Bolus gastric feeds improve nutrition delivery to mechanically ventilated pediatric medical patients: Results of the COntinuous vs BOlus multicenter trial

Abstract

Background: Comparison of bolus gastric feeding (BGF) vs continuous gastric feeding (CGF) with respect to timing and delivery of energy and protein in mechanically ventilated (MV) pediatric patients has not been investigated. We hypothesized that bolus delivery would shorten time to goal nutrition and increase the percentage of goal feeds delivered.Methods: Multicenter, prospective, randomized comparative effectiveness trial conducted in seven pediatric intensive care units (PICUs). Eligibility criteria included patients aged 1 month to 12 years who were intubated within 24 h of PICU admission, with expected duration of ventilation at least 48 h, and who were eligible to begin enteral nutrition within 48 h. Exclusion criteria included patients with acute or chronic gastrointestinal pathology or acute surgery. Results:We enrolled 158 MV children between October 2015 and April 2018; 147 patients were included in the analysis (BGF = 72, CGF = 75). Children in the BGF group were slightly older than those in the CGF; otherwise, the two groups had similar demographic characteristics. There was no difference in the percentage of patients in each group who achieved goal feeds. Time to goal feeds was shorter in the BGF group (hazard ratio 1.5 [CI 1.02-2.33]; P = 0.0387). Median percentage of target kilocalories (median kcal 0.78 vs 0.59; P ≤ 0.0001) and median percentage of protein delivered (median protein 0.77 vs 0.59; P ≤ 0.0001) was higher for BGF patients. There was no difference in serial oxygen saturation index between groups. Conclusion:Our study demonstrated shorter time to achieve goal nutrition via BGF compared with CGF in MV pediatric patients. This resulted in increased delivery of target energy and nutrition. Further study is needed in other PICU populations.

Is bolus or continuous enteral feeding better in critically ill children: An evidence‐based review

“…Energy and Protein requirements were calculated using a combination of the Schofield Equation 10 and the American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines for protein recommendations. 11 The study did find that the bolus fed group achieved a higher energy and protein intake at 24 h (p = 0.007); however the relevance of this for patients who are intubated and enterally fed for much longer than 24 h is unclear. Further results at 48 h and beyond, could have given more insight into whether that initial attainment of higher energy intake has an impact on the long-term outcomes for patients intubated and tube fed for longer periods.…”

“…Brown et al in 2018 9 conducted a prospective, randomized comparative effectiveness intervention pilot study using computerized block randomization, but had a small sample size of 25 patients, 11 of which could only be assessed for 24 h due to extubation and progress to oral feeding. Energy and Protein requirements were calculated using a combination of the Schofield Equation 10 and the American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines for protein recommendations 11 . The study did find that the bolus fed group achieved a higher energy and protein intake at 24 h ( p = 0.007); however the relevance of this for patients who are intubated and enterally fed for much longer than 24 h is unclear.…”

“…neither method was superior, however this did not include the last two studies. 9,11 A recent survey of UK PICUs enteral nutrition practices on PICU in 2019, 7 found that just under half (37%) of UK PICUs utilized bolus feeding as their default method, with more using continuous feeding.…”

“…These articles provide conflicting results, and despite the largest and most recent RCT 11 suggesting bolus feeding might be advantageous in improving the time to achieve goal feeds, the time difference was so small this is unlikely to confer any clinical benefits. Of note, most of the significant results identified in all the studies are based around time to reach target feed, and very few studies found any significant differences related to other measurable outcomes that could impact on a child's nutrition and longer‐term outcomes.…”

“…Although further research is still required into specific population groups such as surgical patients, and on the longer‐term impact of each feeding method, the current evidence is not strong enough to recommend one approach over another and pragmatically, the best choice may be related to the PICUs nurse staffing ratios and available feeding equipment (pumps). A systematic review published in 2020 6 which included a question on optimal feeding method, also concluded neither method was superior, however this did not include the last two studies 9,11 …”