goal rate be achieved? Which strategies will reduce intake deficits and ensure patients meet calorie and protein goals? How can we minimize the risks associated with enteral feeding? What nutrition and outcome benefits can be pursued through provision of optimal EN? Once we provide EN as an imperative therapy and use it to its fullest potential in the PICU, we can begin to examine the associated outcome benefits. 2 Other groups have reported their experiences with the inadvertent inadequate nourishment of PICU patients. 3-8 This publication is unique in that it focuses on a PICU population with a wide variation of ages and diagnoses (as is commonly encountered in a moderate- to large-sized PICU), exclusively looking at preventable obstacles to optimal EN during a 4-week period. What can you do to improve EN delivery in your PICU? Many of us who read the article by Mehta et al 1

Approach to Enteral Feeding in the PICU

The pediatric intensive care unit (PICU) environment poses unique challenges to achieving enteral nutrition (EN) goals for the critically ill child. Nutrition support in the PICU is often in conflict with the complexity of care provided to acutely ill children. A significant proportion of eligible patients do not receive optimal enteral nutrition for avoidable reasons. Early institution of EN is recommended and the gastric route is preferred because of ease of administration and reduced costs compared with the transpyloric route. In patients with poor gastric emptying or in cases where a trial of gastric feeding has failed, transpyloric or postpyloric feeding may be used to decrease the risk of aspiration and to improve enteral feed tolerance. However, there is no evidence of benefit for routine use of small bowel feeding in all patients admitted to the PICU. The placement of blind nasoenteric feeding tubes can be technically challenging, is not without complications, and requires local expertise and experience for successful placement and maintenance. A protocolized approach to selecting the optimal route and advancing enteral feedings may optimize EN delivery. Institutional practice guidelines based on consensus, available evidence, and national guidelines may decrease time to reaching caloric goal, improve protein balance, and potentially affect clinical outcomes. The rationale and challenges to the delivery and maintenance of optimal EN, and strategies to achieve optimal EN during critical illness, are discussed.

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...

Transpyloric versus gastric tube feeding for preterm infants.

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

Clotted Feeding Tubes Associated with Transpyloric Feeding of Premature Infant Formula

SummaryUse of a constant infusion of formula via transpyloric (TP) administration has been utilized as a means of supplying nutrition to the smaller (&lt; 1,200 g) premature infant. We have noticed that many of our infants being fed with a “reformulated” premature infant formula (Enfamil®) by TP route have experienced clotted feeding tubes in spite of regular irrigation with sterile water. A retrospective study was conducted over a 9‐month period comparing all infants fed via TP tube (5 French polyvinyl) and receiving either premature formula or their own mother's milk. An in vitro study was also conducted comparing the premature infant formula and a standard formula with human milk placed in TP tubes at the milk's own original pH and an alkaline pH. A total of 59 infants received feedings via TP infusion. Thirty‐nine were fed premature formula and 20 infants received human milk. There were no differences in birth weight and gestational age between the two groups. No infant receiving human milk developed a clotted feeding tube. However, of infants receiving premature formula, 15 of the 39 (389?) developed at least one clotted feeding tube. The clotted group was smaller in birth weight (mean of 1,044 vs. 1,418 g, p &lt; 0.001) and younger in gestational age (mean of 29 vs. 32 weeks, p &lt; 0.05) than the nonclotted group. There were no differences between the two groups in age of initial feeding or rate of infusion. The in vitro study showed that feeding tubes were completely occluded consistently after 24 h for the premature formula at both original pH (6.70) and alkaline pH (8.0). Neither the human milk nor standard formula developed any clot. We believe that premature infant formulas should be used with caution when administered via a TP route.

Letters to the Editor

Drs Minoli and Moro's response to our controlled prospective study of transpyloric and intermittent gavage feeding states that the nature of our study did not permit the demonstration of the major advantage of transpyloric feedings, ie, ability to administer large volumes of formula. Our study was controlled in that we attempted to achieve 120 kcal/kg/day intake by 10 days of age in both groups of babies fed either by intermittent gastric gavage or the transpyloric route. This was achieved without a difference in complication rate by either method of feeding.

611 CLOTTED TRANSPYLORIC FEEDING TUBES USING A PREMATURE FORMULA

Transpyloric (TP) feeding has been used as a method of feeding the smaller (<1200 gms) infant. We have noticed that many of our infants being fed with a “reformulated” premature infant formula (Enfamil) by TP route have developed clotted feeding tubes in spite of regular irrigation with sterile water. During a 9 month period, we studied all infants fed either the premature formula or their own mothers milk via TP route. An in vitro study was also conducted comparing the premature infant formula and a standard formula with human milk placed in TP tubes at the milk's own original pH and alkaline pH.Fifty-nine infants received TP feedings; 39 were fed premature formula and 20 received human milk. Birth weight and gestational ages between the two groups were similar. No infant receiving human milk developed a clotted feeding tube. However, 15 of the 39 (38%) infants receiving premature formula developed at least one clotted tube. The clotted group was smaller in birth weight (mean of 1044 vs. 1418 gms, p<.001), and younger in gestational age (29 vs. 32 weeks, p<.05) than the non-clotted group. There were no differences between the two groups in age of initial feeding or rate of infusion. The in vitro study showed that the tubes were completely occluded, consistently, after 24 hours for the premature formula at both original pH (6.70) and alkaline pH (8.0). Neither the human milk nor the standard formula developed any clot. We feel that premature infant formulas should be used with caution when used via the transpyloric route.