Feed intolerance and postpyloric feeding in the critically ill child

Background

Feeding intolerance (FI) is a common problem in critically ill patients that results in feed interruptions potentially impacting on outcome (1).

The lack of consistent and validated definition for FI makes difficult to know the real prevalence of this problem in sick patients (2) and precludes obtaining conclusive results on predictors and outcomes (3). Moreover, the false perception of FI, may withhold enteral nutrition unnecessarily leading to an under delivery of protein and energy and malnutrition (4).

There are several definitions for FI but most of them includes an increase in gastric residues associated or not, to other gastrointestinal (GI) problems (vomiting, diarrhea, abdominal pain or abdominal distension). However, many other reasons different from FI such as drugs, infections, gastroesophageal reflux, ascites or edema can cause these symptoms in critically ill patients (4).

Factors involved in FI in critically ill children

Critically ill children usually experience gastric dysmotility (GD) that is an abnormally slow and/or uncoordinated activity of the stomach or antroduodenal musculature (5). In addition, these patients suffer from gastrojejunal dissociation with atony or hypomotility of the stomach but adequate peristalsis in the small intestine (6). As a result, an increase in gastric residues and abdominal distension develops, potentially leading to a higher risk of aspiration and nosocomial pneumonia (7) and lower caloric and protein intake (8). Impaired GI motility is the principal mechanism underlying FI (7). The aetiology of GD is largely unknown but many factors may be involved in its appearance (3). Critically ill children often require sedative and muscle relaxation drugs that have a relaxant effect on the intestinal smooth muscle and abdominal skeletal muscle inducing abdominal distension (9). Epinephrine and high doses of dopamine are common drugs used in severely ill patients that can impair tolerance to nutrition because they reduce intestinal perfusion (10).

Patients with gastric, peritoneal or cerebral disease are at higher risk of developing this complication (7). On the other hand, sick patients often have circulatory shock that alters gut tissue due to hypoperfusion and gut inflammation, leading to malabsorption and bowel dysmotility (11). They also have alterations in hormonal responses and vagal tone, and increased levels of GI peptides (especially CCK and PYY) that impairs gastric emptying (4).

Severity of GD depends on the phase of the illness (acute, stable, recovery) (4), the severity of illness of the patient and the treatment required to achieve the stabilization of the patient (12). The ability to tolerate different amount of nutrients and the organ support required by the child, changes along the different stages of the critical illness and can be useful to develop a FI model (13).

Finally, factors related to the formula as the osmolality, the composition, or the form of administration of the diet can also increase gastric residues (7).

Future research must focus on clarifying the potential mechanisms of FI during critical illness as well as finding a proper and validate definition of FI (3,13).

Based on Eveleens et al. systematic review (3) and on Marino et al. editorial (13), a practical tool for FI diagnosis and severity can be developed to allow the clinician to identify and treat this problem efficiently (Table 1).

Several actions are used in clinical practice to reduce FI in critically ill children. Prokinetic agents, change from polymeric to semi-elemental formulation and change of feed delivery method from intermittent bolus to continuous feeding (4) are common methods used in PICU to manage FI and to improve nutrient delivery. However, currently no studies have compared polymeric versus (semi)-elemental formulas, nor analyzed the use of prokinetic agents or the influence of feeding route in FI (3). Therefore, currently the evidence does not support the routine use of these methods to manage FI.

The use of transpyloric enteral nutrition (TEN) is another option to manage FI in critically ill children. Although existing evidence cannot make recommendations regarding the optimal site to deliver EN in sick children, guidelines suggest the gastric route be the preferred site for EN in the first instance (14). However, TEN may be an alternative feeding route in critically ill children unable to tolerate gastric feeding, those at high risk for aspiration or requiring frequent fasting for surgery or procedures (14,15).

Benefits of postpyloric feeding in critically ill children

Malnutrition is associated with increased mortality in critically ill patients (16) while successful nutrition is associated with reduced complications and improves outcome (17). Enteral nutrition is the preferred method of nutrient delivery in Pediatric Intensive Care Unit (PICU) because it maintains intestinal trophism, improves immune function and reduces bacterial translocation and multiorgan failure (17,18). As FI may hamper enteral nutrition in severely ill PICU patients, duodenojejunal enteral nutrition can be an alternative to gastric or parenteral nutrition (PN) in critically ill children because it is safe, well tolerated and has few complications (9,10,19,20). TEN can reduce the volume of gastric residues and the number of enteral nutrition interruptions (21-23) and may increase energy intake because it promotes early nutrition and enables to reach the maximum volume of nutrition prescribed rapidly (24-27). Early enteral nutrition has many benefits in critically ill children (25,28-30) and adults (31,32) because it improves nutritional status and immune system activity and associated with reduced incidence of septic complications and muscle fatigue (17,18,30,33,34). Moreover, the incidence of abdominal distension is lower in critically ill children on early TEN than children on late TEN (25).

A previous study in PICU comparing children on PN and on TEN found that patients in the first group developed higher number of metabolic complications (hyperglycemia, hypertriglyceridemia and cholestasis) than children in the TEN group (35). The study also highlighted that the cost of TEN was lower than that of PN with an estimated annual saving of $5.422.

Postpyloric feeding tube placement in children

Transpyloric tube insertion is a complex technique and must be performed by trained personal (36). Postpyloric tubes are usually inserted into sick patients at the bedside by blind insertion (9,10,19,27). However, TEN is often delayed by the difficulties in placement of the feeding tube, resulting in multiple attempts (35). Different techniques for advancing tubes across the pylorus exist including the use of stylets and weighted tube tips, magnet, lateral decubitus position, air insufflations and prokinetic agents (9,17,36-41).

Feeding tubes should be emplaced ideally into the third or the fourth part of the duodenum (42), however, advancing the tubes across the pylorus without direct visualization may be difficult and sometimes fluoroscopy (43) or endoscopy (9,44) are required to be successful.

Another method for this purpose based on electromagnetic guidance can be useful in critically ill patients (6,37). The technique uses a stylet with an electromagnetic tip inside the tube, which transmits its signal to a receiver unit, placed at the epigastric region of the patient and a graphic display of the tube location is displayed (6). Electromagnetic guidance system seems to be a successful, efficient and cost-effective method of bedside postpyloric tube placement in critically ill children (37).

Sonographic technique is also feasible in sick patients with severe impairment of the peristaltic activity of the stomach (45).

After insertion, clinicians must confirm proper tube emplacement to avoid complications. Assistance by auscultation can significantly improve the success rate of nasal feeding tube placement (46). Radiology is widely used for this purpose but other methods without radiation exposure, as measurement of the volume of gas aspirated from the tube, and determination of the change in aspirate pH and color during tube advancement are also useful (9,10,19,20,42). More recently, other test based in bilirubin, pepsin and trypsin concentration have proved to predict tube position (42).

Indications of TEN in critically ill children

TEN in critically ill children is currently indicated for FI or when increased risk of pulmonary aspiration exist (14,15). It can also be used in children on mechanical ventilation, suffering from respiratory failure without mechanical ventilation and with neurologic complications or abdominal surgery (27).

A prospective study in postsurgical and nonsurgical children admitted to PICU, showed that most of these patients tolerated TEN with few abdominal complications (19). Although feeding tolerance was similar in different groups of age, GI complications were significantly more prevalent in postsurgical than in nonsurgical patients.

Children with congenital cardiac disease are frequently malnourished due to an increase in metabolic requirements, a decrease in nutrition intake, or malabsorption secondary to changes in the intestinal mucosa because of low cardiac output (47). Malnutrition in these patients has deleterious hemodynamic effects (48) so it is advised that nutritional status to be improved before and after surgical treatment (49). TEN is a safe practice after pediatric cardiac surgery and allows an early initiation and a rapid advance of enteral nutrition in these patients with increased chance of an adequate energy intake within 24–48 hours of the procedure (9). Moreover, the low incidence of diarrhea in these children (9,36) confirms that an adequate absorption of the nutrients with standard diets is achieved.

TEN may also be useful in shocked children (10). Shock leads to a poor organ perfusion due to an imbalance between oxygen delivery and oxygen consumption (50). Splanchnic perfusion is particularly affected during shock and can even get worse during feeding leading to GI complications (51-53). On the other hand, shocked children need high doses of vasoactive drugs that reduce intestinal perfusion and impair tolerance. TEN is feasible in critically ill children with shock although the incidence of complications is higher than in other sick children (10). A previous study showed that abdominal distension, gastric residues and diarrhea were significantly more frequent in pediatric patients with shock than in children admitted to PICU for other pathologies. Most of the patients tolerated enteral nutrition without complications but two of them developed a necrotizing enterocolitis and one child died because of a complication related to nutrition (10). TEN must be used with caution in shocked patients with closely monitoring of GI complications.

Most of the sickest patients admitted to PICU develop acute kidney injury (AKI) as part of other syndromes (i.e., heart failure, liver failure, and sepsis) or due to a primary renal disease. Incidence of GI complications is higher in patients with AKI than in patients with normal renal function (20,54). Uremia may impair feeding tolerance due to its implication in delaying gastric emptying (55) and produce GI mucosal abnormalities ranging from edema to ulceration (56). TEN can be useful in critically ill children with AKI even if they are on inotropic support, sedative or muscle relaxant drugs, as these children achieve lower caloric intake than children whit no AKI (20).

Complications associated with transpyloric feeding tubes

TEN is safe and well tolerated in critically ill children (19,35,36,57) and has many advantages (23), however, mechanical and abdominal complications have been described (19,36,58). Mechanical complications are associated with the type of transpyloric tube, the technique of tube insertion, the anatomic localization and the duration of postpyloric feeding. Small and flexible tubes should be used to decrease the incidence of mucosal nasal injuries, pressure ulcers, otitis and sinus infection (36).

Transpyloric feeding tube must be inserted by trained personal as it is a complex technique and pleural o bronchial break can develop during the emplacement (27,36). Although insertion is easier in children than in adult patients (7), duodenal perforation due to transpyloric tube placement in infants has been reported (58). Unsuccessful attempts of tube insertion may improve with the administration of prokinetic agents (19) or under endoscopic vision (9). Adequate location of the tube must be confirmed radiographically especially if any complication is suspected (19,58).

Development of pyloric stenosis (59) or enterocutaneous fistulas (60) is rare and is associated with prolonged TEN.

Critically ill children on TEN can also develop GI complications (9,10,19,20). Abdominal distension, excessive gastric residue and diarrhea are the most prevalent digestive tract complications but rarely involves enteral nutrition discontinuation (19,36,61). Even though they are minor complications, a higher incidence of shock and increased dopamine or epinephrine requirement in these patients has been reported (61). These results support the hypothesis that FI may be a sign of poor vital prognosis (19,62).

Shock, epinephrine infusion at a rate higher than 0.3 µg/kg/min and hypophosphatemia are the most important factors associated with GI complications in critically ill children (61). Acute renal failure, hypokalemia and dopamine and vecuronium infusions are also risk factors for this problem (61).

Despite high doses of inotropic infusion may reduce intestinal perfusion and affect tolerance to enteral nutrition, most of the critically ill children present an adequate tolerance to TEN (10,61). Sick children on inotropic support can receive duodeno-jejunal enteral nutrition with careful monitoring (9,10).

Conclusions

GD is a common problem in critically ill children resulting in FI, high risk of aspiration and pneumonia and lower caloric and protein intake. Future research must focus on clarifying the potential mechanisms of FI during critical illness as well as finding a proper and validate definition of FI.

TEN is feasible in this population, as it seems to be safe and well tolerated with few complications. In addition, postpyloric feeding tubes may promote early nutrition and reduce the volume of gastric residues and the number of enteral nutrition interruptions increasing energy intake. However, feeding tube insertion is difficult and it is not exempt of problems. Staff must be trained to detect and decrease complications associated with its utilization.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Lyvonne Tume, Frederic Valla and Sascha Verbruggen) for the series “Nutrition in the Critically Ill Child” published in Pediatric Medicine. The article was sent for external peer review organized by the Guest Editors and the editorial office.

Conflicts of Interest: The authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/pm-20-57). The series “Nutrition in the Critically Ill Child” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Blaser AR, Starkopf J, Kirsimägi Ü, et al. Definition, prevalence, and outcome of feeding intolerance in intensive care: a systematic review and meta-analysis. Acta Anaesthesiol Scand 2014;58:914-22. [Crossref] [PubMed]
2. Bartlett Ellis RJ, Fuehne J. Examination of accuracy in the assessment of gastric residual volume: a simulated, controlled study. JPEN J Parenter Enteral Nutr 2015;39:434-40. [Crossref] [PubMed]
3. Eveleens RD, Joosten KFM, de Koning BAE, et al. Definitions, predictors and outcomes of feeding intolerance in critically ill children: A systematic review. Clin Nutr 2020;39:685-93. [Crossref] [PubMed]
4. Tume LN, Valla FV. A review of feeding intolerance in critically ill children. Eur J Pediatr 2018;177:1675-83. [Crossref] [PubMed]
5. Martinez EE, Douglas K, Nurko S, et al. Gastric Dysmotility in Critically Ill Children: Pathophysiology, Diagnosis, and Management. Pediatr Crit Care Med 2015;16:828-36. [Crossref] [PubMed]
6. Mathus-Vliegen EM, Duflou A, Spanier MB, et al. Nasoenteral feeding tube placement by nurses using an electromagnetic guidance system (with video). Gastrointest Endosc 2010;71:728-36. [Crossref] [PubMed]
7. López-Herce J. Gastrointestinal complications in critically ill patients: what differs between adults and children? Curr Opin Clin Nutr Metab Care 2009;12:180-5. [Crossref] [PubMed]
8. Mentec H, Dupont H, Bocchetti M, et al. Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications. Crit Care Med 2001;29:1955-61. [Crossref] [PubMed]
9. Sánchez C, López-Herce J, Carrillo A, et al. Transpyloric enteral feeding in the postoperative of cardiac surgery in children. J Pediatr Surg 2006;41:1096-102. [Crossref] [PubMed]
10. López-Herce J, Mencía S, Sánchez C, et al. Postpyloric enteral nutrition in the critically ill child with shock: a prospective observational study. Nutr J 2008;7:6. [Crossref] [PubMed]
11. Rokyta R Jr, Matĕjovic M, Krouzecký A, et al. Enteral nutrition and hepatosplanchnic region in critically ill patients - friends or foes? Physiol Res 2003;52:31-7. [PubMed]
12. Fruhwald S, Holzer P, Metzler H. Intestinal motility disturbances in intensive care patients pathogenesis and clinical impact. Intensive Care Med 2007;33:36-44. [Crossref] [PubMed]
13. Marino LV, Johnson MJ, Beattie RM. Feeding intolerance in children with critical illness. Clin Nutr 2020;39:609-11. [Crossref] [PubMed]
14. Mehta NM, Skillman HE, Irving SY, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric critically-ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Pediatr Crit Care Med 2017;18:675-715. [Crossref] [PubMed]
15. Tume LN, Valla FV, Joosten K, et al. Nutritional support for children during critical illness: European Society of Pediatric and Neonatal Intensive Care (ESPNIC) metabolism, endocrine and nutrition section position statement and clinical recommendations. Intensive Care Med 2020;46:411-25. [Crossref] [PubMed]
16. Pollack MM, Ruttimann UE, Wiley JS. Nutritional depletions in critically ill children: associations with physiologic instability and increased quantity of care. JPEN J Parenter Enteral Nutr 1985;9:309-13. [Crossref] [PubMed]
17. Galbán C, Montejo JC, Mesejo A, et al. An immune-enhancing enteral diet reduces mortality rate and episodes of bacteremia in septic intensive care unit patients. Crit Care Med 2000;28:643-8. [Crossref] [PubMed]
18. Hadfield RJ, Sinclair DG, Houldsworth PE, et al. Effects of enteral and parenteral nutrition on gut mucosal permeability in the critically ill. Am J Respir Crit Care Med 1995;152:1545-8. [Crossref] [PubMed]
19. Panadero E, López-Herce J, Caro L, et al. Transpyloric enteral feeding in critically ill children. J Pediatr Gastroenterol Nutr 1998;26:43-8. [Crossref] [PubMed]
20. López-Herce J, Sánchez C, Carrillo A, et al. Transpyloric enteral nutrition in the critically ill child with renal failure. Intensive Care Med 2006;32:1599-605. [Crossref] [PubMed]
21. Mesejo A, Juan M, García-Simón M. Enteral access and intestinal function assessment in the critically ill patient. Nutr Hosp 2007;22:37-49. [PubMed]
22. Montejo JC, Grau T, Acosta J, et al. Multicenter, prospective, randomized, single-blind study comparing the efficacy and gastrointestinal complications of early jejunal feeding with early gastric feeding in critically ill patients. Crit Care Med 2002;30:796-800. [Crossref] [PubMed]
23. Ho KM, Dobb GJ, Webb SA. A comparison of early gastric and post-pyloric feeding in critically ill patients: a meta-analysis. Intensive Care Med 2006;32:639-49. [Crossref] [PubMed]
24. Heyland DK, Dhaliwal R, Drover JW, et al. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr 2003;27:355-73. [Crossref] [PubMed]
25. Sánchez C, López-Herce J, Carrillo A, et al. Early transpyloric enteral nutrition in critically ill children. Nutrition 2007;23:16-22. [Crossref] [PubMed]
26. Khlevner J, Antino J, Panesar R, et al. Establishing early enteral nutrition with the use of self-advancing postpyloric feeding tube in critically ill children. JPEN J Parenter Enteral Nutr 2012;36:750-2. [Crossref] [PubMed]
27. Sánchez Sánchez C, López-Herce Cid J, Carrillo Alvarez A, et al. Transpyloric enteral nutrition in critically-ill children (I): technic and indications. An Pediatr (Barc) 2003;59:19-24. [PubMed]
28. Sánchez C, López-Herce J, Moreno M, et al. The use of transpyloric enteral nutrition in the critically ill child. J Intens Care Med 2000;15:247-54. [Crossref]
29. Chellis MJ, Sanders SV, Webster H, et al. Early enteral feeding in the pediatric intensive care unit. JPEN J Parenter Enteral Nutr 1996;20:71-3. [Crossref] [PubMed]
30. Suri S, Eradi B, Chowdhary SK, et al. Early postoperative feeding and outcome in neonates. Nutrition 2002;18:380-2. [Crossref] [PubMed]
31. Zaloga GP. Early enteral nutritional support improves outcome: hypothesis or fact? Crit Care Med 1999;27:259-61. [Crossref] [PubMed]
32. Moore FA, Feliciano DV, Andrassy RJ, et al. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Ann Surg 1992;216:172-83. [Crossref] [PubMed]
33. Ho MY, Yen Yu, Hsieh MC, et al. Early versus late nutrition support in premature neonates with respiratory distress syndrome. Nutrition 2003;19:257-60. [Crossref] [PubMed]
34. Briassoulis G, Zavras N, Hatzis T. Malnutrition, nutritional indices, and early enteral feeding in critically ill children. Nutrition 2001;17:548-57. [Crossref] [PubMed]
35. de Lucas C, Moreno M, López-Herce J, et al. Transpyloric enteral nutrition reduces the complication rate and cost in the critically ill child. J Pediatr Gastroenterol Nutr 2000;30:175-80. [Crossref] [PubMed]
36. Sánchez Sánchez C, López-Herce Cid J, Carrillo Alvarez A, et al. Transpyloric enteral nutrition in critically-ill children (II): complications. An Pediatr (Barc) 2003;59:25-30. [PubMed]
37. October TW, Hardart GE. Successful placement of postpyloric enteral tubes using electromagnetic guidance in critically ill children. Pediatr Crit Care Med 2009;10:196-200. [Crossref] [PubMed]
38. Levenson R, Turner WW, Dyson A, et al. Do weighted nasoenteric feeding tubes facilitate duodenal intubations? JPEN J Parenter Enteral Nutr 1988;12:135-7. [Crossref] [PubMed]
39. Gabriel SA, Ackermann RJ, Castresana MR. A new technique for placement of nasoenteral feeding tubes using external magnetic guidance. Crit Care Med 1997;25:641-5. [Crossref] [PubMed]
40. Chellis MJ, Sanders SV, Dean M, et al. Bedside transpyloric tube placement in the pediatric intensive care unit. JPEN J Parenter Enteral Nutr 1996;20:88-90. [Crossref] [PubMed]
41. Zaloga GP. Bedside method for placing small bowel feeding tubes in critically ill patients. A prospective study. Chest 1991;100:1643-6. [Crossref] [PubMed]
42. Gharpure V, Meert KL, Sarnaik AP, et al. Indicators of postpyloric feeding tube placement in children. Crit Care Med 2000;28:2962-6. [Crossref] [PubMed]
43. Cone LC, Gilligan MF, Kagan RJ, et al. Enhancing patient safety: the effect of process improvement on bedside fluoroscopy time related to nasoduodenal feeding tube placement in pediatric burn patients. J Burn Care Res 2009;30:606-11. [Crossref] [PubMed]
44. Byrne KR, Fang JC. Endoscopic placement of enteral feeding catheters. Curr Opin Gastroenterol 2006;22:546-50. [Crossref] [PubMed]
45. Hernández-Socorro CR, Marin J, Ruiz-Santana S, et al. Bedside sonographic-guided versus blind nasoenteric feeding tube placement in critically ill patients. Crit Care Med 1996;24:1690-4. [Crossref] [PubMed]
46. Xiao J, Mao Z, Hua M, et al. Auscultation-assisted bedside postpyloric placement of feeding tube in critically ill patients: a prospective, observational study. Asia Pac J Clin Nutr 2019;28:435-41. [PubMed]
47. Lama R, More A. Nutrición en niños con cardiopatías congénitas. Acta Pedatr Esp 2000;58:57-61.
48. Viart P. Hemodynamic findings in severe protein-caloric malnutrition. Am J Clin Nutr 1977;30:334-48. [Crossref] [PubMed]
49. Koretz RL. Nutritional supplementation in the ICU. How critical is nutrition for the critically ill? Am J Respir Crit Care Med 1995;151:570-3. [Crossref] [PubMed]
50. Standl T, Annecke T, Cascorbi I, et al. The nomenclature, definition and distinction of types of shock. Dtsch Arztebl Int 2018;115:757-68. [Crossref] [PubMed]
51. McClave SA, Chang WK. Feeding the hypotensive patient: does enteral feeding precipitate or protect against ischemic bowel? Nutr Clin Pract 2003;18:279-84. [Crossref] [PubMed]
52. Frey C, Takala J, Krähenbühl L. Non-occlusive small bowel necrosis during gastric tube feeding: a case report. Intensive Care Med 2001;27:1422-5. [Crossref] [PubMed]
53. Venkateswaran RV, Charman SC, Goddard M, et al. Lethal mesenteric ischaemia after cardiopulmonary bypass: a common complication? Eur J Cardiothorac Surg 2002;22:534-8. [Crossref] [PubMed]
54. Fiaccadori E, Maggiore U, Giacosa R, et al. Enteral nutrition in patients with acute renal failure. Kidney Int 2004;65:999-1008. [Crossref] [PubMed]
55. Van Vlem B, Schoonjans R, Vanholder R, et al. Delayed gastric emptying in dyspeptic chronic hemodialysis patients. Am J Kidney Dis 2000;36:962-8. [Crossref] [PubMed]
56. Kang JY. The gastrointestinal tract in uremia. Digest Dis Sci 1993;38:257-68. [Crossref] [PubMed]
57. Pettignano R, Heard M, Davis R, et al. Total enteral nutrition versus total parenteral nutrition during pediatric extracorporeal membrane oxygenation. Crit Care Med 1998;26:358-63. [Crossref] [PubMed]
58. Flores JC, López-Herce J, Sola I, et al. Duodenal perforation caused by a transpyloric tube in a critically ill infant. Nutrition 2006;22:209-12. [Crossref] [PubMed]
59. Latchaw LA, Jacir NN, Harris BH. The development of pyloric stenosis during transpyloric feedings. J Pediatr Surg 1989;24:823-4. [Crossref] [PubMed]
60. Patrick CH, Goodin J, Fogarty J. Complication of prolonged transpyloric feeding: formation of an enterocutaneous fistula. J Pediatr Surg 1988;23:1023-4. [Crossref] [PubMed]
61. López-Herce J, Santiago MJ, Sánchez C, et al. Risk factors for gastrointestinal complications in critically ill children with transpyloric enteral nutrition. Eur J Clin Nutr 2008;62:395-400. [Crossref] [PubMed]
62. Dunham CM, Frankenfield D, Belzberg H, et al. Gut failure--predictor of or contributor to mortality in mechanically ventilated blunt trauma patients? J Trauma 1994;37:30-4. [Crossref] [PubMed]