The title of the post sneakily did not mention that I am referring to a study in a specific subgroup of babies, the paper is a report of an RCT in newborn infants who had heart surgery. Yildirim MI, et al. The Impact of Nasal Intubation on Feeding Outcomes in Neonates Requiring Cardiac Surgery: A Randomized Control Trial. Pediatr Cardiol. 2024;45(2):426-32. Full term babies who needed intubation for cardiac surgery were randomized to an oral or nasal intubation group, 70 babies were included, and 3 of the nasal group actually had oral intubation. There are a couple of problems with the study, the 3 babies randomized to nasal intubation who couldn’t be nasally intubated were analyzed as oral intubations, in other words there was not an intention to treat analysis, also the outcome variable had 3 possible values, completely orally fed, or needing an NG tube, or having a gastrostomy, but each outcome was analyzed independently.

All but one of the nasally intubated babies were fully orally fed at discharge with the other needing NG feeding, compared to 28 of the 37 who were orally intubated being full fed by mouth, with 3 going home with an NG tube, and 5 with a gastrostomy. The authors do mention that eliminating the 3 babies from the nasal group who were orally intubated made the results “non-significant” for full oral independence.

I don’t think there is another similar study available, previous randomized comparisons of oral and nasal intubation have not examined feeding outcomes to my memory; but this sounds like a major advantage for families of nasal intubation in this group of babies.

It would be interesting to see the impacts on oral feeds in preterm infants of route of endotracheal intubation. The tiniest preterm babies, who have the most feeding problems, cannot in my experience be nasally intubated at birth, usually the nostril will blanche around the tube, so I no longer even try below about 800 g. I do think there is a role for an RCT in other term infants and in preterm infants with prolonged intubation. I don’t think a day or two of intubation at 29 weeks (for example) is likely to have differential impacts on long term feeding outcomes between oral and nasal intubation. But babies with severe lung injury, ventilator dependent, and especially those approaching the PMA where oral feeding skills start to progress, might well benefit from having no oro-tracheal tube in place.

There is one older study, by the group in Rhode Island (Bier JA, et al. The oral motor development of low-birth-weight infants who underwent orotracheal intubation during the neonatal period. Am J Dis Child. 1993;147(8):858-62), led by the amazing Betty Vohr, that showed that preterm babies who had prolonged oral intubation had poorer sucking skills at term, and even after 3 months corrected age. It seems likely that oral endotracheal tubes do have an impact on oromotor development, it is unclear in the preterm whether nasotracheal intubation is preferable in this regard, as there are no coparative data I am aware of. Prolonged nasotracheal intubation can lead to distortion of the nose in smaller preterm babies, so it would warrant, I think, a good RCT to determine which route is preferable. What I would do would be to randomize very preterm infants who arrive at 30 to 32 weeks PMA, who look like they will need prolonged intubation, to either oral or tracheal intubation until their final extubation. The development of their feeding skills could then be followed over several months, in addition to investigating whether there were impacts on unplanned extubation, nasal growth and injury, oral/palatal groove development, pulmonary injury, time to discharge, etc.

This also makes me wonder whether there is a difference in feeding development and progression between oro- and naso-gastric tubes. As far as I am aware there are a few small RCTs, which have looked at things like pain scores during insertion, cardiorespiratory stability, and feeding tolerance. One did show that babies with orogastric tubes generated lower sucking pressure than those with nasogastric tubes, but no data about progression of feeding was given.

1. Upadhyay J, et al. Cortical hemodynamic activity and pain perception during insertion of feeding tubes in preterm neonates: a randomized controlled cross-over trial. J Perinatol. 2021 (cross over trial) showed higher PIPP scores (indicator of more pain) during NG insertion than OG.
2. Two studies have looked at apnea and bradycardia during oral or nasal tube use, one showed no difference (Bohnhorst B, et al. Oral versus Nasal Route for Placing Feeding Tubes: No Effect on Hypoxemia and Bradycardia in Infants with Apnea of Prematurity. Neonatology. 2010;98(2):143-9), the other showed more bradycardias with nasal tubes (Gupta NP, et al. Nasogastric vs Orogastric Feeding in Stable Preterm (≤32 Weeks) Neonates: A Randomized Open-Label Controlled Trial. Indian Pediatr. 2023;60(9):726-30.
3. A more recent trial (Badran AT, et al. Nasogastric versus Orogastric Bolus Tube Feeding in Preterm Infants: Pilot Randomized Clinical Trial. Am J Perinatol. 2021;38(14):1526-32) randomizing infants >28 weeks GA to OG vs NG, showed a faster progression of their nutrition with the NG route, among babies who had no respiratory support. They achieved full enteral nutrition at 4.7 days compared to 6 days in the OG group. I am not sure why that would be. As a result they had 2 days less TPN. There is no report of what happened to their feeding competence.

I don’t know of any trials that have looked at whether there is an adverse impact of oral feeding tubes (compared to nasal tubes) on development of feeding competence, or duration of hospitalisation (which is often prolonged by feeding problems) and yet it is an extremely common practice, with potential important impacts that would be of interest to families, I’m sure.

Feeding problems, slow development of feeding competence, oral aversion, and various difficulties feeding are very common. Waiting for full oral feeding is commonly the last thing that keeps a preterm baby hospitalised. After discharge, one of the commonest concerns of families are those feeding issues, yet there is next to nothing in terms of good quality evidence to help improve those problems. Even something as simple as whether we should use oral or nasal endotracheal tubes, or oral vs nasal gastric feeding tubes has never been well studied for impacts on feeding development.

The field is wide open for young investigators to perform studies that could have a big impact on clinically important outcomes that concern parents.