Certainly you will be seeing some sicker children with bronchiolitis this winter who have issues with feeding. The copious nasal congestion and increased work of breathing may preclude adequate oral intake. Some of these children will merit admission and generally we obtain IV access for hydration. But why can’t we use their gut via a nasogastric tube? Logically this makes sense – but it hadn’t (re)ocurred to me until I read the following article from Lancet Respiratory Medicine.
Oakley et al. conducted a multicenter randomized study in Australia and New Zealand of almost 800 infants aged 2-12 months with bronchiolitis who were admitted. They used computerized block stratified randomization. What does that mean? Well, they randomized within 2 groups (stratification) – 2 to <6 months and 6 to 12 months – and in small blocks (a few patients in a row got the same treatment). The stratification is done to try to account for age related differences, and the block randomization helps keep things more convenient – especially across different sites.
The primary outcome was length of hospital stay. Secondary outcomes included rates of intensive-care unit admission, adverse events, and success of insertion.
They found that the mean length of stay for 381 infants randomized to NG hydration was 86.6 hours (SD 58·9) vs 82·2 h (58·8) for 378 infants assigned intravenous hydration. The Risk difference of 4·5 h [95% CI -3·9 to 12·9] was not significant with a p=0·30. There was no difference in rates of admission to intensive-care units, need for ventilatory support, and adverse events. It is important to note that a number of patients “crossed over” to the opposite group (i.e. couldn’t get an IV so they went to NG). When you see this in a study you’ll want to look for intention to treat. This is important because the randomization was initially done to account for all variability in the groups that could ultimately affect the results. “Once randomized always analyzed” – essentially means that patients should stay in their original groups that they were randomized into even if they didn’t get the intervention the investigators initially thought they would. Of note in this study 275 (85%) of 323 infants in the NG group and 165 (56%) of 294 infants in the IV group required only one attempt for successful insertion.
So, there was no significant difference in length of stay – nor the secondary outcomes. So does this mean that NG hydration is inferior? Not necessarily. For the child that needs 5-6 attempts at a peripheral IV suggesting NG hydration may be amenable to the parents and nurses. So, it is worth considering, and I plan to think about it the next time I encounter a bronchiolitic in need of continuous hydration.
Check out the article here (may require institutional account to get the full pdf)
Ok, let me get this right. Respiratorily sick kid, don’t like to put in an IV so they want us to shove a tube into the upper respiratory tract of a patient with respiratory distress?
Ask any adult who has had an IV and an NG tube which they would prefer
The reason this came up – without going into too much detail – is a family who absolutely, categorically refused an IV. My resident, me, their RN and the charge nurse all tried to convince to try again for the IV. The baby was also 7 mos old. So an easier decision with smaller nasal passages.
Mike, ask an infant what they would prefer!
NG rehydration for bronchiolitis is routine practice in most Australian centers I’ve worked at – IV rehydration is rarely required. Similarly for gastroenteritis.
Chris
I guess I just wonder about the wisdom of obstructing the airways of someone in respiratory distress. As for asking an infant which they prefer, I have, but I never understood the answer!! All in all I might go NG before IO, but there’s probably no logic to that either. I have the advantage of generally being able to get IV access pretty routinely in our infants.
Most of my colleagues in the states at pediatric EDs would feel confident in their abilities (or their nurses’) at getting an IV. Of course, we also rehydrate gastroenteritis via IV almost exclusively whereas I’m sure the gut would work just fine.