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Transpyloric versus gastric tube feeding for preterm infants

  1. Julie Watson1,
  2. William McGuire2,*

Editorial Group: Cochrane Neonatal Group

Published Online: 28 FEB 2013

Assessed as up-to-date: 30 JUN 2012

DOI: 10.1002/14651858.CD003487.pub3


How to Cite

Watson J, McGuire W. Transpyloric versus gastric tube feeding for preterm infants. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD003487. DOI: 10.1002/14651858.CD003487.pub3.

Author Information

  1. 1

    University of York, Maternal and Infant Health and Care, Yorkshire and the Humber Health Innovation and Education Cluster, Department of Health Sciences, York, UK

  2. 2

    Hull York Medical School & Centre for Reviews and Dissemination, University of York, York, Y010 5DD, UK

*William McGuire, Hull York Medical School & Centre for Reviews and Dissemination, University of York, York, Y010 5DD, UK. William.McGuire@hyms.ac.uk.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 28 FEB 2013

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Characteristics of included studies [ordered by study ID]
Drew 1979

MethodsQuasi-randomised controlled trial


Participants66 appropriate for gestational age infants of birth weight < 1500 g

Infants who were receiving assisted ventilation were not included


InterventionsNasojejunal (N = 32) versus nasogastric feeding (N = 34) until achieving an enteral intake of 200 ml/kg/day


OutcomesGain in weight, length, and head circumference prior to hospital discharge, calorie intake, and adverse events (including death, necrotising enterocolitis, intestinal perforation, and aspiration pneumonia)


NotesSetting: University of Melbourne, Australia, 1974-1977


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskAlternate allocation

Allocation concealment (selection bias)High riskAlternate allocation

Blinding (performance bias and detection bias)
All outcomes
High riskUnblinded

Incomplete outcome data (attrition bias)
All outcomes
High riskNasojejunal group: 11 infants withdrawn after allocation; 1 required assisted ventilation, 10 because of failure to pass the feeding tube

Nasogastric group: 11 infants withdrawn after allocation; 5 required assisted ventilation, 4 died within 24 hours, 2 had "insufficient data to compute"

Laing 1986

MethodsQuasi-randomised controlled trial


Participants100 infants allocated, of whom 80 were included. These were infants of birth weight < 1500 g (and appropriate for gestational age - between the 10th and the 90th centile for birth weight)


InterventionsContinuous nasoduodenal (N = 45) versus intermittent nasogastric tube feeding (N = 35) for 7 weeks


OutcomesWeight and length gain, head growth prior to hospital discharge, and adverse events (including death, necrotising enterocolitis, intestinal perforation, and aspiration pneumonia)


NotesSetting: University of Edinburgh, 1982-1984

There were statistically significant differences in the baseline characteristics of the 2 cohorts that may have affected clinical outcomes. The group of infants who were allocated to nasoduodenal feeding were of statistically significantly lower gestational age, and had statistically significantly lower Apgar scores at 1 minute and at 5 minutes. It seems unlikely that these differences were due to chance. We consider that because of the lack of allocation concealment it is likely that some of the less mature and sicker infants were allocated preferentially to nasoduodenal feeding


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskAlternate allocation

Allocation concealment (selection bias)High riskAlternate allocation

Blinding (performance bias and detection bias)
All outcomes
High riskUnblinded

Incomplete outcome data (attrition bias)
All outcomes
High riskGrowth data were reported only for infants who had successfully tolerated the allocated feeding route: 16 of the 45 infants allocated to the nasoduodenal route, and 25 of the 35 infants allocated to the nasogastric route.

In this review, the data on adverse events on all 80 infants included have been extracted from the report

Macdonald 1992

MethodsRandomised controlled trial


Participants43 infants of birth weight < 1400 g

Infants fed with expressed human breast milk were excluded from the trial


InterventionsContinuous nasoduodenal tube feeding (N = 15) versus bolus nasogastric (N = 15) or continuous nasogastric (N = 13) tube feeding until a weight of 1600 g was attained


OutcomesGain in weight, head circumference, and length in surviving infants until 36 weeks gestation, calorie intake, time to achieve enteral feeding, plasma albumin, transferrin, urea, and alkaline phosphatase levels, and adverse events (including necrotising enterocolitis, intestinal perforation, and aspiration pneumonia)


NotesSetting: University of Glasgow, late 1980s

The data from the bolus nasogastric and continuous nasogastric feeding groups have been combined in this review

The number of infants who died in each group is reported. Growth data are reported only for those infants who survived to the end of the study period

Transpyloric group: 15 infants allocated
- 10 infants completed study - growth data available
- 3 infants died before milk feeding established - no growth data available
- 1 infant transferred to another hospital - no growth data available
- 1 infant failure to position tube - no growth data available
Nasogastric group: 28 infants (13 in the continuous NG feed group, 15 in the bolus NG feed group)
- 24 "completed study" - growth data available
- 3 infants died before milk feeding established - no growth data available
- 1 infant transferred to another hospital - no growth data available


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot stated

Allocation concealment (selection bias)Low riskSealed envelopes containing random sequence

Blinding (performance bias and detection bias)
All outcomes
High riskUnblinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskNear-complete follow-up; see notes above

Pereira 1981

MethodsRandomised controlled trial


Participants53 infants of birth weight < 1700 g or gestational age < 33 completed weeks


InterventionsContinuous nasojejunal (N = 26) versus intermittent nasogastric tube feeding (N = 27) until breast feeding was established


OutcomesWeight gain and head growth prior to hospital discharge, calorie intake, and adverse events (including death, necrotising enterocolitis, intestinal perforation, and aspiration pneumonia)


NotesSetting: University of Colorado, late 1970s

There were not any standard deviations reported with the growth velocity data


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot reported

Allocation concealment (selection bias)Unclear riskNot reported

Blinding (performance bias and detection bias)
All outcomes
High riskUnblinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskNear-complete follow-up

Pyati 1976

MethodsRandomised controlled trial


Participants19 infants of birth weight < 1500 g. All participants were of birth weight "appropriate for gestational age"


InterventionsContinuous nasojejunal (N = 8) versus nasogastric feeding (N = 11) with standard-calorie formula milk started within 30 hours after birth and continued until 3 weeks after birth


OutcomesCalorie intake and weight gain until 3 weeks after birth


NotesSetting: Chicago Medical School, early 1970s

There were limited numerical data reported. We have not been able to contact the investigators to obtain any unpublished data


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot reported

Allocation concealment (selection bias)Unclear riskNot reported

Blinding (performance bias and detection bias)
All outcomes
High riskUnblinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskNear-complete follow-up

Roy 1977

MethodsRandomised controlled trial


Participants21 infants of birth weight < 1500 g and appropriate for gestational age
Infants who required assisted ventilation or phototherapy were excluded


InterventionsContinuous nasojejunal (N = 12) versus intermittent nasogastric tube feeding (N = 9) for 7 days


OutcomesGain in weight, length, and skinfold thickness prior to hospital discharge, and stool frequency


NotesSetting: University of Toronto, early 1970s

3 infants in the nasojejunal tube feeding group who developed complications were withdrawn, and not included in the growth comparison
1 infant was withdrawn because of persistent displacement of the tube back to the stomach. A second infant developed "transitory but extensive abdominal distention". Since it is unclear whether this complication resulted in cessation of enteral feeding, we have not classified this as an adverse event. The third infant developed peritonitis following duodenal perforation (confirmed at laparotomy)


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot reported

Allocation concealment (selection bias)Unclear riskNot reported

Blinding (performance bias and detection bias)
All outcomes
High riskUnblinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskNear-complete follow-up; see notes above

Van Caillie 1975

MethodsQuasi-randomised controlled trial


Participants11 preterm infants of birthweight < 1300 g


InterventionsAllocated alternately to continuous nasoduodenal (N = 6) versus continuous nasogastric tube feeding (N = 5) for 40 days


OutcomesWeight gain prior to hospital discharge, calorie intake, adverse events (including death, necrotising enterocolitis, intestinal perforation, and aspiration pneumonia)


NotesSetting: University of Texas, USA. Early 1970s

The report gives outcome data on all infants who entered the study. However, one of the infants who had been allocated to nasoduodenal feeding died at aged 30 hours. This infant was included in the analysis of adverse outcomes, but not included in the calculations of short-term growth parameters presented by the investigators


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskAlternate allocation

Allocation concealment (selection bias)High riskAlternate allocation

Blinding (performance bias and detection bias)
All outcomes
High riskUnblinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskNear-complete follow-up; see notes above

Wells 1975

MethodsQuasi-randomised controlled trial


Participants22 infants of birth weight < 500 g and of gestational age < 32 completed weeks


InterventionsContinuous nasojejunal (N = 11) versus intermittent nasogastric tube feeding (N = 11) for 21 days


OutcomesWeight gain for the 21-day study period, calorie intake, and adverse events (death, necrotising enterocolitis)


NotesSetting: Wisconsin Perinatal Center, early 1970s

3 of the infants who had been allocated to the nasogastric feeding group were switched during the study to nasojejunal feeding because of concern about the level of calorie intake. These infants were not included in the analysis of growth rates. There were insufficient data for 1 other infant, who had been allocated to nasojejunal feeding, to be included in the analysis of growth outcomes presented in the report


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskAlternate allocation

Allocation concealment (selection bias)High riskAlternate allocation

Blinding (performance bias and detection bias)
All outcomes
High riskUnblinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskNear-complete follow-up; see notes above

Whitfield 1982

MethodsQuasi-randomised controlled trial (alternate months)


Participants44 appropriate for gestational age preterm infants of birth weight 1000 to 1500 g


InterventionsContinuous nasojejunal (N = 28) versus intermittent nasogastric tube feeding (N = 16) until attaining a weight of 1500 g


OutcomesWeight gain and head growth until 6 months old, and adverse events (death, necrotising enterocolitis, intestinal perforation)


NotesSetting: University of Sheffield. Late 1970s

1. Short-term weight gain data are presented for only those infants with birth weight less than 1.4 kg - i.e. these data are not presented for infants of birth weight 1.4 to 1.5 kg
- Transpyloric group: 20 infants
- NG group: 10 infants

2. Longer-term growth data: presented for infants for whom a weight at the expected data of delivery was available:

At EDD:
- Transpyloric group: 21 infants available for follow-up (4 infants had died, 2 infants had been transferred to another hospital, 1 infant had been "withdrawn" because of "intractable abdominal distension", and the reason for the non-availability of the unaccounted for infant is unclear from the report)
- NG group: 15 infants available for follow-up (1 infant had been transferred to another hospital)

At EDD +3 months - further loss to follow-up occurred, leaving:
- Transpyloric group: 18 infants available for evaluation
- NG group: 15 infants available for evaluation

At EDD + 6 months - further loss to follow-up occurred, leaving:
- Transpyloric group: 16 infants available for evaluation
- NG group: 15 infants available for evaluation


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskAlternate monthly allocation

Allocation concealment (selection bias)High riskAlternate monthly allocation

Blinding (performance bias and detection bias)
All outcomes
High riskUnblinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskNear-complete follow-up; see notes above

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Agarwal 1980Although not apparent from the title, this is not a report of either a randomised or quasi-randomised trial

Avery 1977Although not apparent from the title, this is not a report of either a randomised or quasi-randomised trial

Boros 1974Although not apparent from the title, this is not a report of either a randomised or quasi-randomised trial

Celestin 1978Although not apparent from the title, this is not a report of either a randomised or quasi-randomised trial

Cheek 1973Although not apparent from the title, this is not a report of either a randomised or quasi-randomised trial

Chen 1974Although not apparent from the title, this is not a report of either a randomised or quasi-randomised trial

Price 1978Although not apparent from the title, this is not a report of either a randomised or quasi-randomised trial

Uauy 1975Reported as an abstract only, this is described as a "controlled study", but is unlikely to represent a report of a randomised or quasi-randomised trial

Valman 1973Although not apparent from the title, this is not a report of either a randomised or quasi-randomised trial

Wolfsdorf 1975Although not apparent from the title or abstract, this is not a report of a randomised or quasi-randomised trial

 
Comparison 1. Transpyloric versus gastric tube feeding for preterm infants: growth

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Change in weight (g/week)493Mean Difference (IV, Fixed, 95% CI)-5.50 [-26.88, 15.89]

 2 Change in crown heel length (mm/week)393Mean Difference (IV, Fixed, 95% CI)-0.67 [-2.36, 1.02]

 3 Change in occipito-frontal head circumference (mm/week)275Mean Difference (IV, Fixed, 95% CI)0.56 [-0.95, 2.08]

 4 Change in subscapular skinfold thickness (mm/week)118Mean Difference (IV, Fixed, 95% CI)-0.20 [-1.18, 0.78]

 
Comparison 2. Transpyloric versus gastric tube feeding for preterm infants: adverse events

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Death prior to hospital discharge6245Risk Ratio (M-H, Fixed, 95% CI)2.46 [1.36, 4.46]

 2 Death prior to hospital discharge (excluding Laing 1986)5165Risk Ratio (M-H, Fixed, 95% CI)2.19 [0.89, 5.35]

 3 Gastrointestinal disturbance (including diarrhoea) prior to hospital discharge7297Risk Ratio (M-H, Fixed, 95% CI)1.48 [1.05, 2.09]

 4 Gastrointestinal disturbance (including diarrhoea) prior to hospital discharge (excluding Laing 1986)6217Risk Ratio (M-H, Fixed, 95% CI)1.43 [1.02, 2.01]

 5 Necrotising enterocolitis prior to hospital discharge7298Risk Ratio (M-H, Fixed, 95% CI)0.63 [0.26, 1.53]

 6 Necrotising enterocolitis prior to hospital discharge (excluding Laing 1986)6218Risk Ratio (M-H, Fixed, 95% CI)0.91 [0.32, 2.58]

 7 Aspiration pneumonia prior to hospital discharge5171Risk Ratio (M-H, Fixed, 95% CI)1.35 [0.44, 4.14]

 8 Intestinal perforation prior to hospital discharge4129Risk Ratio (M-H, Fixed, 95% CI)2.31 [0.10, 50.85]