Optimal Feeding Tube Dwell Time in VLBW Infants to Reduce Feeding Tube Contamination
Phase: NA
Conditions: Infection
Sponsor: University of Florida

 
 
 
Title: Optimal Feeding Tube Dwell Time in VLBW Infants to Reduce Feeding Tube Contamination 
 
NCT03728608 
 
Date: 2/15/2024 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
Protocol 
 
4. Background: 
The long-term goal of this research is to improve short and long-term health outcomes for 
premature infants in the NICU by decreasing complications caused by contaminated feeding 
tubes such as sepsis, pneumonia and feeding intolerance. Because premature infants in the 
NICU may be too immature or ill to orally feed, a feeding tube is required to meet their nutritional 
needs. These feeding tubes have been shown to be a reservoir for pathogenic and often 
antibiotic-resistant bacteria and are thus a risk to neonatal health.  
 
Contaminated feeding tubes are a conduit for bacterial migration into the stomach and intestines 
leading to gastrointestinal pathogenic bacterial overgrowth, abnormalities in pro-inflammatory 
cytokine response and increasing the risk of late onset sepsis, necrotizing enterocolitis and 
feeding intolerance. Feeding tubes also disrupt the oral microbiota increasing pathogenic mouth 
bacterial and the risk of pneumonia. The critically ill infant’s significantly suppressed immunity, 
impaired intestinal barrier function and lack of beneficial gastrointestinal bacteria place them at 
tremendous risk of morbidity related to feeding tube contamination.   
 
Contamination of medical devices such as feeding tubes is related to length of time the device 
remains in place (dwell time). In the NICU, universal guidelines regarding feeding tube dwell 
time are non-existent and feeding tube replacement is often delayed for weeks following 
insertion. The optimal feeding tube dwell time to reduce or prevent contamination and its 
associated morbidity is currently unknown. In addition, the optimal feeding tube dwell time to 
avoid abnormal bacterial colonization of the stomach and intestines and the extent to which 
contamination of these domains relate to adverse neonatal health outcomes is unknown. Thus, 
the primary purpose of this study is to determine if a maximum feeding tube dwell time of 48 
hours reduces contamination compared to a feeding tube dwell time of 7 days, thereby 
improving neonatal health outcomes.  
 
Aims include the following: 
Primary Aim: To determine if a 48 hour maximum dwell time reduces bacterial contamination 
and biofilm formation of feeding tubes, feeding tube hubs, and intraluminal fluid in premature 
VLBW infants. Primary hypothesis: Feeding tubes which remain in place 0-48 hours will have 
less contamination and less biofilm formation compared to those left in place for 7 days.   
Aim 2: Compare gastrointestinal microbial dysbiosis and inflammation between Group 1 and 
Group 2. Hypothesis: Infants in Group 1 will have less GI microbial dysbiosis and inflammation 
compared to Group 2.  
Aim 3: Determine the effect of feeding tube dwell time and feeding tube contamination, and 
biofilm formation on selected health outcomes in premature VLBW infants. Hypothesis: Infants 
in Group 1 will have lower odds for necrotizing enterocolitis and late onset sepsis, and improved 
nutritional outcomes compared to Group 2.  
5. Research Plan: 
A randomized controlled trial will be conducted to determine whether feeding tube dwell time is 
associated with level of feeding tube contamination.  Infants will be randomly assigned to have 
their feeding tubes removed at 0-48 hours or 7 days for the first 4 weeks of life. The feeding 
tube lumen, interluminal liquid and hub will be analyzed for level of contamination.   
 
Sample and Setting  

 
The proposed study will follow a prospective cohort (N =151) premature VLBW male and female 
infants for 4 weeks following birth. If the mother is providing breast milk to her infant, she will 
also be included in the study since she will be providing 2 samples of her breast milk for 
analysis. 
 
Inclusion criteria are: 1) be born to a mother who is at least 18 years of age and English or 
Spanish speaking, 2) born at < 30 weeks 3) have a birthweight < 1500 grams, 4) be born to a 
mother who is COVID Negative, 5) have a feeding tube placed within 24 hours of birth and 5) be 
expected to require a feeding tube for 4 weeks following birth.  
 
Exclusion criteria are: 1) Infant with known congenital GI anomalies, (2) are not expected to live, 
or (3) Infants will be withdrawn from the study if they require abdominal surgery for GI 
morbidities.   
Sample Size Determination/Power Analysis: The primary aim of this study is to test for 
associations between feeding tube dwell time and the bacterial load present in the feeding tube. 
Pilot study results were used to estimate variance for the log transformed values of bacterial 
load observed in cultures. The study employs a repeated measures design, with measurements 
performed on each neonate each week of the 4 week study duration. For the primary bacterial 
contamination aim, each measurement consists of measures from 5 individual feeding tube 
sections for 5 individual colony types, providing a total of 100 within-subjects data points per 
neonate. Given the repeated measures design and the incorporation of selected covariates, a 
Generalized Linear Mixed Model (GLMM) analysis is planned for the primary aim. The data 
derived from the pilot study of 31 feeding tubes informed the covariance structure and means 
vectors for entry into PASS 14’s procedure which estimates mixed models power using 
simulation.  Using a .005 level of significance (in recognition of the multiple inferential tests), 400 
simulation samples, a minimum detectable difference of 3.0 (natural log transformed colony 
forming units), and employing the pilot data to inform mean vectors and the unstructured 
covariance matrix for the simulations, the lower 99% confidence limit for power is .97 for the 
Dwell Group by Colony Type interaction, which is of primary interest. To accommodate the 
anticipated 10% loss due to surgery or death, 134 neonates will be enrolled. If mothers are 
providing breast milk samples, 151 mothers would also be enrolled. 
 
 
Standard Infant Feeding Protocol 
As per standard NICU protocol, all infants will begin receiving TPN within 24 hours of life. In 
addition, all infants will have an orogastric (OG) or nasogastric (NG) tube placed upon 
admission to the NICU and begin receiving some enteral feeding within 72 hours. Length of 
insertion of the OG/NG tube is determined by measuring from the tip of the nose to the tip of the 
ear lobe and then halfway between the xyphoid process and umbilicus (Ellett et al., 2011). 
Minimum insertion length based on the weight of the infant (Cordero et al., 2011). If the infant 
receives an X-ray upon admission, placement of the OG/NG tube is verified.  Placement is also 
verified if additional X-rays are taken during the study as per usual OG/NG placement protocol 
in the NICU. Depending on the infant’s gestational age, weight, and clinical status, feedings are 
initiated at up to 20mL/kg/d and advanced daily by no more than 20mL/kg/d toward a goal of 
120-150mL/kg/d divided into 8 equal feedings per day using the established University of 
Florida Children’s Hospital NICU feeding guidelines. If mothers own breast milk is unavailable, 
infants will be provided donor breast milk as per NICU standard care.   
 
Consent Process 

 
Within 72 hours of life, and within 24 hour of initiating feeds of < 20 mL/kg/d, informed consent 
will be obtained from the mother either in her hospital room or the NICU.  The PI or research 
coordinator will ask the mother’s or infant’s nurse whether the mother is willing to speak with 
someone regarding enrolling her infant in a research study. If the mother says yes, the PI or 
research coordinator will explain the study and invite the mother to have her infant enrolled. All 
questions will be answered and mothers will be provided ample time to discuss with family and 
friends. If the mother consents and is providing breast milk to her infant, she will also be 
consented since will be providing 2 samples of breast milk for analysis 
 
Breast Milk Feedings 
Current practice in this NICU is to provide donor breast milk to all infants born prior to 30 weeks 
until they are 32 weeks post conceptual age.  For this study, all infants will receive either 
mother’s own breast milk or donor human milk for the 4 week study. If the infant is scheduled to 
be discharged prior to 4 weeks, the infant will be transitioned to formula as per NICU standards.  
Procedure 
Following consent, data including gestational age, chronologic age, birth weight, race, gender, 
date and time of sample collection, feeding tube dwell time, duration of antibiotic therapy since 
birth, episodes of sepsis, other medications, mode of delivery, and mode and type of feeding will 
be obtained from the EMR. Other data including incidence of stage 2 or greater necrotizing 
enterocolitis; episodes of presumed or culture proven late onset sepsis (occurring > 3 days of 
life); days to discharge; nutritional outcomes, including weekly enteral intake, days to full enteral 
feedings (120 mL/kg/d),(150ml/kg/day), hours of parenteral nutrition, evidence of PNALD (level 
of direct bilirubin, alkaline phosphatase, aspartate aminotransferase (AST) and alanine 
aminotransferase (ALT); growth indices (weekly weight, head circumference and length); and 
hours with a central venous line will be collected. 
  
Infants in both groups will have a bedside sign and EPIC note stating which group they are 
assigned to and when they are scheduled for feeding tube replacement. Infants will have their 
feeding tubes replaced 0-48h (Group 1) and every 7 days (Group 2). At the designated time, the 
feeding tube will be replaced by either the bedside nurse or the research coordinator (an 
experienced NICU nurse) using the NICU’s standard method of feeding tube insertion. 
 
All tubes will be adhered to the infant’s face using the same procedure designed to decrease 
the risk of feeding tube dislodgement and protect skin integrity. The method of tube securement 
will be approved by NICU management/staff and comply with NICU skin care guidelines. The 
orogastric tubes will be taped to the chin from the middle of the mouth and nasogastric tubes 
will be taped under the lateral edge of nares. The research team will check the security of the 
tube adherence 3x per week and re-secure as necessary. On the day that the study feeding 
tube is scheduled to be removed, the research coordinator will coordinate with the bedside 
nurse when the feeding tube will be removed and replaced. In the event the infant has a 
Replogle tube instead of a feeding tube on lab collection day, the Replogle tube will collected.  
At the designated time, the feeding tube or Replogle will be removed and immediately placed in 
a sterile Ziploc bag and placed on ice for immediate transfer to laboratory by member to 
research team. 
 
Microbial Culturing and Analysis After feeding tubes are removed, the tube will be divided in 
three portions; 1) the inner (stomach) intra-corporeal portion, 2) the inner intra-corporeal portion, 
and c) the extracorporeal portion. The external surface of the tube will be cleaned with isopropyl 
alcohol. The outside of the tube will be rolled across 5% sheep blood agar and McConkey’s at 
two separate points as a control for external contamination. Using sterile technique, the tube 

 
then will be sectioned into 5-cm portions and submerged in 20 mL sterile saline in a conical test 
tube (we will probably add in another cutting step in order to split the tubes open using a sterile 
scalpel). This will be vortexed on high for 1 minute. The saline will be decanted into a second 
sterile test tube, leaving the tube pieces in the first test tube. Another 20 mL aliquot of sterile 
saline will be placed in the first test tube, and this was vortexed and will be decanted into the 
second test tube. The decanted saline will then be centrifuged at 8,000 rpm for 10 minutes. 
After centrifugation, the supernatant will be discarded and the pellet resuspended in 1 mL sterile 
saline. Serial 10-fold dilutions will be performed, each will be plated onto both 5% sheep blood 
agar and McConkey’s agar. Incubated up to 48 hours at 37 C.  After 24 hours of incubation, 
unique colony types will be counted. We will also isolate colonies by replating onto their 
respective medium, and reincubated. (Original plates were reincubated an additional 24 hours 
and reassessed for unique colony types). After isolation, each organism was identified and 
frozen at -70 C in glycerol trypticase soy broth. 
DNA Extraction and 16S rRNA sequencing. DNA will be extracted from cells pellets 
obtained after tube processing. DNA will be extracted using PowerFecal DNA isolation kit (MO 
BIO Laboratories). DNA will be quantified using a Nanodrop spectrophotometer (Thermo 
Scientific, Wilmington, DE). V4 universal primers will be used for 16S rRNA amplification and 
subsequent Illumina MiSeq sequencing. Samples will be amplified in 25 μl reactions containing 
0.5 Units Phusion High-Fidelity Polymerase (New England Biolabs, Ipswich, MA), 1X Phusion 
HF Reaction Buffer, 0.75 μl DMSO, and 0.2 mM each dNTP. Triplicate PCR amplifications will 
be pooled for each sample, and cleaned with a QIAquick PCR Purification kit (Qiagen). Two 
hundred nanograms of each cleaned amplicon library will be submitted for sequencing at the 
ICBR core facility at the University of Florida. Sequencing will be performed on an Illumina 
MiSeq with a 300-bp paired-end protocol, using single indexing. 
Microbiome 16S rRNA Gene Analysis. Sequencing reads will be parsed by Illumina 
index at the sequencing center. Paired reads will be merged, and primers and adaptors will be 
removed using a combination of tools in cutadapt, Galaxy, and eautils. Parsed raw sequencing 
reads will be made available to the scientific community after publication through NCBI’s 
Sequence Read Archive (SRA). Sample names will be added to the definition lines of 
sequencing reads using sed and concatenated into one fasta file, to make them compatible for 
analysis in QIIME v1.9. Clustering of Operational Taxonomic Units (OTUs) at 97% similarity will 
be performed with the subsampled open-reference OTU picking method, with no removal of 
singletons. The Greengenes reference dataset version 13.8 will be used as the reference for 
OTU picking and for taxonomy assignment with uclust. Community structure will be analyzed in 
R with phyloseq and will be plotted with ggplot2. Analysis of similarities (ANOSIM) will be 
performed in R using VEGAN v2.0-8. Statistical significance of QIIME profiles will be assessed 
using STAMP.  
Metagenomic analyses. For metagenomic data production, libraries will be constructed 
for each section of the feeding tube at the Interdisciplinary Center for Biotechnology Research 
at the University of Florida (ICBR). Libraries will be sequenced on the Illumina HiSeq 2500 
platform, targeting ~3 Gb of sequence per sample with 100 bp, paired-end reads. Profiling of 
metabolic pathways will be performed using with Blast2GO at https://www.blast2go.com. To 
identify genes encoding proteins with potential antibiotic resistance functions, the metagenomes 
will be analyzed using ResFinder 2.1. The ResFinder program 
(http://cge.cbs.dtu.dk/services/ResFinder/) is an acquired antimicrobial resistance search tool 
which identifies genes with > 40% identity to known antibiotic resistance genes to identify genes 
encoding proteins with potential virulence functions will be used VirulenceFinder 1.5 
(http://cge.cbs.dtu.dk/services/VirulenceFinder/). Using this tool curated by the Center for 
Genomic Epidemiology we will be able to identify virulence factors associated with adherence, 

 
toxin production, exoenzymes, host immune evasion, and secretion. Based on the findings of 
the metagenomic data, the antibiotic susceptibility of bacterial isolates will be confirmed by 
antimicrobial susceptibility tests using the Kirby-Bauer method.  
To determine bacteria in the feeding tube which may originate from the mother’s breast milk or 
donor milk, a small sample will be obtained at week 1 and week 4 and similar 16S rRNA and 
metagenomics sequencing will be performed. If still providing breast milk to their infant, the 
infant’s mother will be asked to provide 2-5 ml of her breast milk which she has pumped per 
standard NICU policy. This sample will be analyzed using similar microbiome and metagenomic 
analyses. 
Biofilm Analysis. The presence of biofilm in the interior surface of the feeding tubes will 
be determined using fluorescent stains and visualized by confocal microscopy. We will utilize a 
variety of fluorophores to discriminate live/dead cells (FilmTracer LIVE/DEAD biofilm viability kit, 
Invitrogen) and the matrix components (FilmTracer SYPRO/Ruby biofilm matrix stain, 
Invitrogen) as directed by the manufacturer. The results obtained will be confirmed by scanning 
electron microscopy (SEM).   
 
Gastric/Stool/Sputum/Sampling. Gastric sample of at least 1.0-2.0 mL will be collected weekly 
by the research coordinator, immediately following insertion of a new feeding tube, by gently 
aspirating gastric contents from the feeding tube into a syringe. Gastric aspiration assessment 
for feeding tube placement as per NICU protocol. One baseline pH will be obtained at start of 
study. To assess gastric pH, the research coordinator will use one-two drops of the gastric 
sample to test using Hydrion pH strips and Fischer Scientific Horiba LAQUA twin pH 11 meter. 
The rest of the gastric sample will be used to analyze the microbiome and level of inflammatory 
markers. Stool samples will be collected weekly by the research nurse and pH check of sample 
will be done. Following collection, all samples will be placed in a sterile specimen container and 
immediately frozen at -80 degrees Celsius for later analysis. This team has extensive 
experience in the collection of gastric aspirates, and stool from premature VLBW infants in the 
NICU as well as the analysis of inflammatory markers and 16S rRNA sequencing of these 
samples. Oropharyngeal swabs will be collected weekly by the research coordinator (a 
registered nurse experienced in the care of critically ill infants) by placing a tiny soft brush into 
the infant’s mouth and gently rotating the swab to collect the infant’s saliva.  
Microbiota Sequencing and Analyses: DNA from samples will be extracted and 
analyzed as described above (see Aim 1). 
Inflammatory Response. The samples will be analyzed for inflammatory markers using 
a combination of multiplex technologies using the BioRad Bio-Plex platform as well as S100A12 
and calprotectin immunoassays.  
Statistical Analysis  
Data integrity will be evaluated using descriptive statistics (e.g.: means, standard deviations, 
frequencies, percents, range) appropriate for measurement level. Checks for implausible or out-
of-range values, distributional forms, the presence and distribution of censored values (e.g.: 
inflammatory markers), and missingness will be performed. Data transformations (e.g.: Box-Cox 
family of transforms) will be made, if required, based on evaluation of model fit and tenability of 
assumptions. If applicable, regression techniques which can accommodate censored variables 
(e.g. MPLUS version 8 or higher)58 will be employed. Selected variables (e.g.: type of feed 
(mother’s breast milk or donor breast milk), whether NPO, antibiotic use, gestational age, 
chronological age, gastric pH and sex) will be screened for potential inclusion as covariates in 
each of the statistical models tested. Associations between each potential covariate and the 
respective dependent variable will be examined, and only those variables having a p<.10 

 
association and whose inclusion improves model fit will be retained. The general modeling 
strategy will be a generalized linear mixed model (GLMM) approach. A GLMM is able to 
accommodate different numbers of measurements between subjects, utilize data from subjects 
when some of the data is missing (that is, subjects with some missing data points will not be 
dropped from analysis), can incorporate time-varying covariates, flexible covariance structures, 
and a variety of dependent variable distributions (including dichotomous),  and thus will be able 
to accommodate the analyses proposed. Model fit and strength of association will be evaluated 
using Vonesh’s GOF macro for SAS. Our primary goal will be to assess differences in marginal 
least squares means between the dwell time groups. All analyses will be performed using SAS 
software version 9.4 or later. Statistically significant interaction effects will be evaluated using 
simple main effects analyses via the SLICE option available in the SAS/STAT GLMM 
procedures. Due to the number of inferential tests planned, it is not practical to maintain a 5% 
experiment-wise Type I error rate; however, significance levels will be adjusted to maintain a 
model-wise 5% Type I error rate through use of a Benjamini-Hochberg approach. 
Data Entry and Management 
A code key stored separate from the data set will be used.  The code key will be kept in a 
locked cabinet in the research office. All data will be entered into a REDCAP database having 
integrated data quality and consistency checks. The study database created in REDCap will be 
password-protected and housed on a designated database server. Data quality will be 
monitored and assured as reported and as entered into the database. All hardcopy forms will be  

 
Variable 
Measurement 
Timing 
Descriptive (1-2) below 
 
 
1. Maternal, prenatal and 
perinatal demographics 
Maternal history, prenatal and perinatal 
complications and medications, mode of delivery, 
antibiotic use, steroid use 
Collected upon entry into study. 
2. Infant demographics 
Race/ethnicity, sex, gestational age, birth weight, 
Apgar scores, resuscitation at birth and neonatal 
acuity (SNAP II) score, type of feeding, whether or 
not the infant is NPO, medications effecting gastric 
pH, chronologic age, NPO, number of days and type 
of antibiotics 
Collected upon entry into study and 
during the 4 week study period.  
Antibiotic data tracked for 6 weeks 
Microbial analysis of feeding tubes, 
feeding tube hubs and residual 
intraluminal liquid 
Culture based analysis and microbial analysis (16S 
rRNA and metagenomics sequencing). Presence of 
biofilm in feeding tube or Replogle tube 
Following removal of each feeding 
tube for 4 weeks 
Analysis of gastric contents (1-2) 
below 
 
 
1. Microbial analysis 
16S rRNA and metagenomics sequencing 
Weekly for 4 weeks 
2. Inflammatory markers 
Analysis of inflammatory markers 
Weekly for 4 weeks 
3. pH testing 
Measuring acidity 
Initially and weekly for 4 weeks 
Analysis of stool (1-2) below 
 
 
1. Microbial analysis 
16S rRNA and metagenomics sequencing 
Weekly for 4 weeks 
2. Inflammatory markers 
Analysis of inflammatory markers 
Weekly for 4 weeks 
3. pH testing 
Measuring acidity 
Weekly for 4 weeks 
Nutritional outcomes (1-6) below 
 
 
1. Enteral intake  
24-hour enteral feeding intake in mL/kg  
Daily for 6 weeks 
2. Time to full feeds 
First day infant received >120 mL/kg/d of enteral 
feedings. First day infant received 150ml/kg/d 
Recorded daily until 150 mL/kg/d 
reached (up to 6 weeks) 
3. Hours of PN 
Number of hours infant received some parenteral 
nutrition 
Daily for up to 20 weeks   
1. PNALD 
Liver function tests (level of direct bilirubin, alkaline 
phosphatase, AST and ALT) 
Weekly or biweekly for 6 weeks 
Peak alkaline phosphatase and Peak 
direct bilirubin for up to 20 weeks or 
discharge 
2. Hours of central venous line 
access 
Number of hours infant has a central venous line 
Daily for up to 20 weeks 
3. Growth indices 
Weight, length, and head circumference 
Daily for 4 weeks and at discharge 
4. Episodes of late onset sepsis 
Episodes of culture proven or presumed sepsis 
(treated with >3 days of antibiotics but with negative 
cultures) 
Daily from birth up to 20 weeks 
5. Episodes of NEC 
Episodes of radiologic or surgical evidence of NEC 
All incidences for up to 20 weeks 
6. Length of hospital stay 
Days infant remains in hospital  
From birth until discharge 
Covariates (1-5) below 
 
 
1. Gastric pH 
pH of gastric aspirates, use of medications which 
affect gastric pH 
Gastric pH analysis will be done 
weekly, information regarding 
medications will be collected during 
the 4 weeks study period 
2. Oropharyngeal swabs 
Time of last feed, oral medications 
Sputum samples weekly for 4 weeks 
3. Analysis of maternal breast 
milk or donor milk 
Microbiota and metagenomic sequencing 
At week 1 and week 4  

 
visually inspected before data entry. A manual comparison of randomly selected data hardcopy 
forms with data output listing generated from the study database will be performed, and 
consistency checks will be generated by SQL or SAS programs as part of data cleaning 
procedures. The system will assign a global unique identifier to each enrolled subject that will 
serve as the subject id. Study case report forms (CRFs) will be maintained in study specific 
folders and when CRFs not actively being processed, will be secured in locked file cabinets. In 
addition to the use of passwords and other security measures, all documents containing 
identifying information are considered confidential materials and will be safeguarded. Data to be 
collected are found in Table 3. Data collected in REDCap will be shared with an outside 
affiliated researcher at Old Dominion University for secondary data analysis. All data sets 
shared will be verified with CTSI REDCap, before giving outside researcher access. 
 
7.  Possible Discomforts and Risks:  
Although little information exists concerning the discomfort associated with feeding tube 
replacement in VLBW infants, it is likely associated with some degree of discomfort. Therefore, 
prior to insertion of each feeding tube, strategies known to reduce pain in neonates will be 
implemented. Comfort measures are routinely utilized during feeding tube removal and insertion 
in this NICU. Comfort measures implemented may include the use of a pacifier dipped in a 
sweet solution for infants with a sustained suck and greater than 28 weeks gestation, (2) 0.2 ml 
of a sweet solution placed on the gums for infants that are greater than 28 weeks but too ill or 
immature to have a sustained suck, (3) all infant will be swaddling and/or tucking and (4) use of 
a securement device or taping method approved by the NICU to minimize skin irritation.  These 
measures are consistent with current practice in this NICU for pain reduction and will include the 
following; (1) providing a pacifier dipped in a 25% sucrose solution for infants who have a 
sustained suck, (2) placing 0.2 ml of a 25% sucrose solution in the oral/buccal cavity for infants 
too immature or ill to have a sustained suck and (3) provide all infants with swaddling and 
facilitated tucking. Sucrose solutions given orally before painful procedures has been 
extensively studied are safe, well tolerated and reduce pain in premature VLBW infants.  
 
8.   Possible Benefits:  
Feeding tubes that remain in place for a shorter period of time may be less contaminated and 
lead to decreased complications 
 
 
4. Nutritional data 
Medications and disease processes associated with 
decreased intestinal motility, episodes and duration 
of kangaroo care 
Upon entry into study and for 4  
active weeks.