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Reply to: ‘Early transyploric feeding: an old wine in a new bottle’

Journal of Perinatology volume 39, pages 1155–1156 (2019)Cite this article

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We greatly appreciate the thoughtful letter to the editor by R Sahoo and KM Gulla [1, 2]. Here, we provide our responses to their comments.

  1. 1.

    We agree that there is some evidence of harm associated with the use of infant formula during transpyloric feeding (TPF) [3, 4]. As a result, we recommend against the use of formula during TPF, both in clinical and research settings.

  2. 2.

    It is true that some infants in the TPF group may have received gastric feeding after the first week, and visa versa for the gastric group. We were unable to use these data in our final analysis. However, we believe that the first week after birth represents a critical window of vulnerability to lung injury from aspiration, which is both clinically intuitive and supported by analyses of tracheal aspirates. In one study, infants who died or developed bronchopulmonary dysplasia (BPD) had three-fold higher concentrations of pepsin, a sensitive and specific marker of gastric contents, in tracheal aspirate samples collected in the first 7 days after birth, compared to infants who survived without BPD [5]. The association between quantity of aspirated contents and death or BPD became weaker, albeit still statistically significant, beyond the first week after birth.

  3. 3.

    Infants who received trophic feeds during the first 7 days were included in the final analysis.

  4. 4.

    The theoretical risk that you describe appears to have little effect, if any, on clinically relevant outcomes. We found no evidence of growth disparity between the transpyloric and gastric groups [5], which is consistent with a meta-analysis of 9 randomised controlled trials of 359 preterm infants from the 1970s and 1980s [4]. Furthermore, meta-analysis of 14 clinical trials with a total of 1109 adults showed that transpyloric feeding actually increased total nutrient delivery compared to gastric feeding, presumably due to less feeding intolerance [6].

  5. 5.

    No babies were discharged home with transpyloric feeding tubes during the period of study. In general, clinicians first transition from transpyloric to gastric tube feeding, and subsequently to oral feeding, although we did not collect data related to these practices. Despite these and other limitations of the present study, we believe that the evidence is sufficient to merit further investigation of early TPF in the form of a randomised controlled trial [7].

We agree that there is some evidence of harm associated with the use of infant formula during transpyloric feeding (TPF) [3, 4]. As a result, we recommend against the use of formula during TPF, both in clinical and research settings.

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References

  1. Wallenstein MB, Brooks C, Kline TA, Beck R, Yang W, Shaw GM, et al. Early transpyloric vs gastric feeding in preterm infants: a retrospective study. J Perinatol. 2019;39:837–41.

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  2. Sahoo T, Gulla KM. Early Transpyloric feeding: an old wine in a new bottle. J Perinatol. 2019; https://doi.org/10.1038/s41372-019-0417-7.

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  7. Wallenstein MB, Stevenson DK. Need for reassessment of early tranpsyloric feeding in preterm infants. JAMA Pedia. 2018;172:997.

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Authors and Affiliations

  1. Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, 94305, USA

    Matthew B. Wallenstein, Wei Yang, Gary M. Shaw & David K. Stevenson

  2. Neonatal Department, Christchurch Women’s Hospital, Christchurch, 8011, New Zealand

    Matthew B. Wallenstein

  3. Fairfax Neonatal Associates Neonatal Intensive Care Unit at Inova Children’s Hospital, Falls Church, VA, 22042, USA

    Cindy Brooks, Timothy A. Kline & Rebecca Q. Beck

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  1. Matthew B. Wallenstein
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Correspondence to Matthew B. Wallenstein.

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Wallenstein, M.B., Brooks, C., Kline, T.A. et al. Reply to: ‘Early transyploric feeding: an old wine in a new bottle’. J Perinatol 39, 1155–1156 (2019). https://doi.org/10.1038/s41372-019-0418-6

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