HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Respond to This Article Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Horn, D. Articles by Chaboyer, W. Search for Related Content PubMed PubMed Citation Articles by Horn, D. Articles by Chaboyer, W.

Gastric Feeding in Critically Ill Children: A Randomized Controlled Trial

	Abstract

Top Abstract Review of the Literature Method Results Discussion Limitations Implications for Clinical... Conclusion References

 
• Background Provision of enteral nutrition via the gastric route is a common nursing procedure in pediatric intensive care units. Little research, however, has focused on children’s tolerance of different types of gastric feeding regimens.

• Objectives To examine the relationship between 2 gastric feeding regimens, continuous and intermittent, and children’s tolerance as measured by the number of stools and prevalences of diarrhea and vomiting.

• Methods A randomized controlled trial was conducted in an Australian pediatric intensive care unit; 45 children were randomly assigned to either the continuous or the intermittent gastric feeding groups. Participants remained in the assigned feeding group for the duration of the study, and values of variables used to monitor patients’ tolerance were recorded.

• Results Both feeding groups were similar with respect to Pediatric Index Mortality score, age, weight, sex, diagnosis, and use of pharmacological agents known to affect the gastrointestinal tract. Additionally, the 2 groups did not differ in study duration or the daily volume of administered enteral formula per kilogram of body weight. The number of stools per day and the prevalences of diarrhea and vomiting did not differ significantly between the 2 groups.

• Discussion Continuous and intermittent gastric feeding regimens have similar outcomes with respect to the number of stools per day and the prevalence of diarrhea and vomiting in pediatric intensive care patients. Further gastric feeding studies and the development of enteral feeding guidelines for critically ill children are needed.

To this day, the provision of enteral nutritional solutions via the gastric route remains a common nursing procedure in pediatric intensive care units (PICUs). However, little research has been done to compare different types of gastric feeding regimens in critically ill children. In fact, in only a few studies with adults and very-low-birth-weight and preterm infants have patients’ outcomes been compared for continuous and intermittent gastric feeding regimens.^2–9

The effects of continuous and intermittent gastric feeding on diarrhea and vomiting have been compared in both adults and very-low-birth-weight and preterm infants, with inconsistent results.

 

	Review of the Literature

Top Abstract Review of the Literature Method Results Discussion Limitations Implications for Clinical... Conclusion References

 
We found 7 studies that compared intermittent and continuous feeding regimens in adults (Table 1) or very-low-birth-weight or preterm infants (Table 2). Although a variety of outcome measures have been examined, in the following review of the literature, we focus on the number of stools and the prevalences of diarrhea and vomiting.

Additionally, 2 of the studies involving very-low-birth-weight infants used stool type and/or frequency as a marker of patients’ tolerance to gastric feeding. Silvestre et al⁶ compared the effects of continuous and intermittent feeding regimens on 82 very-low-birth-weight preterm infants. No significant differences were found in number or type of stools. Toce et al⁸ investigated the prevalence of feeding intolerance and number of stools in 53 preterm very-low-birth-weight infants fed either continuously or intermittently via the gastric route. The authors found no significant difference in the number of stools per day between the 2 feeding groups (2.3 vs 2.4).

The results of the studies we found differ, and none of the studies included a comparison of continuous and intermittent gastric feeding regimens with respect to number of stools or the prevalence of diarrhea in critically ill children.

Previous researchers also used the prevalence of vomiting as an indicator of patients’ tolerance to gastric feeding.^10–12 Montejo¹⁰ investigated the frequency of gastrointestinal complications related to enteral nutrition in 400 continuously fed critically ill adult patients. In that study, the overall prevalence of vomiting was 12.2%, with 71% of those participants experiencing only a single episode of vomiting during the study. Similarly, in a randomized study conducted by Reece et al,¹³ vomiting affected 10 (11%) of 92 participants. Pinilla et al¹² reported that vomiting related to continuous gastric feeding occurred in 6% and 7% of 2 study groups. In that study, the patients were randomized according to definitions for a high gastric residual volume (150 mL or 250 mL). The results of these studies^10,12,13 suggest that vomiting occurs in approximately 10% of adult patients. We did not find any studies that compared continuous and intermittent feeding regimens in critically ill children.

Therefore, we examined the relationship between 2 gastric feeding regimens, continuous and intermittent, and measured the tolerance of critically ill children to those 2 regimens by assessing the following outcome variables: number of stools, prevalence of diarrhea, and prevalence of vomiting.

	Method

Top Abstract Review of the Literature Method Results Discussion Limitations Implications for Clinical... Conclusion References

 
A convenience sample was drawn from all patients admitted to an Australian PICU during a 9-month period who did not meet any of the exclusion criteria. Exclusion criteria were defined as a history of diarrhea or vomiting in the 24 hours preceding randomization, anticipated transfer from the PICU within 72 hours after gastric feedings were started, or when a specific gastric feeding protocol was requested because of an underlying condition. The institutional review board of the associated hospital and university approved the study protocol, and consent was sought from the parent(s) of each patient once eligibility for inclusion in the study had been determined. Participants were randomly assigned to 1 of 2 feeding regimens: continuous or intermittent. Random assignment was generated by toss of a coin, as we had no access to a centralized random process, and assignments were then concealed in sealed opaque envelopes ahead of time.

All participants were fed via a polyvinyl nasogastric or orogastric feeding tube that was appropriate in size for the patient’s age. Continuous gastric feedings were delivered during the entire 24-hour period via a feeding pump (Kangaroo 324 feeding pump, Sherwood Medical, St Louis, Mo).^2,3,5 Intermittent feedings were delivered once every 2 hours and were delivered for 20 to 30 minutes via a syringe by using a gravity method. This feeding regimen was selected for the intermittent feeding protocol to limit the effect of abdominal distention, which can occur with larger feeding volumes administered less frequently.¹⁴ Additionally, this process reflected current practice within the study unit. Each outcome measure was defined in the study protocol. Diarrhea was defined as the passage of 3 or more loose or liquid stools in a 24-hour period.^4,11,15–19 Vomiting was defined as the observed expulsion of gastric contents.^10,11,20

Children in the intensive care unit were randomly assigned to either a continuous or an intermittent (every 2 hours) feeding regimen, and the prevalences of diarrhea and vomiting were determined by using direct observation.

 

Education sessions were provided to registered nurses and medical officers working in the PICU. These sessions were conducted by using a computerized slide presentation and provided staff with information related to the research study. At each session, the importance of administering the intermittent gastric feedings during a 20- to 30-minute period was emphasized. Additional education sessions were held for the 8 registered nurses nominated as research assistants. The research assistants were selected on the basis of their clinical experience in the PICU and the fact that at least 1 of these persons would be on duty each shift during the data-collection phase of the study. In order to improve interrater reliability, research assistants were provided additional information related to the descriptors, or key terms, used to classify bowel movements (pebble/hard, soft/formed, and loose/liquid) because only the assistants or the principal researcher (D.H.) classified bowel movements during the study. All educational material was available in an electronic format on each bedside computer.

A written medical order for enteral feeding was completed for all participants once the assigned feeding group was known. The enteral feeding order included the type and volume of formula to be administered for each participant, based on the participant’s age and weight. All participants received an age-appropriate enteral formula. All participants were fed via a polyvinyl nasogastric or orogastric tube appropriately sized for each patient’s age; an 8F tube was the most common size in both feeding groups. All continuously fed participants (n = 22) received a full-strength age-appropriate formula; intermittently fed participants received an age-appropriate formula that was either full strength (n = 22) or full strength with an added carbohydrate supplement (n = 1). The types of feeding preparations administered to participants in both groups included human milk (2 in continuous group, 4 in intermittent group), infant formula (14 in continuous group, 13 in intermittent group), pediatric formula (2 in continuous group, 4 in intermittent group), and adult formula (2 in continuous group, 2 in intermittent group). Two participants in the continuously fed group received other formula variations (1 received adult and pediatric formula, 1 received semielemental formula). Types of feeding preparations did not differ significantly between groups (P = .44). The median volume of delivered formula per kilogram of body weight per 24-hour period was calculated. Continuously fed participants received a median volume of 66 mL/kg per day of formula compared with 73 mL/kg per day for intermittently fed participants (P = .39). Gastric residual volumes were measured before the start of feeding and then, once every 4 hours, the aspirated volume was returned to the participant. All bowel movements and episodes of vomiting were recorded when they occurred. All data were analyzed by using a t test, Mann-Whitney U test, or Pearson ² test. The level of significance was set at .05.

	Results

Top Abstract Review of the Literature Method Results Discussion Limitations Implications for Clinical... Conclusion References

 
Study Sample
Of the 46 participants enrolled in the study, 22 were randomly assigned to the continuous feeding group and 24 to the intermittent feeding group. One participant in the intermittent feeding group was removed from the study before statistical analysis because the child received only 1 feeding via the gastric tube before oral feedings were begun, and no outcome data were obtained during the single gastric feeding. Thus, data on 22 continuously fed participants and 23 intermittently fed participants were included in the analyses.

Children in the continuous and intermittent feeding groups did not differ significantly in sex, age, weight, duration of study hours, or volume of formula delivered per 24 hours (Table 3). However, wide variations in age were observed in both feeding groups, and 1 participant in the continuous feeding group was less than 28 days old. The most common diagnosis was a respiratory problem (50% of continuous group, 57% of intermittent group). A Pediatric Index Mortality score was calculated upon admission to the PICU for all participants: the median score was 8 for the continuously fed group and 5 for the intermittently fed group (P = .16).

In addition, we found no difference between the 2 feeding groups in the use of pharmacological agents known to affect the gastrointestinal tract (including narcotics, prokinetic agents, gut protection agents, bowel preparations, and antibiotics). Morphine was the narcotic most commonly administered to participants in both feeding groups, and its use did not differ between the groups on any study day. Five participants (3 in continuous group, 2 in intermittent group) received the prokinetic agents cisapride or metoclo-pramide, known to accelerate gastric emptying, during the study period (P = .60). No participants received erythromycin during the study period. Sucralfate, a cytoprotective agent, and ranitidine, a histamine receptor antagonist, were the 2 gut protection agents most commonly administered to participants in both feeding groups. Bowel preparation agents were administered infrequently to participants in both feeding groups. In contrast, administration of antibiotic agents was a common intervention for participants in both the continuous (73%) and intermittent (61%) feeding groups (P = .53).

Outcomes
The prevalences of diarrhea and vomiting were calculated by using 3 different methods: number of participants with 1 or more episodes, number of episodes per participant, and percentage of days (Table 4). These 3 methods were used to provide a more comprehensive description of the outcomes and also to permit a comparison of these results with results of other studies.²¹ The mean number of bowel movements per 24-hour period was 1.5 for the continuously fed group and 1.6 for the intermittently fed group (P = .83). Diarrhea was experienced more than once in 1 continuously fed participant and 3 intermittently fed participants, a nonsignificant difference (P = .53). Additionally, continuously fed participants had a mean of 0.32 episodes of diarrhea, whereas intermittently fed participants had a mean of 0.52 episodes of diarrhea (P = .30).

	Discussion

Top Abstract Review of the Literature Method Results Discussion Limitations Implications for Clinical... Conclusion References

 
The protocol for intermittent feedings was based on current standard practice, which ensured that participants were not placed at a greater risk than normal. The number of stools per day and the prevalences of diarrhea and vomiting did not differ significantly between the 2 feeding groups. However, patients’ ages varied widely: 73% of continuously fed participants and 70% of intermittently fed participants were 12 months old or younger. The volume of enteral feedings each participant received each day was calculated on the basis of the participant’s age, weight, and medical condition. No attempt was made to calculate the energy intake for the study participants, which could have been another outcome variable. Restricting fluid intake usually to 60% to 70% of the daily total requirement is a clinical reality in the PICU. Additionally, the energy intake provided by all infant formula preparations is less than 4.184 kJ (1 kcal) per milliliter. Thus, PICU patients may not have received adequate energy intake, irrespective of the method of feeding, and this may in itself be an interesting area to study.

The mean number of stools per 24-hour period for the continuously fed participants was 1.5 compared with 1.6 in the intermittently fed participants. Other investigators^2,5,6,8,9 considered the effect of gastric tube feeding on the number of stools per day. For the most part, the results of these studies were congruent with the results of our study.

The outcome measure, diarrhea, was defined as the passage of 3 or more loose or liquid bowel movements in a 24-hour period. The prevalence of diarrhea did not differ significantly between the feeding groups, regardless of whether the number of participants with at least 1 episode, the number of episodes per participant, or the percentage of study days was compared between groups. Other investigators who compared continuous and intermittent gastric feeding regimens reported different prevalences of diarrhea. Ciocon et al³ reported diarrhea as occurring in 66% of the continuously fed participants and 97% of the intermittently fed participants. In comparison, Taylor⁴ reported the prevalence of diarrhea for continuously fed participants as 75% and for the intermittently fed participants as 33%. These results^3,4 indicate that the prevalence of diarrhea varies considerably. This variance most likely is due to the use of different definitions to describe the outcome variable diarrhea, populations of different ages, different durations of study, and the use of pharmacological agents such as laxatives, which can affect the frequency and consistency of bowel motions.

The tolerances of children in intensive care units to intermittent and continuous feedings are similar. This initial work may provide a foundation for making decisions about feeding regimens in critically ill children and lays the groundwork for further study.

 

The final measure of patients’ tolerance, vomiting, was defined as the observed expulsion of gastric contents. The prevalence of vomiting did not differ significantly between the 2 feeding groups, regardless of whether the number of participants with at least 1 episode, the number of episodes per participant, or the percentage of study days was compared between groups. The percentage of days with vomiting was low and was similar for both feeding groups. This finding is congruent with those of an earlier study,¹¹ in which vomiting was reported to occur on 6% of days for 23 continuously fed adult patients. In our study, the number of participants with at least 1 episode of vomiting did not differ significantly between the 2 feeding groups (18% in continuous group; 22% in intermittent group). However, all participants in the continuous feeding group who vomited (n = 4) did so on more than 1 occasion, whereas none of the participants in the intermittently fed group who vomited (n = 5) did so more than once. Montejo¹⁰ examined the prevalence of vomiting in 400 continuously fed critically ill adult patients. In that study, 35 participants (9%) experienced 1 episode of vomiting, 9 participants (2%) experienced 2 episodes, 4 participants (1%) experienced 3 episodes, and 1 participant (0.25%) experienced more than 3 episodes of vomiting. This finding suggests that an isolated occurrence of vomiting may not be a true reflection of a patient’s intolerance to gastric feeding. In other studies,^13,20 the percentage of continuously fed participants with vomiting was from 2% to 11%. The higher prevalence of vomiting in our study may be due to a number of factors, including patients’ ages, the volume of formula delivered, the time enteral feeding was started, and the low use of pharmacological agents known to accelerate gastric emptying. Further studies of enteral feeding are needed to examine the prevalence of vomiting in other critically ill children.

	Limitations

Top Abstract Review of the Literature Method Results Discussion Limitations Implications for Clinical... Conclusion References

 
We did not address the effect of the gastric feeding regimen on nutritional intake or growth patterns, and we did not examine the effect of the gastric feeding regimen on other adverse outcomes for patients. Because only a single PICU was used to recruit participants, sampling bias cannot be ruled out. Additionally, the generalizability of the results is unknown because of the sample size, the age of the majority of patients in both groups (12 months or younger), and the small proportion of surgical cases. The inability to detect any differences between the 2 feeding groups may have occurred because the feeding regimens were not dissimilar enough or because a maximum study duration of 72 hours was not long enough to detect differences. The outcome measures, diarrhea and vomiting, were measured by direct observation; therefore, an episode might have gone unnoticed. However, all subjects were closely monitored, and 1-to-1 nursing care was standard practice in the study setting.

	Implications for Clinical Practice

Top Abstract Review of the Literature Method Results Discussion Limitations Implications for Clinical... Conclusion References

 
This study has a number of significant implications for clinical practice, particularly in the area of pediatric critical care nursing. First, before this study, no comparisons of different gastric feeding regimens in critically ill children and/or the frequency of patients who did not tolerate such feedings had been published. Thus, our results provide pediatric critical care nurses a beginning knowledge base to use to guide their clinical practice. This outcome is important because enteral nutrition via a gastric feeding tube is common in PICUs. Second, our results indicate that continuous and intermittent gastric feeding regimens have similar outcomes in terms of the number of stools and the prevalence of diarrhea and vomiting. These findings are important to the practice of pediatric critical care nurses because anecdotal reports have suggested that a continuous gastric feeding regimen is better tolerated by critically ill children than is an intermittent feeding regimen.^19,22 Finally, our results indicate a protocol and definitions of outcome measures that can be used by others interested in pursuing this area of research.

	Conclusion

Top Abstract Review of the Literature Method Results Discussion Limitations Implications for Clinical... Conclusion References

 
Although both feeding regimens yielded similar outcomes for patients, further research is needed to confirm our findings. Finally, evidence-based guidelines for enteral feeding of critically ill children must be developed because the provision of enteral nutrition via the gastric route is a common nursing procedure in the PICU.

	ACKNOWLEDGMENT

 
Financial support for this study was provided by the Australian College of Critical Care Nurses, South Carlton, Victoria, Australia.

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.

Commentary by Mary Jo Grap (see shaded boxes).

	REFERENCES

Top Abstract Review of the Literature Method Results Discussion Limitations Implications for Clinical... Conclusion References

 

1. Randall H. The history of enteral nutrition. In: Rombeau J, Caldwell M, eds. Clinical Nutrition: Enteral and Tube Feeding. Philadelphia, Pa: WB Saunders; 1990:1–9.
2. Hiebert J, Brown A, Anderson R, Halfacre S, Rodeheaver G, Edlich R. Comparison of continuous versus intermittent tube feedings in adult burn patients. JPEN J Parenter Enteral Nutr. 1981;5:73–75.[Abstract/Free Full Text]
3. Ciocon J, Galindo-Ciocon D, Tiessen C, Galindo D. Continuous compared with intermittent tube feeding in the elderly. JPEN J Parenter Enteral Nutr. 1992;16:525–528.[Abstract/Free Full Text]
4. Taylor T. A comparison of two methods of nasogastric tube feedings. J Neurosurg Nurs. 1982;14:49–55.[Medline]
5. Kocan M, Hickisch S. A comparison of continuous and intermittent enteral nutrition in NICU patients. J Neurosci. 1986;18:333–337.
6. Silvestre M, Marbach C, Brans Y, Shankaran S. A prospective randomized trial comparing continuous versus intermittent feeding methods in very low birth weight neonates. J Pediatr. 1996;128:748–752.[Medline]
7. Macdonald P, Skeoch C, Carse H, et al. Randomized trial of continuous nasogastric, bolus nasogastric, and transpyloric feeding in infants of birth weight under 1400 g. Arch Dis Child. 1992;67:429–431.[Abstract/Free Full Text]
8. Toce S, Keenan W, Homan S. Enteral feeding in very-low-birth-weight infants. Arch Pediatr Adolescent Med. 1987;141:439–444.[Abstract/Free Full Text]
9. Schanler R, Shulman R, Lau C, O’Brian-Smith E, Heitkemper M. Feeding strategies for premature infants: randomized trial of gastrointestinal priming and tube-feeding method. Pediatrics. 1999;103:434–439.[Abstract/Free Full Text]
10. Montejo J. Enteral nutrition-related gastrointestinal complications in critically ill patients: a multicenter study. Crit Care Med. 1999;27:1447–1453.[Medline]
11. Viall C, Porcelli K, Teran C, Varma R, Steffee W. A double-blind clinical trial comparing the gastrointestinal side effects of two enteral feeding formulas. JPEN J Parenter Enteral Nutr. 1990;14:265–269.[Abstract/Free Full Text]
12. Pinilla J, Samphire J, Arnold C, Liu L, Thiessen B. Comparison of gastrointestinal tolerance to two enteral feeding protocols in critically ill patients: a prospective randomized controlled trial. JPEN J Parenter Enteral Nutr. 2001;25:81–86.[Abstract/Free Full Text]
13. Reece J, Means M, Hanrahan K, Clearman B, Colwill M, Dawson C. Diarrhea associated with nasogastric feedings. Oncol Nurs Forum. 1996;23:59–66.[Medline]
14. American Society for Parenteral and Enteral Nutrition. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 1993;17:27SA–49SA.
15. Guenter P, Settle G, Perlmutter S, Marino P, DeSimone G, Rolandelli R. Tube-feeding related diarrhea in acutely ill patients. JPEN J Parenter Enteral Nutr. 1991;15:277–280.[Abstract/Free Full Text]
16. Guenter P, Sweed M. A valid and reliable tool to quantify stool output in tube-fed patients. JPEN J Parenter Enteral Nutr. 1998;22:147–151.[Abstract/Free Full Text]
17. Kelly T, Patrick M, Hillman K. Study of diarrhea in critically ill patients. Crit Care Med. 1983;11:7–9.[Medline]
18. Kudsk K, Croce M, Fabian T, et al. Enteral versus parenteral feeding: effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg. 1992;5:503–513.
19. Taylor R, Baker A. Enteral nutrition in critical illness: part two. Pediatr Nurs. 1992;11:26–31.
20. Cataldi-Betcher E, Seltzer M, Slocum B, Jones K. Complications occurring during enteral nutrition support: a prospective study. JPEN J Parenter Enteral Nutr. 1983;7:546–552.[Abstract/Free Full Text]
21. Bliss D, Guenter P, Settle R. Defining and reporting diarrhea in tube-fed patients: what a mess! Am J Clin Nutr. 1992;55:753–759.[Abstract/Free Full Text]
22. Curley M, Castillo L. Nutrition and shock in pediatric patients. New Horiz. 1998;6:212–225.[Medline]

This article has been cited by other articles:

				N. M. Mehta Approach to Enteral Feeding in the PICU Nutr Clin Pract, June 1, 2009; 24(3): 377 - 387. [Abstract] [Full Text] [PDF]

				N. M. Mehta, C. Compher, and A.S.P.E.N. Board of Directors A.S.P.E.N. Clinical Guidelines: Nutrition Support of the Critically Ill Child JPEN J Parenter Enteral Nutr, May 1, 2009; 33(3): 260 - 276. [Full Text] [PDF]

				J. A. Weckwerth Monitoring Enteral Nutrition Support Tolerance in Infants and Children Nutr Clin Pract, October 1, 2004; 19(5): 496 - 503. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Respond to This Article Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Horn, D. Articles by Chaboyer, W. Search for Related Content PubMed PubMed Citation Articles by Horn, D. Articles by Chaboyer, W.