Intermittent versus continuous enteral nutrition on feeding intolerance in critically ill adults: A meta-analysis of randomized controlled trials

doi:10.1016/j.ijnurstu.2020.103783

International Journal of Nursing Studies

Volume 113, January 2021, 103783

https://doi.org/10.1016/j.ijnurstu.2020.103783 Get rights and content

Abstract

Objectives

Enteral formula delivery strategy is an important part of enteral nutrition. We aimed to synthesize up-to-date studies to clarify the effects of intermittent versus continuous feeding on feeding intolerance during enteral nutrition in critically ill adults.

Design

A meta-analysis of randomized controlled trials.

Data sources

Embase, PubMed, Information Sciences Institute Web of Science, CINAHL EBSCO, Cochrane Central Register of Controlled Trials, Chinese Biomedical Literature Database, China National Knowledge Infrastructure databases were searched from inception to 17th of June 2020.

Review methods

The Cochrane “risk of bias” tool was used to assess the quality of individual studies, and the quality of each outcome was assessed by GRADE approach. Fixed or random effect meta-analysis was used pending the presence of heterogeneity. Dichotomous data synthesis was presented as risk ratio and 95% confidence interval, and quantitative data synthesis was shown as mean difference and 95% confidence interval.

Results

Fourteen trials with 1025 critically ill adults were included in the meta-analysis. We found that intermittent feeding could significantly increase the occurrence of feeding intolerance (risk ratio = 1.64, 95% confidence interval = 1.23 to 2.18, P < 0.001) compared with continuous feeding, as well as the incidence of high gastric volume (risk ratio = 3.62, 95% confidence interval = 1.43–9.12, P = 0.006) and aspiration (risk ratio = 3.29, 95% confidence interval = 1.18–9.16, P = 0.02) in > 1-week trial duration, while constipation rate was reduced in intermittent feeding group (risk ratio = 0.66, 95% confidence interval = 0.45–0.98, P = 0.04). Patients in intermittent feeding group received more calories compared with continuous feeding group (mean difference = 184.81, 95% confidence interval = 56.61–313.01, P = 0.005). The quality of all evidence synthesis was “low” or “very low”.

Conclusions

In critically ill adults, continuous feeding was associated with lower overall incidence of feeding intolerance, especially in high gastric volume and aspiration. However, decreased constipation incidence and more calorie intake were observed in intermittent feeding group. Because quality of the synthesized evidence was “low” or “very low”, there is considerable uncertainty about this estimate.

Section snippets

What is already known about the topic?

•
Feeding intolerance occurs frequently in patients with critical illness, which hampers the administration of enteral nutrition.
•
Intermittent feeding and continuous feeding are two common feeding strategies.
•
Some randomized controlled trials have investigated the effects of intermittent and continuous feeding strategies on feeding intolerance in critically ill adults, but the evidence is inconsistent.

What this paper adds

•
In critically ill adults, continuous feeding is associated with lower overall incidence of feeding intolerance compared to intermittent feeding, as well as decreased risks of high gastric volume and aspiration.
•
Decreased constipation incidence and more calorie intake are observed in intermittent feeding group compared with continuous feeding.
•
It is recommended that continuous feeding is preferred for patients with high risk of feeding intolerance, and if patients could gradually tolerate enteral

Search strategy

A systemic search for relevant randomized controlled trials published up to 17th of June 2020 was conducted in the Embase, PubMed, Information Sciences Institute Web of Science, CINAHL EBSCO, Cochrane Central Register of Controlled Trials, Chinese Biomedical Literature Database, China National Knowledge Infrastructure databases. Trials were included with no limitations on publication type and language. The full Embase search strategy is included in Table S1.

Inclusion and exclusion criteria

Intermittent feeding is administered

Flow and characteristics of included studies

There were 7113 articles initially identified and 3611 articles after removal of duplicates. After screening for titles and abstracts, 88 articles remained for full text assessment, of which 74 articles were excluded (12 were non-randomized controlled trials, 7 were not focused on critically ill adults, 2 were with incomplete outcomes, 12 did not report adequate descriptions of enteral nutrition strategy, 41 were with wrong feeding strategies). Finally 14 trials with 1025 participants were

Feeding intolerance

Five studies enrolling 356 patients reported the feeding intolerance incidence in intermittent and continuous feeding groups, and were included in the meta-analysis. The pooled data showed that intermittent feeding could significantly increase the occurrence of feeding intolerance during enteral nutrition compared with continuous feeding in critically ill adults (risk ratio = 1.64, 95% confidence interval = 1.23 to 2.18, P < 0.001, I² = 0%) (Fig. 2A).

Diarrhea

Thirteen studies enrolling 991 patients

Discussion

In the present study, we comprehensively reviewed currently available literature that compare the effects of intermittent and continuous feeding on feeding intolerance in critically ill adults. This meta-analysis found that continuous, rather than intermittent feeding was with lower risks of feeding intolerance, as well as occurrence of high gastric volume and aspiration in > 1-week enteral nutrition duration, while decreased incidence of constipation and increased calorie intake were observed

Limitations

This meta-analysis has several limitations. First, because the 2 feeding strategies can be easily distinguished, it's hard to ensure the blindness in the trials, and some studies did not report random sequence generation and allocation concealment, which might lead to selection bias, performance bias and detection bias. Second, trials included in the meta-analysis were of limited sample size and only one was a multi-center study, and some subgroup analysis included only 2 studies, which were

Conclusions

Continuous feeding could reduce the incidence of feeing intolerance, as well as high gastric volume and aspiration during enteral nutrition, while it also associates with higher risks of constipation and decreased calorie intake in adult patients with critically illness. It seems that continuous feeding is preferred for patients with high risk of feeding intolerance, and when patients could gradually tolerate enteral nutrition, delivery method should be switched to intermittent feeding. As

Conflicts of interest

The authors declare that they have no conflict of interests.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Ethical Approval

None declared.

Funding disclosure

None.

References (44)

M.H. Hooper et al.
Controversies and misconceptions in intensive care unit nutrition
Clin. Chest Med.
(2015)
J.D. Johnston et al.
Circadian rhythms, metabolism, and chrononutrition in rodents and humans
Adv. Nutr.
(2016)
I. Kadamani et al.
Incidence of aspiration and gastrointestinal complications in critically ill patients using continuous versus bolus infusion of enteral nutrition: a pseudo-randomised controlled trial
Aust. Crit. Care
(2014)
J.S. Lee et al.
Can continuous pump feeding reduce the incidence of pneumonia in nasogastric tube-fed patients? A randomized controlled trial
Clin. Nutr.
(2010)
P. Singer et al.
ESPEN guideline on clinical nutrition in the intensive care unit
Clin. Nutr.
(2019)
Y.M. Arabi et al.
The intensive care medicine research agenda in nutrition and metabolism
Intensive Care Med.
(2017)
A. Azim et al.
Early feeds not force feeds: enteral nutrition in traumatic brain injury
J. Trauma Acute Care Surg.
(2016)
D.E. Bear et al.
Continuous or intermittent feeding: pros and cons
Curr. Opin. Crit. Care
(2018)
A.E. Bharucha et al.
Mechanisms, evaluation, and management of chronic constipation
Gastroenterology
(2020)
A.H. Chowdhury et al.
Effects of bolus and continuous nasogastric feeding on gastric emptying, small bowel water content, superior mesenteric artery blood flow, and plasma hormone concentrations in healthy adults
Ann. Surg.
(2016)

T.A. Davis et al.

Bolus vs. continuous feeding to optimize anabolism in neonates

Curr. Opin. Clin. Nutr. Metab. Care

(2015)

G. Elke et al.

Gastric residual volume in critically ill patients: a dead marker or still alive?

Nutr. Clin. Pract.

(2015)

E. Erichsén et al.

Constipation in specialized palliative care: factors related to constipation when applying different definitions

Support Care Cancer

(2015)

P.L. Greenhaff et al.

Disassociation between the effects of amino acids and insulin on signaling, ubiquitin ligases, and protein turnover in human muscle

Am. J. Physiol. Endocrinol. Metab.

(2008)

U. Gungabissoon et al.

Prevalence, risk factors, clinical consequences, and treatment of enteral feed intolerance during critical illness

JPEN J. Parenter Enteral Nutr.

(2014)

B. Hu et al.

Prognostic value of prolonged feeding intolerance in predicting all‐cause mortality in critically ill patients: a multicenter, prospective, observational study

JPEN J. Parenter Enteral Nutr.

(2019)

T. Huang et al.

Comparison of continuous and intermittent infusion of enteral nutrition in critically ill patients

Strait Pharm. J.

(2017)

S. Ichimaru et al.

Intermittent and bolus methods of feeding in critical care

Diet and Nutrition in Critical Care

(2014)

A.Y. Kamel et al.

Enteral nutrition administration record (ENAR) prescribing process using computerized order entry: a new paradigm and opportunities to improve outcomes in the critically ill

JPEN J. Parenter Enteral Nutr.

(2020)

M.J. Kocan et al.

A comparison of continuous and intermittent enteral nutrition in NICU patients

J. Neurosci. Nurs.

(1986)

M. Kudo et al.

High level of intra-gastric pressure is risk factor for patients with percutaneous endoscopic gastrostomy (PEG)

Gastrostomy

(2011)

J.B. MacLeod et al.

Prospective randomized control trial of intermittent versus continuous gastric feeds for critically ill trauma patients

J. Trauma

(2007)

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Acute gastrointestinal injury (AGI) is very common in critically ill patients, and its severity is positively correlated with mortality. Critically ill patients with digestive and absorption dysfunction caused by AGI face higher nutritional risks, making nutritional support particularly important. Early enteral nutrition (EN) support is extremely important because it can promote the recovery of intestinal function, protect the intestinal mucosal barrier, reduce microbiota translocation, reduce postoperative complications, shorten hospital stay, and improve clinical prognosis. In recent years, many nutritional guidelines have been proposed for critically ill patients; however, there are few recommendations for the implementation of EN in patients with AGI, and their quality of evidence is low. The use of EN feeding strategies in critically ill patients with AGI remains controversial. The aim of this review was to elaborate on how EN feeding strategies should transition from limited to progressive to open feeding and explain the time window for this transition.
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Observational prospective study conducted from September 1st to October 30th, 2019 and from August 1st to October 30th, 2021, in an ICU of a 1000-bed third-level hospital. General characteristics, nutritional variables, and medications administered were recorded and analysed. This study was registered on ClinicalTrials.gov (Identifier: NCT05473546).
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GI complications of enteral nutrition represent still a very common issue in ICU. The main predictor of constipation was an admission for trauma whereas the main predictor of diarrhoea was the use of diuretics. Clinicians should consider and integrate these findings into more personalized nutritional and management protocols to avoid gastrointestinal complications.
Intermittent bolus versus continuous feeding in children receiving an enteral formula with food derived ingredients: A national multicentre retrospective study
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A perceived factor believed to have an impact on feed tolerance relates to the mode in which nutrition is delivered regarding intermittent bolus or continuous feeding. Enteral formulas with food derived ingredients have been developed to help address some of the many feeding issues experienced by children who are tube fed. This study aimed to evaluate the tolerance of different feeding modes in children who are fed with an enteral formula with food derived ingredients.
Data was collected by paediatric dietitians from dietetic records over a month period on children who had switched to an enteral formula with food derived ingredients. Data was inputted to a Microsoft form to capture the impact of varying modes of feeding (intermittent bolus/continuous/combination) on gastrointestinal and anthropometric outcomes.
Forty-three children were recruited between March 2021 to July 2021 across four National Health Service Trusts. Children who were continuously fed saw the greatest reported improvement in retching, abdominal pain and loose stools. Children who were fed intermittent bolus reported the greatest increase in weight (p-value 0.003). Over 90% of dietitians reported nutritional goals were achieved after switching formula; children who were fed continuously reported the highest achievement to meet dietitian's nutritional goals.
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Citation Excerpt :
Enteral nutrition (EN) has been the preferred means of nutritional support for feeding critically ill patients because it could improve patient nutritional status, reduce disease severity, shorten the duration of hospital stay and decrease mortality (Schultz et al., 2000; Fengchan et al., 2017; Chen et al., 2021). However, complications associated with EN are not uncommon and the most common complication is enteral feeding intolerance (EFI)(Heyland et al., 2021; Ma et al., 2021). A meta-analysis reported that the prevalence of EFI in critical ill patients is 38% (Blaser et al., 2014).
Although some studies have explored the relationships between dietary fibre and enteral feeding intolerance in critically ill patients, the results are equivocal.
This study aimed to explore the effects of dietary fibre on enteral feeding intolerance and clinical outcomes in critically ill patients.
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Thirteen studies enrolled 709 critically ill patients included in the study. The results showed the dietary fibre group had a significantly decreased risk of diarrhea (OR: 0.46, 95% CI: 0.30,0.69, P < 0.001), regurgitation (OR: 0.28, 95%CI: 0.13, 0.60, P < 0.05), vomiting (OR: 0.40, 95%CI: 0.17, 0.92, P < 0.05), constipation (OR: 0.21, 95%CI: 0.09, 0.47, P < 0.001) and mortality (OR:0.34; 95%CI:−0.13, 0.91; P < 0.05) compared with the fibre free group. Besides, there was a significant decrease on time to reach full enteral nutrition (MD:−2.08; 95%CI:−4.05, −0.12; P < 0.05), the duration of the intensive care unit stay (MD:−4.62; 95%CI:−6.60, −2.64; P < 0.001) and hospital stay (MD:−6.42; 95%CI:−9.49, −3.36; P < 0.001) in the dietary fibre group.
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Remarkably, the patients in the Osuna-padilla et al. study received enteral feeding over an 18-h period [16], as opposed to over 24 h in this study. Given cyclic feeding is thought to increase the rate of feeding intolerance and GRVs [29], this again suggests some other difference between these to study groups which lead to a two-fold difference in high aspirates. The prevalence of high GRVs reported in this study are similar to those reported by Liu and colleagues [15], though the definition of a high GRV was significantly different, as in their study a volume threshold was not used, but instead any aspirate which led to enteral nutrition being withheld was considered high.
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A variety of preventive and curative strategies for feeding intolerance were applied in clinical practice. Feeding by nasointestinal tube, continuous feeding, prokinetic agents, probiotics, and other strategies could reduce the feeding intolerance rates among critically ill patients [9–11]. However, the application of preventive strategies for feeding intolerance is discrepant among different hospitals and even different departments in the same hospital.
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Intermittent versus continuous enteral nutrition on feeding intolerance in critically ill adults: A meta-analysis of randomized controlled trials

Abstract

Objectives

Design

Data sources

Review methods

Results

Conclusions

Section snippets

What is already known about the topic?

What this paper adds

Search strategy

Inclusion and exclusion criteria

Flow and characteristics of included studies

Feeding intolerance

Diarrhea

Discussion

Limitations

Conclusions

Conflicts of interest

Funding

Ethical Approval

Funding disclosure

Clin. Chest Med.

Adv. Nutr.

Aust. Crit. Care

Clin. Nutr.

Clin. Nutr.

The intensive care medicine research agenda in nutrition and metabolism

Intensive Care Med.

Early feeds not force feeds: enteral nutrition in traumatic brain injury

J. Trauma Acute Care Surg.

Continuous or intermittent feeding: pros and cons

Curr. Opin. Crit. Care

Mechanisms, evaluation, and management of chronic constipation

Gastroenterology

Effects of bolus and continuous nasogastric feeding on gastric emptying, small bowel water content, superior mesenteric artery blood flow, and plasma hormone concentrations in healthy adults

Ann. Surg.

Bolus vs. continuous feeding to optimize anabolism in neonates

Curr. Opin. Clin. Nutr. Metab. Care

Gastric residual volume in critically ill patients: a dead marker or still alive?

Nutr. Clin. Pract.

Constipation in specialized palliative care: factors related to constipation when applying different definitions

Support Care Cancer

Disassociation between the effects of amino acids and insulin on signaling, ubiquitin ligases, and protein turnover in human muscle

Am. J. Physiol. Endocrinol. Metab.

Prevalence, risk factors, clinical consequences, and treatment of enteral feed intolerance during critical illness

JPEN J. Parenter Enteral Nutr.

Prognostic value of prolonged feeding intolerance in predicting all‐cause mortality in critically ill patients: a multicenter, prospective, observational study

JPEN J. Parenter Enteral Nutr.

Comparison of continuous and intermittent infusion of enteral nutrition in critically ill patients

Strait Pharm. J.

Intermittent and bolus methods of feeding in critical care

Diet and Nutrition in Critical Care

Enteral nutrition administration record (ENAR) prescribing process using computerized order entry: a new paradigm and opportunities to improve outcomes in the critically ill

JPEN J. Parenter Enteral Nutr.

A comparison of continuous and intermittent enteral nutrition in NICU patients

J. Neurosci. Nurs.

High level of intra-gastric pressure is risk factor for patients with percutaneous endoscopic gastrostomy (PEG)

Gastrostomy

Prospective randomized control trial of intermittent versus continuous gastric feeds for critically ill trauma patients

J. Trauma