The importance of nutrition in the pediatric intensive care unit (PICU) has been recognized for many years. Mortality, morbidity, and length of stay all are increased in malnourished ICU patients (1–7). Studies have shown decreased risk of infection in patients who are enterally fed compared with those who are not (8,9). Enteral feeding is thought to decrease bacterial translocation (10). Although nasogastric feeding has been used extensively, many ICUs have started feeding transpylorically. We reviewed our transpylorically fed patients to determine whether we were able to achieve and maintain full energy support and whether any complications developed.
PATIENTS AND METHODS
Approval for the study was granted by the institutional review board, and the need for informed consent was waived. Patients who were hospitalized in the 20-bed PICU and who were believed to have been fed transpylorically from July 2000 until June 2004 were selected from the PICU database. The following information was collected from the chart review: age, sex, diagnosis, length of PICU stay, number of tubes placed, duration of time tube was in place, location of tube on radiograph (based on the radiologist's interpretation of the radiograph), whether the patient was ventilated and length of ventilation, the length of time feedings were held before extubation, number of hours to reach goal energy units, duration of full support from transpyloric feeding, and complications related to transpyloric feeding. Full energy support was determined by review of the daily notes written by the nutritionist on service.
During the period reviewed for the study, either a 6-F or an 8-F Coreflo feeding tube was placed, depending on the size of the patient and the discretion of the physician placing the tube. A standard protocol was used for placing the tube. This involved premeasurement of the correct distance and administration of metoclopramide before the tube was placed. The tube was placed nasogastrically and then advanced through the pylorus while air was slowly injected into the tube. When the tube was thought to be in a transpyloric position, a radiograph was taken to confirm placement.
All statistics are presented as mean ± standard deviation and median and range. The Student t test and χ2 test were performed, and P < 0.05 were considered significant.
A total of 240 patients were identified. Ten patients were excluded because the chart was incomplete or could not be found. Thirty patients originally identified were not fed transpylorically, and therefore 190 charts were reviewed in detail for this study.
The baseline patient characteristics and patient variables can be seen in Table 1. The most common primary diagnosis was respiratory illness, followed by neurological and cardiac disorders. The median length of stay in the PICU was 12 days for these transpylorically fed patients. A total of 228 transpyloric feeding tubes were placed in 190 patients (1.2 tubes per patient). The tubes were in place for a median length of 9 (3–104) days.
One hundred forty-eight patients receiving transpyloric feeding underwent mechanical ventilation for a median length of 9 (0.33–230) days. All of the patients receiving transpyloric feeding were receiving ranitidine, and all of the patients undergoing mechanical ventilatory support also had nasogastric tubes. Patients undergoing ventilation had their feedings held for an average of 2.8 hours before extubation, and 43 patients (29%) were extubated while the feedings continued. Five of the patients who were extubated while receiving feedings had to be reintubated, and no episodes of aspiration occurred.
The feeding characteristics can be seen in Table 2. Full energy support was reached in 182 patients (96%). The average time to reach full-volume feedings was 21.6 hours, and for full energy support it was 44 hours. However, many patients were receiving trophic feedings and slowly advanced because of systemic illness. When these patients were excluded from analysis, a shorter time was needed to reach full energy support (34 ± 33 hours). There was a significant difference in the time required to reach full energy units in patients younger than 1 year of age compared with patients older than 1 year of age (P = 0.008). Overall, transpyloric feeding provided full energy support for an average of 12 days. Even in nonintubated patients with respiratory distress, transpyloric feeding allowed full energy support for an average of 4.2 ± 3.4 days during their 6.7 ± 3.5 days in the PICU.
The most frequent complication seen was inadvertent removal, malposition, or malfunction of the tube, which was seen in 43 patients (22.6%). Diarrhea was seen in 13 patients (6.8%) and generally responded to reduction of the energy unit density or change to an elemental formula. Four patients experienced abdominal distension that necessitated holding feedings, which were restarted after clinical improvement and negative results of radiographic studies. Gastritis diagnosed by endoscopy developed in 2 patients, who were changed to nasogastric feeding with resolution of symptoms.
The most serious complication was necrotizing enterocolitis (NEC), which occurred in 4 patients (2.1%). In 2 of the patients, transpyloric feeding was restarted after a period of total parenteral nutrition. Both these patients had cyanotic heart disease and were receiving low-dose inotropic support at the time of the NEC. Neither was hypotensive, and 1 of the patients had reached full feedings. Another patient with cyanotic heart disease experienced NEC and an intestinal stricture that required surgery and was subsequently fed by a gastrostomy tube. This patient had been receiving full feedings but then experienced hypotension and was subsequently found to have NEC. The fourth patient did not have heart disease, was receiving full feedings when NEC was diagnosed, and ultimately received nasogastric feeding. There was a significant difference in the number of cyanotic patients who experienced NEC in comparison with acyanotic patients (P = 0.001).
One patient death was directly attributable to a transpyloric feeding tube. This patient had a residual coarctation and severe gastroesophageal reflux disease, and both oral and nasogastric feeding had been unsuccessful for 4 weeks before a transpyloric tube was placed. The patient experienced an intestinal perforation the day after transpyloric tube placement and died of intraabdominal sepsis despite surgical repair. In the operating room the perforation was seen to be located at the tip of the feeding tube.
In this retrospective study we found that transpyloric feeding provided full nutrition to 96% of these PICU patients. This is a greater percentage of patients than has been previously reported in other studies (11,12). We attribute this to an active nutritional service that makes daily rounds and to physicians being proactive in placing transpyloric feeding tubes. When we exclude patients who had limits placed on their enteral feeding because of systemic illnesses, we achieved full support in nearly all of the patients (98%).
In many centers, infants with respiratory syncytial virus bronchiolitis and pertussis who are not intubated are unlikely to be fed for several days until their breathing has returned to normal. We found transpyloric tubes to be essential in these infants for the institution of early enteral and sustainable nutrition. These patients received full energy support for more than half of their PICU stay. Only 1 of these infants did not reach full energy level, and no episodes of aspiration pneumonia were seen.
During this study, transpyloric feeding had become the standard of care for intubated patients in our PICU. Others have reported delayed gastric emptying in a variety of patients receiving mechanical ventilation, and this has been associated with increased gastric residuals (13,14). With little information on normal gastric residuals in pediatric patients, we found that this accounted for limitations in achieving full feeding before transpyloric feeding was instituted. A low incidence of feeding intolerance was found in patients in this study who were being fed transpylorically.
Another problem with nasogastric feeding that we have observed in patients receiving ventilation is that the feedings are held 6 hours before extubation. In some cases feedings are held several times before a patient is extubated. We found in this study that on average, feedings were held only 2.8 hours before extubation in the transpylorically fed patients, and no complications were found when reintubation was required, as others have reported (15).
We did find a delay in achievement of adequate energy levels in infants because they were initially given 20-kcal formulas and advanced to maintenance fluids, but not energy units. Older patients receiving 30-kcal formulas reached full energy levels more quickly, so our new protocol is to give all infants 24-kcal formulas initially unless there is a history of feeding intolerance.
Finally, we noted an incidence of 43% (3 of 7 patients) of NEC in patients with cyanotic heart disease who were receiving transpyloric feeding. A recent article also noted 2 cases of NEC in postcardiac surgery neonates who were fed transpylorically and who were thought to have other significant risk factors for NEC (16). Our 3 cyanotic infants who experienced NEC were at various points in their feeding regimen. It is possible that NEC could have developed in the infants receiving nasogastric feeding, but we believe that the cyanosis, together with the instillation of formula with increased energy unit density directly into the intestine, may have put them at higher risk for NEC. Our policy has now changed so that we do not feed cyanotic infants transpylorically.
We did find 1 death directly attributable to transpyloric tube usage. No difficulties were noted during placement of the feeding tube and we are not aware of any other reports of bowel perforation from these types of nonweighted tubes except in premature neonates. It is unclear what role the residual coarctation of the aorta played in this case.
In summary, transpyloric feeding allowed us to achieve and maintain full feeding in patients who otherwise may have presented feeding problems. This, coupled with an active nutritional support service, accounted for optimal enteral nutrition in our patients. We noted a high incidence of NEC in patients with cyanotic heart disease, however, and we advise caution in the use of transpyloric feeding in these patients.
The author recognizes the limitations of this small retrospective analysis. A prospective study would be helpful in deciding whether transpyloric feeding offers benefits over nasogastric feeding and whether complications occur more frequently with transpyloric feeding.
The author thanks Shannon Cunningham, RD, and Emily Burritt, RD, of Pediatric Nutrition, and Karen Daniels from Medical Records for their contributions.
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