The effectiveness and safety of various methods of post-pyloric feeding tube placement and verification in infants and children

  • Protocol
  • Intervention

Authors


Abstract

This is the protocol for a review and there is no abstract. The objectives are as follows:

To compare the success rate of methods of post-pyloric tube placement and verification in ill children under the age of 18, and to assess the distress and safety of each insertion method.

Background

Description of the condition

Lack of nutrition can be a serious obstacle to recovery in critically ill patients. Providing early nutrition support to these patients is an important therapy for attenuating disease severity, modulating the immune response, reducing complications, and improving patient outcomes (ASPEN 2009; ASPEN 2015).

Enteral nutrition is a common technique used to deliver nutritional sustenance to patients with a functioning gastrointestinal tract who are unable to eat. The method involves delivering nutrition directly to the gastrointestinal tract via a feeding tube. Several nutritional guidelines have recommended the method for preventing poor outcomes in critically ill patients who are unable to eat (ASPEN 2009; ASPEN 2015; ESPEN 2006). The technique is preferable to parenteral nutrition, which involves delivering calories via an intravenous tube (Seres 2013). Theoretical advantages include the preservation of mucosal architecture and immune function (Seres 2013).

Clinical studies show that enteral nutrition significantly reduces the risk of infection compared to parenteral nutrition (ASPEN 2009; ASPEN 2015; ESPEN 2006; Prieto 2011). A systematic review found that enteral nutrition resulted in a significant decrease in infectious complications in critically ill patients compared with parenteral nutrition (Gramlich 2004).

A routine technique for delivering enteral nutrition is post-pyloric feeding, which involves placing a tube through the nasal passage, past the pylorus, to the duodenum or jejunum. An alternative technique involves extending a gastric tube only to the stomach. Patients fed via post-pyloric nasoenteral tubes have a lower incidence of complications compared to those fed via nasogastric tubes because of their lower rate of gastroesophageal reflex, regurgitation, excessive salivation, and irritation of the mucosa. Nasogastric feeding tubes are easy to insert but frequently cause gastroesophageal reflex in children (Noviski 1999). Gastroesophageal reflex may lead to respiratory complications such as pulmonary aspiration, which occurs when food or liquid secretions go down the wrong way and enter the airways and lungs.

Compared with gastric tube insertion, post-pyloric feeding tubes can reduce the risk of pneumonia, and they have not been associated with epistaxis, pneumothoraces, or gastrointestinal bleeding. These results suggest that post-pyloric feeding increases the amount of nutrition delivered to the patient (Alkhawaja 2015).

Post-pyloric tube feeding is an important technique for preventing malnutrition in children with severe diseases. Malnutrition is a serious condition caused by a lack of the right amount or type of food (ESPEN 2006). Children have a lower percentage of muscle mass and fat than adults, which means that they have fewer energy reserves and higher energy expenditure, making them more prone to malnutrition (Prieto 2011). The prevalence of malnutrition among hospitalised children is 15% to 30% (Silva 2013), and the incidence of malnutrition in paediatric intensive care units (ICUs) varies between 25% and 70% (Prieto 2011). Higher rates of malnutrition have an impact on the length of hospitalisation, as well as on the number of deaths in a particular situation or period of time (mortality), and the occurrence of symptoms, diseases, or adverse effects caused by a medical intervention such as surgery (morbidity) (Silva 2013).

Critically ill children in the ICU are frequent candidates for post-pyloric feeding (ESPEN 2006), especially those who are prone to gastroesophageal reflex from nasogastric feeding. However, while post-pyloric feeding has some benefits over gastric feeding, the placement of post-pyloric tubes is technically challenging and often requires the use of subsidiary methods, such as imaging techniques (AGA 1995; ESPEN 2006). These difficulties, and a lack of expertise and resources in individual facilities, can cause delays in the insertion of post-pyloric feeding tubes (ESPEN 2006).

Description of the intervention

Several methods are used in clinical practice to insert feeding tubes through the pylorus, as well as to verify their placement (Marsland 2010).

The standard technique for inserting an enteral feeding tube involves first ensuring that the child is tilted at a 45-degree angle (if there is no contraindication), and inserting the lubricated tube into the nostril while at the same time gently bending back the child's head to facilitate easy movement through the pharynx (Leaes 2012).

The use of prokinetic agents, such as metoclopramide and erythromycin, prior to tube insertion can help to improve the success of the manual insertion procedure. Metoclopramide is a gastrointestinal stimulant and antiemetic drug used to treat gastroesophageal reflex, which increases gastric motility and the rate at which it empties. The contraction of the muscles helps to move the tube along (Simons 2012).

The proper placement of the feeding tube can be verified through auscultation, which involves using a syringe to fill the feeding tube with air while placing a stethoscope over the stomach to listen for rushing air (ASPEN 2009). Feeding tube placement can also be verified by measuring the pH of the fluid aspirated from the feeding tube (ASPEN 2009). Capnography can be used to verify that the feeding tube has been properly inserted through the oesophagus by measuring and displaying carbon dioxide levels in gas samples aspirated into a monitoring unit (Kindopp 2001).

For patients who cannot be moved, portable ultrasonographic units can be used to visualise and control the insertion of feeding tubes. In studies using the ultrasound technique, participants are placed in the supine and sniffing position with the left side down, if possible. A sonographic examination is performed from the neck to the abdomen. The feeding tube is directly visualised in the oesophagus and stomach (Hernandez-Socorro 1996).

Another technique involves the insertion of a feeding tube via endoscopic guidance. Endoscopes are thin and hollow tubes attached to a small video camera on the end, which can be inserted into the body to look inside. General anaesthesia is typically required in children during upper gastrointestinal endoscopy procedures.

A recently developed alternative to endoscopic guidance is electromagnetic-guided tube placement. This method uses a special stylet with a tip containing an electromagnetic transmitter that generates a real-time signal as the feeding tube is inserted and advanced to the desired position (October 2009).

The post-pyloric feeding tube can also be guided by fluoroscopy. Fluoroscopy is a type of medical imaging procedure that uses x-rays to acquire continuous, real-time images of the body. The image is continuously transmitted to a monitor, which enables the detailed observation of a moving instrument, such as a feeding tube, as it passes through the body (ASPEN 2009). Feeding is usually stopped several hours before the insertion procedure. The patient is brought into the procedure room and placed on the fluoroscopic table in the supine position, and sedated if necessary.

How the intervention might work

Prokinetic agents can aid the blind and manual placement of feeding tubes by stimulating the smooth muscle of the stomach and intestines. Metoclopramide stimulates gastrointestinal smooth muscle by blocking the neurotransmitter dopamine and triggering the release of the neurotransmitter acetylcholine. It facilitates peristalsis and gastric emptying. A previous Cochrane review described a study in which metoclopramide was found to be useful in post-pyloric catheter placement when administered before catheter introduction (Silva 2002). However, a more recent review has found that metoclopramide may cause drowsiness, anxiety, agitation, urticaria and, rarely, extrapyramidal symptoms (Silva 2015). Another gastrointestinal prokinetic agent is erythromycin, which belongs to a group of closely related antibiotics known as macrolides. Erythromycin activates receptors that bind to the hormone, motilin, located in gastric and duodenal smooth muscle. Its prokinetic properties also increase gastric motility and facilitate gastric emptying (AGA 1995; Leaes 2012). The use of erythromycin as an agent for treating gastric dysmotility, however, raises concerns about promoting macrolide resistance (Hawkyard 2007).

Ausculcation is not considered a reliable method for verifying the correct placement of a post-pyloric feeding tube. An experimental study demonstrated that auscultation could not determine where the tube had been placed (ASPEN 2009).

Measuring the pH of fluid aspirated from the feeding tube is considered a more useful technique for verifying the correct placement of a post-pyloric feeding tube. Gastric fluid usually has a pH less than or equal to 5 and the intestine has an approximate pH of 6.6, while respiratory secretions are almost always alkaline (Leaes 2012). However, as the pH level of the aspirated fluid is often elevated due to the presence of either medication or feeding formulas, pH testing is not always reliable (Simons 2012). The appearance of the aspirated gastric and small bowel fluid is usually different. Gastric fluid is typically clear and colourless or green, and small bowel fluid is typically bile-stained. The pH level of gastric fluid is often lower than that of small bowel secretions (ASPEN 2009).

Capnography is widely used in the ICU for confirming endotracheal tube placement, and can be used to verify exhaled CO2 if the enteral tube is placed in the tracheal position (Leaes 2012). Both capnography and colorimetric CO2 detection are easier to perform than the standard technique, and capnography is more time-efficient for tube insertion (Burns 2006). A calorimetric indicator is a disposable device which changes its colour from purple to yellow if it indicates the presence of carbon dioxide.

Sonographic guidance is a useful method for both inserting a tube and monitoring the tube's position. This technique has shown a high success rate for tube insertion compared with the blind manual method. It can also be used as an alternative to radiography in order to reduce exposure to radiation (Leaes 2012). While the ultrasound method has proved successful in adults, it could not confirm the feeding tube position in neonates (Tamhne 2006).

Endoscopy guidance allows placement under direct vision. This technique is simple but it requires a complete endoscopy system which increases the cost and procedure time, and has some risks related to sedation and complications associated with endoscopy such as perforation (Niv 2009).

Electromagnetic-guided tube placement is a new technique, with the first report of its use for post-pyloric enteral tube placement published about 15 years ago. The electromagnetic-guided system visualises the path of the feeding tube in the patient through the tip of a guide wire, which transmits an electromagnetic signal to a receiver placed on the abdomen of the patient. The system shows the position of the feeding tube on a monitor screen to facilitate steering of the tube. This method however, requires a trained operator and furthermore, electromagnetic tubes are more expensive than normal tubes (Koot 2011; October 2009).

Fluoroscopy is one of the most reliable methods for tube placement, however it exposes patients and operators to rather high levels of radiation.

Although both endoscopy and fluoroscopy provide accurate methods of tube placement, these procedures can be expensive, time-consuming, and cause additional risks, such as transporting the child to the imaging department, and in the case of fluoroscopy, exposure to radiation. Moreover, as feeding tubes frequently reposition or migrate back into the stomach, recurrent tube insertion can increase costs (AGA 1995; ASPEN 2009; Simons 2012).

Why it is important to do this review

In children with severe conditions who are admitted to the ICU, it is important to avoid complications related to tube feeding, such as aspiration pneumonia. Aspiration pneumonia is an inflammation of the lung and bronchial tubes caused by inhaling materials such as gastric contents. Feeding via a post-pyloric tube may be an appropriate technique for preventing these complications; however, placement of the transpyloric tube in children can be challenging and can take more time depending on the size of the child and the operator's skill. Furthermore, methods that do not involve radiation exposure are necessary for young children. It is therefore important to evaluate the efficacy and risks associated with methods of post-pyloric tube placement. This review will provide clinical evidence on initial placement of post-pyloric feeding tubes in children and focus on children aged under 18 years.

Objectives

To compare the success rate of methods of post-pyloric tube placement and verification in ill children under the age of 18, and to assess the distress and safety of each insertion method.

Methods

Criteria for considering studies for this review

Types of studies

We will include randomised controlled trials (RCTs) and quasi-RCTs. We will also include cluster-RCTs trials if possible.

Types of participants

We will include children aged under 18 years old who require enteral nutrition during hospitalisation.

Types of interventions

This review seeks to include any methods for facilitating, confirming, and monitoring feeding tube placement (measuring pH, prokinetic agents, ultrasound, capnography, endoscopic guidance, electromagnetic guidance, and fluoroscopy). We will compare these methods with other methods, placebo, or the standard technique (i.e. blinding).

  • Blinding versus measuring pH

  • Blinding versus using:

    • prokinetic agents

    • capnography

    • ultrasound

    • endoscopy

    • electromagnetic-guided system

    • fluoroscopy

  • Measuring pH versus using:

    • prokinetic agents

    • capnography

    • ultrasound

    • endoscopy

    • electromagnetic-guided system

    • fluoroscopy

  • Using prokinetic agents versus using:

    • capnography

    • ultrasound

    • endoscopy

    • electromagnetic-guided system

    • fluoroscopy

  • Using capnography versus using:

    • ultrasound

    • endoscopy

    • electromagnetic-guided system

    • fluoroscopy

  • Using ultrasound versus using:

    • endoscopy

    • electromagnetic-guided system

    • fluoroscopy

  • Using endoscopy versus using an electromagnetic-guided system

  • Using endoscopy versus using fluoroscopy

  • Using an electromagnetic-guided system versus using fluoroscopy

Types of outcome measures

Primary outcomes

The probability of success (defined as the percentage of cases in which the feeding tube is initially placed beyond the pylorus, verified using radiography).

  • Success rate of initial feeding tube placement beyond the pylorus.

  • Procedure time.

Secondary outcomes

Complications associated with the procedure are the following.

  • Incidence of bleeding.

  • Incidence of perforation.

  • Incidence of disrupted breathing.

  • Incidence of sinusitis.

  • Incidence of pneumonia.

  • Incidence of pulmonary or pleural formula infusion.

  • Incidence of pneumothorax.

  • Incidence of pleural abscess.

  • Incidence of drug-induced adverse effects including restlessness, anxiety, drowsiness, headache, dystonic reactions, and irreversible tardive dyskinesia.

Search methods for identification of studies

Electronic searches

We will conduct a literature search to identify all published and unpublished RCTs. The literature search will identify potential studies in all languages. We will translate non-English language papers and fully assess them for potential inclusion in the review as necessary.

We will search the following electronic databases for identifying potential studies.

  • Cochrane Central Register of Controlled Trials (CENTRAL).

  • MEDLINE (1966 to present) (Appendix 1).

  • EMBASE (1988 to present).

  • CINAHL (1982 to present).

We will also conduct a search of ClinicalTrials.gov and ISRCTN registry
Our literature search will commence in Febrary 2016.

Searching other resources

We will check reference lists of all primary studies and review articles for additional references. We will contact authors of identified trials and ask them to identify other published and unpublished studies. We will also conduct handsearches of the reference lists from recent systematic reviews and relevant studies.

We will include studies reported as full-text, those published as abstract only, and unpublished data if we can contact the study authors for further information.

We will contact members of the Cochrane Upper Gastrointestinal and Pancreatic Disease (UGPD) Group, and experts in the field, and ask them to provide details of outstanding clinical trials and any relevant unpublished materials that are known to them.

We will search for errata or retractions from eligible trials on http://www.ncbi.nlm.nih.gov/pubmed, and report the date this was done within the review.

Data collection and analysis

Selection of studies

Two review authors (AM and AK) will independently screen titles and abstracts for inclusion. AM and AK will code all potential studies identified as a result of the search as 'retrieve' (eligible or potentially eligible/unclear) or 'do not retrieve'. After retrieval of the full-text study reports/publications, AM and AK will independently screen the full-text, identify studies for inclusion, and identify and record reasons for exclusion of the ineligible studies. We will resolve any disagreement through discussion or, if required, we will consult a third review author (YK or DY). We will identify and exclude duplicates and collate multiple reports of the same study so that each study rather than each report is the unit of interest in the review. We will record the selection process in sufficient detail to complete a PRISMA flow diagram (Moher 2009), and a 'Characteristics of excluded studies' table.

Data extraction and management

We will use a standard data collection form for study characteristics and outcome data which has been piloted on at least one study in the review. Two review authors (AM and AK) will extract study characteristics from included studies. We will extract the following study characteristics.

  1. Methods: study design, total duration of study and run-in period, number of study centres and location, study setting, withdrawals, date of study.

  2. Participants: N, mean age, age range, gender, severity of condition, diagnostic criteria, use of ventilation, inclusion criteria, exclusion criteria.

  3. Interventions: intervention, comparison, concomitant medications, excluded medications.

  4. Outcomes: primary and secondary outcomes specified and collected, time points reported.

  5. Notes: funding for trial, notable conflicts of interest of trial authors.

Two review authors (AM and AK) will independently extract outcome data from the included studies. We will note in the 'Characteristics of included studies' table if outcome data were reported in an unusable way. We will resolve disagreements by consensus or by involving a third review author (YK or DY). One review author (AM) will copy across the data from the data collection form into the Review Manager file (RevMan 2014). We will double check that the data are entered correctly by comparing the study reports with how the data are presented in the systematic review. A second review author will spot-check study characteristics for accuracy against the trial report.

Assessment of risk of bias in included studies

Two review authors (AM and AK) will independently assess risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). Any disagreement will be resolved by discussion or by involving a third assessor (YK or DY). We will assess the risk of bias according to the following domains.

  1. Random sequence generation.

  2. Allocation concealment.

  3. Blinding of participants and personnel.

  4. Blinding of outcome assessment.

  5. Incomplete outcome data.

  6. Selective outcome reporting.

  7. Other bias.

We will grade each potential source of bias as 'high', 'low' or 'unclear' and provide a quote from the study report together with a justification of our judgment in the 'Risk of bias' table. We will summarise the risk of bias judgements across different studies for each of the domains listed. We will consider blinding separately for different key outcomes where necessary, e.g. for unblinded outcome assessment, risk of bias for all-cause mortality may be very different than for a patient-reported pain scale. Where information on risk of bias relates to unpublished data or correspondence with a trialist, we will note this in the 'Risk of bias' table.

When considering treatment effects, we will take into account the risk of bias for the studies that contribute to that outcome.

Assesment of bias in conducting the systematic review

We will conduct the review according to this published protocol and report any deviations from it in the 'Differences between protocol and review' section of the systematic review.

Measures of treatment effect

We will analyse dichotomous data as risk ratios and continuous data as mean differences or standardised mean differences. We will ensure that higher scores for continuous outcomes have the same meaning for the particular outcome, explain the direction to the reader, and report where the directions were reversed, if this was necessary.

We will undertake meta-analyses only where this is meaningful, i.e. if the treatments, participants, and the underlying clinical question are similar enough for pooling to make sense.

A common way for trialists to indicate when they have skewed data is by reporting medians and interquartile ranges. When we encounter this we will note that the data are skewed and consider the implications.

Where multiple trial arms are reported in a single trial, we will include only the relevant arms. If two comparisons (e.g. drug A versus placebo and drug B versus placebo) must be entered into the same meta-analysis, we will halve the control group to avoid double-counting.

Unit of analysis issues

Cluster-randomised trials

We will include cluster-randomised trials in the analyses along with individually randomised trials. We will adjust their sample sizes using the methods described in the Cochrane Handbook for Systematic Reviews of Interventions (see Section 16.3.4 or 16.3.6; Higgins 2011). If possible, we will use an estimate of the intracluster correlation coefficient (ICC), derived either from the trial, or another source. If ICCs from other sources are used, we will report this and will conduct sensitivity analyses to examine the impact of variation in the ICCs. If we identify both cluster- and individually randomised trials, we will synthesise the relevant information, provided there is little heterogeneity between study designs, and we consider that interaction between the effect of intervention and choice of randomisation unit is unlikely (Higgins 2011).

Multi-armed Trials

We will include multi-armed trials if any pair-wise comparisons of the intervention groups are relevant to our review and meet our inclusion criteria. We will use the methods described in the Cochrane Handbook for Systematic Reviews of Interventions to avoid double-counting of participants (Higgins 2011).

Dealing with missing data

We will contact investigators or study sponsors in order to verify key study characteristics and obtain missing numerical outcome data where possible (e.g. when a study is identified as abstract only). We will avoid using mixed population data because of the accuracy of analyses, thus we will try to contact authors to request data of under 18 year-olds if possible.

Assessment of heterogeneity

We will use the I² statistic to measure heterogeneity among the trials in each analysis. If we identify substantial heterogeneity we will explore it by prespecified subgroup analysis. We will consider that I² > 50% denotes significant heterogeneity. In the case of I² > 80% (substantial heterogeneity), we will not perform a meta-analysis, but will present the results using forest plots without pooled estimates.

Assessment of reporting biases

We will attempt to contact study authors asking them to provide missing outcome data. Where this is not possible, and the missing data are thought to introduce serious bias, we will explore the impact of including such studies in the overall assessment of results by sensitivity analysis

If we are able to pool more than 10 trials, we will create and examine a funnel plot to explore possible publication biases.

Data synthesis

We will perform the analysis using Review Manager 5 software (RevMan 2014). As the population will be varied, we plan to use a random-effects model for meta-analysis. If outcomes show a smaller value of the I2 statistic, we will report both random-effects and fixed-effect estimates for these outcome variables. When we judge meta-analysis to be inappropriate, we will analyse and interpret individual trials separately. We will justify all decisions to down- or up-grade the quality of studies using footnotes in the 'Summary of findings' table and make comments to aid reader's understanding of the review where necessary. We will consider whether there is any additional outcome information that was not able to be incorporated into the meta-analyses, note this in the comments, and state if it supports or contradicts the information from the meta-analyses.

'Summary of findings' table

We will create a 'Summary of findings' table using the following outcomes.

  • The probability of success (defined as the percentage of cases of feeding tubes initially placed beyond the pylorus).

  • Procedure time.

  • Incidence of bleeding.

  • Incidence of perforation.

  • Incidence of disrupted breathing.

  • Incidence of drug-induced adverse effects.

We will use the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the quality of a body of evidence as it relates to the studies that contribute data to the meta-analyses for the prespecified outcomes (Balshem 2011; Guyatt 2008; Guyatt 2011; Guyatt 2011a; Guyatt 2011b; Guyatt 2011c; Guyatt 2011d; Guyatt 2011e; Guyatt 2011f). We will use methods and recommendations described in Section 8.5 and Chapter 11 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011), using GRADEpro software (GRADEpro 2008).

Subgroup analysis and investigation of heterogeneity

When data are available or appropriate, we will carry out the following subgroup analyses.

  • Neonates (up to the first 28 days after birth) versus infants (1 month old to 2 years old) versus children (3 to 17 years old).

  • Postoperative patients versus others.

  • Sedated patients versus non-sedated patients.

  • The methods for tube placement under radiation versus others not requiring radiation.

We will only use the primary outcomes for subgroup analyses.

Sensitivity analysis

We will perform a sensitivity analysis based on trial quality. We plan to conduct a sensitivity analysis to assess allocation bias.

Reaching conclusions

We will base our conclusions only on findings from the quantitative or narrative synthesis of included studies for this review. We will avoid making recommendations for practice and our implications for research will give the reader a clear sense of where the focus of any future research in the area is needed, and we will describe the remaining uncertainties on the topic.

Acknowledgements

The background and methods section of this protocol/review is based on a standard template used by the Cochrane Upper Gastrointestinal and Pancreatic Diseases (UGPD) Group.

We thank Karin Dearness, Managing Editor, Cochrane UGPD Group for providing administrative and logistical support for the conduct of the current review, and Racquel Simpson for developing and executing the search strategies. We also thank Emma Barber and Smriti Mallapaty for their editorial support.

Appendices

Appendix 1. MEDLINE search strategy

(Ovid SP)

1. exp *enteral nutrition/
2. exp *intubation, gastrointestinal/
3. ("g-tube*" or "ng-tube*" or "j-tube*" or "nj-tube*" or "PEJ").ab,ti
4. (("nutrition*" or "fed" or "feed*" or "tube*" or "intub*") adj5 ("gastr*" or "nasogastr*" or "stomach" or "duoden*" or "nasoduoden*" or "jejun*" or "nasojejun*" or "bowel*" or "intestine*" or "post?pylor*" or "trans?pylor*" or "nasoenter*" or "orogastric" or "gavage")).ab,ti
5. (("enteral" or "enteric") adj2 ("feed*" or "nutrition")).tw
6. (("nasal" or "nose" or "nasoenteral" or "nasogastric") adj2 ("cannula*" or "tube*" or "tubal" or "intubation")).tw
7. or/1-5
8. limit 7 to animals
9. limit 8 to humans
10. 8 not 9
11. 7 not 10
12. ("adult*" or "aged").af
13. ("infant*" or "child*" or "adolescent*").af
14. 13 not (12 and 13)
15. 11 not 14

Appendix 2. Glossary

CO2 (carbon dioxide)

A waste product made by the body. Breathing out clears carbon dioxide from the lungs.

Colourimetric analysis

A method of determining the concentration of a chemical element in a solution with the aide of colour reagents.

Endoscopy

The visual examination of the interior of a hollow body organ using an endoscope. The endoscope is a long slender medical instrument and has a light and a lens for viewing.

Endotracheal intubation

Placing a tube into the windpipe (trachea) which leads from the voice box to the large airways of the lungs.

Enteral and parenteral nutrition

Everyone needs food to live, but when someone is unable to eat, nutrition must be supplied in a different way. 'Enteral nutrition' or 'tube feeding' is one of the alimentary methods. 'Enteral' refers to feeding within or by way of the gastrointestinal tract. Parenteral nutrition is one of the feeding techniques by means other than through the alimentary tract, such as by intravenous injection.

Fluoroscopy

The visual examination of deep structures of the body using x-rays. A continuous x-ray beam is transmitted to a television-like monitor so that the body and its motions can be seen in detail.

Gastroesophageal reflux

Gastroesophageal refers to the stomach and oesophagus. Gastroesophageal reflux is the return of the stomach's contents back up into the oesophagus.

Intragastric feeding

The administration of food directly into the stomach by a tube. 'Intragastric' refers to 'within the stomach'.

Morbidity

The proportion of sickness or of disease in a specific population.

Mortality

The relative incidence of death in a specific population.

Motilin antagonist

Motilin is an amino acid polypeptide secreted in the duodenum and jejunum. The main function of motilin is to increase gastrointestinal motility. An agonist is a chemical that binds to a receptor and activates the receptor to produce a biological response. Motilin agonists such as erythromycin will provide additional motilin secretion triggers for gastrointestinal motility.

Pharynx

The part inside the mouth where the passage to the stomach and lungs is located.

Post-pyloric feeding

Post-pyloric feeding refers to the delivery of nutrients directly to the duodenum or jejunum (posterior to the pylorus) via a small-bore catheter.

Pylorus

The opening between the stomach and the intestines (duodenum).

Radiography

The production of radiographs, which uses other kinds of radiation than visible light.

Sinusitis

Sinusitis refers to an inflammation of the airspaces within the bones of the face.

Transpyloric

Though the pylorus.

Ultrasound

Using the reflections of high-frequency sound waves to construct images of body organs.

Contributions of authors

Conceiving the protocol: Akinori Moriichi (AM) and Atsushi Kawaguchi (AK).

Designing the protocol: AM, AK, Erika Ota (EO), Yasutoshi Kobayashi (YK), and Daisuke Yoneoka (DY).

Co-ordinating the protocol: AM and AK.

Designing search strategies: AM, AK, EO, YK, and DY.

Writing the protocol: AM, AK, YK, and DY.

Providing general advice on the protocol: AK and EO.

Declarations of interest

AM: none known.

AK: none known.

YK: none known.

DY: none known.

EO: none known.

Sources of support

Internal sources

  • The Japanese Cochrane Branch at the National Center for Child Health and Development in Tokyo, Japan.

    English-language editing. Editor: Ms. Emma Barber (barber-e@ncchd.go.jp)

External sources

  • No sources of support supplied

Ancillary