DOI 10.1515/jpm-2014-0054 J. Perinat. Med. 2015; 43(5): 627–635
Michael Obladen*
Feeding the feeble: steps towards nourishing preterm infants Abstract: This paper describes historic steps in feeding techniques and knowledge on the nutritional needs of premature infants. Devices to overcome weak sucking and swallowing were developed from 1851 to 1920, including tube feeding by gavage, medicine droppers and pipettes, feeding bottles with an air inlet, and beaked spoons for nasal feeding. Indwelling nastrogastric tubes were in use from 1951. For alleged safety concerns in the 1950s, postnatal feeding was postponed until a week of starvation was reached, and studies showed an association with neurological handicaps. The premature infant’s elevated need for energy, protein, and minerals has been established since 1919. However, these remained controversial, and nutritional practices continued to lag behind theoretical knowledge. Concentrated formula was developed in the 1940s, parenteral supplementation in the 1960s, and human milk fortifiers in the 1970s. In the 1990s, necrotizing enterocolitis was found to be more frequent in infants who were fed formula than in those who were fed human milk. Recently, probiotics were shown to reduce the risk of necrotizing enterocolitis. Nevertheless, compared with other aspects of neonatal medicine, there is still remarkably little evidence on how to feed preterm infants. Keywords: Fortification; gavage; history; human milk; nutrient requirements; nutrition; preterm infant. *Corresponding author: Dr. Michael Obladen, Department of Neonatology, Charité University Medicine Berlin, Augustenburger Platz 1, 13353 Berlin, Germany, Tel.: +49 30 (0)30 450566122, Fax: +49 30 (0)30 450566922, E-mail: [email protected]
Introduction Before specialized institutions allowed premature babies to survive, there was little knowledge on how to feed them. The infant’s weak suck usually led to the mother’s production of less amount of milk, creating a vicious circle. Hospitalized preterm infants had next to no chance of survival, as Charles Billard described: “Marie Loisel was brought to the [Paris] Foundling Hospital shortly after birth on August 4, 1826. She was 37 cm in length,
her legs extremely small, face congested and very red, skin discolored, few movements. Her cry, albeit complete, was barely audible. She swallowed without vomiting, but refused the breast… During the following days she remained in the same condition and finally died on the morning of the 10th without any other symptom but extreme weakness” [8]. In a private household, favorable circumstances could improve the child’s chances. In 1839, Charles Richard (de Nancy) described a boy born 12 weeks before term in Lyon: “The infant was extremely small, the skin red, nails incomplete… His room was well heated and his cradle flanked by stoneware jugs filled with warm water… His weakness was so great that he could not suck the breast, so he was spoonfed. The mother placed her milk drop by drop on his lips and into his mouth. For 2 weeks, he was nourished via a téterelle à pompe. During this time the mother first used puppies, then a stronger infant to empty her breast… [The premature boy] eventually learned to suck and developed from day to day” [53]. Focusing particularly on the USA, Thomas Cone described pioneers in the care and feeding of the preterm infant [14]. The aim of the current paper is to describe the development of feeding techniques for and the increase in knowledge on the nutritional needs of premature infants.
Weak sucking and swallowing In 1851, not long after vulcanized rubber was invented, the Charenton obstetrician Marchant described feeding by intermittent gavage as follows: “With such weakness, respiration is impaired and the swallowing of nutrients impossible, so infants perish within several hours and 2 days… In such cases, I propose artificial nutrition via an elastic rubber tube size 14 Charrière. Its introduction into the esophagus is neither dangerous nor difficult. With this method, the infant’s weakness can be overcome and it can benefit from nourishment to save its life” [39]. The thick rubber tube had to be inserted for each meal, possibly impairing respiration. Russian Foundling Hospitals harbored large premature special care units [47]. From St. Petersburg, where 4416 wet nurses were employed in 1831, Philipp Doepp
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628 Obladen, Preterm infant nutrition reported: “We keep premature and atrophic infants alive by carefully injecting good wet-nurses’ milk into the mouth and by the perpetual concern for maintaining ambient warmth” [19]. In Moscow, where 40 incubators were in operation, Nikolaus Miller treated 6036 preterm infants from 1869 to 1880 and reported on their nutrition by stating: “We use an elastic tube to feed those infants who cannot swallow due to weakness or thrush, or we dribble milk through a funnel into the nose, which enhances reflex movements and induces them to swallow” [40]. Exhibitions of the Lion incubator – with living babies – preceded the establishment of premature infant wards in several cities. During the 1898 exhibition in Dr. Frühwald’s Poliklinik in Vienna, Fritz Passini recorded the weight gain of 14 infants
Michael Obladen*
Feeding the feeble: steps towards nourishing preterm infants Abstract: This paper describes historic steps in feeding techniques and knowledge on the nutritional needs of premature infants. Devices to overcome weak sucking and swallowing were developed from 1851 to 1920, including tube feeding by gavage, medicine droppers and pipettes, feeding bottles with an air inlet, and beaked spoons for nasal feeding. Indwelling nastrogastric tubes were in use from 1951. For alleged safety concerns in the 1950s, postnatal feeding was postponed until a week of starvation was reached, and studies showed an association with neurological handicaps. The premature infant’s elevated need for energy, protein, and minerals has been established since 1919. However, these remained controversial, and nutritional practices continued to lag behind theoretical knowledge. Concentrated formula was developed in the 1940s, parenteral supplementation in the 1960s, and human milk fortifiers in the 1970s. In the 1990s, necrotizing enterocolitis was found to be more frequent in infants who were fed formula than in those who were fed human milk. Recently, probiotics were shown to reduce the risk of necrotizing enterocolitis. Nevertheless, compared with other aspects of neonatal medicine, there is still remarkably little evidence on how to feed preterm infants. Keywords: Fortification; gavage; history; human milk; nutrient requirements; nutrition; preterm infant. *Corresponding author: Dr. Michael Obladen, Department of Neonatology, Charité University Medicine Berlin, Augustenburger Platz 1, 13353 Berlin, Germany, Tel.: +49 30 (0)30 450566122, Fax: +49 30 (0)30 450566922, E-mail: [email protected]
Introduction Before specialized institutions allowed premature babies to survive, there was little knowledge on how to feed them. The infant’s weak suck usually led to the mother’s production of less amount of milk, creating a vicious circle. Hospitalized preterm infants had next to no chance of survival, as Charles Billard described: “Marie Loisel was brought to the [Paris] Foundling Hospital shortly after birth on August 4, 1826. She was 37 cm in length,
her legs extremely small, face congested and very red, skin discolored, few movements. Her cry, albeit complete, was barely audible. She swallowed without vomiting, but refused the breast… During the following days she remained in the same condition and finally died on the morning of the 10th without any other symptom but extreme weakness” [8]. In a private household, favorable circumstances could improve the child’s chances. In 1839, Charles Richard (de Nancy) described a boy born 12 weeks before term in Lyon: “The infant was extremely small, the skin red, nails incomplete… His room was well heated and his cradle flanked by stoneware jugs filled with warm water… His weakness was so great that he could not suck the breast, so he was spoonfed. The mother placed her milk drop by drop on his lips and into his mouth. For 2 weeks, he was nourished via a téterelle à pompe. During this time the mother first used puppies, then a stronger infant to empty her breast… [The premature boy] eventually learned to suck and developed from day to day” [53]. Focusing particularly on the USA, Thomas Cone described pioneers in the care and feeding of the preterm infant [14]. The aim of the current paper is to describe the development of feeding techniques for and the increase in knowledge on the nutritional needs of premature infants.
Weak sucking and swallowing In 1851, not long after vulcanized rubber was invented, the Charenton obstetrician Marchant described feeding by intermittent gavage as follows: “With such weakness, respiration is impaired and the swallowing of nutrients impossible, so infants perish within several hours and 2 days… In such cases, I propose artificial nutrition via an elastic rubber tube size 14 Charrière. Its introduction into the esophagus is neither dangerous nor difficult. With this method, the infant’s weakness can be overcome and it can benefit from nourishment to save its life” [39]. The thick rubber tube had to be inserted for each meal, possibly impairing respiration. Russian Foundling Hospitals harbored large premature special care units [47]. From St. Petersburg, where 4416 wet nurses were employed in 1831, Philipp Doepp
Brought to you by | University of California - San Diego Authenticated Download Date | 3/3/16 11:57 AM
628 Obladen, Preterm infant nutrition reported: “We keep premature and atrophic infants alive by carefully injecting good wet-nurses’ milk into the mouth and by the perpetual concern for maintaining ambient warmth” [19]. In Moscow, where 40 incubators were in operation, Nikolaus Miller treated 6036 preterm infants from 1869 to 1880 and reported on their nutrition by stating: “We use an elastic tube to feed those infants who cannot swallow due to weakness or thrush, or we dribble milk through a funnel into the nose, which enhances reflex movements and induces them to swallow” [40]. Exhibitions of the Lion incubator – with living babies – preceded the establishment of premature infant wards in several cities. During the 1898 exhibition in Dr. Frühwald’s Poliklinik in Vienna, Fritz Passini recorded the weight gain of 14 infants
