Enteral Water for ELBW doesn’t Help

Stewart CD, Morris BH, Huseby V, et al. Randomized trial of sterile water by gavage drip in the fluid management of extremely low birth weight infants. J Perinatol (Jan2009); 29: 26-32. Full Text | PDF

Objective: To determine whether extremely low birth weight infants who receive enteral sterile water have a reduction in treated patent ductus arteriosus or death by 28 days.

Study Design: A total of 214 infants were enrolled and randomized by 36 h of age to receive up to 50 ml kg^-1 per day of enteral sterile water (n=109) for 7 days or routine fluid management (n=104). Patent ductus arteriosus treatment was defined as either indomethacin treatment or surgical ligation.

Result: The proportion of infants with a treated patent ductus arteriosus or death at <28 days of age was 63% in the sterile water group vs 64% in the control group (relative risk 0.99, 95% confidence interval 0.81 to 1.22). There were no differences in the proportion of infants in the sterile water group vs control group with a treated patent ductus arteriosus (55 vs 48%), death (21 vs 28%), necrotizing enterocolitis or death (24 vs 32%), or bronchopulmonary dysplasia or death at <28 days (80 vs 77%). Daily mean glucose levels were significantly higher (P=0.04) in control infants than sterile water infants.

Conclusion: The use of sterile water did not decrease the incidence of patent ductus arteriosus or other adverse clinical outcomes. The role of enteral sterile water in the fluid management of extremely low birth weight infants remains uncertain.

Comments: Giving ELBW babies sterile water by gavage does not improve survival, and it does not help with PDA, NEC, CLD or other morbidities. A previous study of this practice showed an increase in GI complications (NEC or isolated intestinal perforations) associated with enteral water treatment (see (8-004). I have not seen any studies demonstrating significant benefit from enteral water in ELBW infants. ABK

Your comment regarding Stewart’s RCT involving enteral water administration needs clarification (January 2009 NeoNotes). You referred to a previous article (Huston et al, see 8-004), that, in fact, did not show a rigorous link between enteral water administration and NEC or spontaneous intestinal perforation (SIP). If you read the Methods and Results carefully of this retrospective chart review, one will note the authors had to combine the diagnoses of NEC and SIP into one entity to achieve statistical significance, a dubious maneuver given that NEC and SIP are widely regarded as separate clinical-pathologic entities. Also, several of the cases of NEC/SIP occurred weeks after the enteral water was given, one case more than nine weeks from “exposure” to “outcome”. Finally, the infants who received enteral water were considerably smaller, younger, and sicker than the “controls”, an unfortunate limitation of retrospective chart reviews.

In summary, considering Stewart’s two RCTs that show no link between enteral water and NEC, and the limitations of Huston’s data, one can conclude there is no published data that links enteral water administration to NEC or SIP. If efforts to prevent hypernatremia and dehydration fail (plastic wrap, skin emollients, hu midified respiratory gases) then enteral water is likely safer than IV boluses of solutions that contain salt they don’t need or carbohydrate solutions that perturb glucose homeostasis.