Comparison of continuous versus intermittent enteral feeding in critically ill patients: a systematic review and meta-analysis

Aaron J Heffernan, C Talekar, M Henain, L Purcell, M Palmer, H White, Aaron J Heffernan, C Talekar, M Henain, L Purcell, M Palmer, H White

Abstract

Background: The enteral route is commonly utilised to support the nutritional requirements of critically ill patients. However, there is paucity of data guiding clinicians regarding the appropriate method of delivering the prescribed dose. Continuous enteral feeding is commonly used; however, a bolus or intermittent method of administration may provide several advantages such as minimising interruptions. The purpose of this meta-analysis is to compare a continuous versus an intermittent or bolus enteral nutrition administration method.

Methods: A systematic review and meta-analysis were performed with studies identified from the PubMed, EMBASE, Cochrane Library and Web of Science databases. Studies were included if they compared a continuous with either an intermittent or bolus administration method of enteral nutrition in adult patients admitted to the intensive care unit. Study quality was assessed using the PEDro and Newcastle-Ottawa scoring systems. Review Manager was used for performing the random-effects meta-analysis on the outcomes of mortality, constipation, diarrhoea, increased gastric residuals, pneumonia, and bacterial colonisation.

Results: A total of 5546 articles were identified, and 133 were included for full text review. Fourteen were included in the final analysis. There was an increased risk of constipation with patients receiving continuous enteral nutrition (relative risk 2.24, 95% confidence interval 1.01-4.97, p = 0.05). No difference was identified in other outcome measures. No appreciable bias was identified.

Conclusion: The current meta-analysis has not identified any clinically relevant difference in most outcome measures relevant to the care of critically ill patients. However, there is a paucity of high-quality randomised controlled clinical trials to guide this decision. Therefore, clinicians may consider either dosing regimen in the context of the patient's care requirements.

Keywords: Enteral nutrition; Gastric residuals; Intensive care unit.

Conflict of interest statement

No authors have any conflicts of interest to declare.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Flow diagram outlining article identification and selection
Fig. 2
Fig. 2
Mortality difference in patients receiving continuous versus intermittent/bolus enteral nutrition
Fig. 3
Fig. 3
Patients colonised with potentially pathogenic bacteria receiving continuous versus intermittent/bolus enteral nutrition
Fig. 4
Fig. 4
Patients developing pneumonia receiving continuous versus intermittent/bolus enteral nutrition
Fig. 5
Fig. 5
Patients with diarrhoea receiving continuous versus intermittent/bolus enteral nutrition
Fig. 6
Fig. 6
Patients with constipation receiving continuous versus intermittent/bolus enteral nutrition
Fig. 7
Fig. 7
Patients with increased gastric residuals receiving continuous versus intermittent/bolus enteral nutrition
Fig. 8
Fig. 8
Funnel plot for diarrhoea outcome assessment

References

    1. McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) J Parenter Enter Nutr. 2016;40:159–211.
    1. Herridge MS, Tansey CM, Matté A, Tomlinson G, Diaz-Granados N, Cooper A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med. 2011;364(14):1293–1304.
    1. Elke G, Wang M, Weiler N, Day AG, Heyland DK. Close to recommended caloric and protein intake by enteral nutrition is associated with better clinical outcome of critically ill septic patients: secondary analysis of a large international nutrition database. Crit Care. 2014;18:R29.
    1. Tagawa R, Watanabe D, Ito K, Ueda K, Nakayama K, Sanbongi C, et al. Dose-response relationship between protein intake and muscle mass increase: a systematic review and meta-analysis of randomized controlled trials. Nutr Rev. 2020;79(1):66–75.
    1. Patel JJ, Kozeniecki M, Peppard WJ, Peppard SR, Zellner-Jones S, Graf J, et al. Phase 3 pilot randomized controlled trial comparing early trophic enteral nutrition with "no enteral nutrition" in mechanically ventilated patients with septic shock. J Parenter Enter Nutr. 2020;44:866–873.
    1. Patel JJ, Kozeniecki M, Biesboer A, Peppard W, Ray AS, Thomas S, et al. Early trophic enteral nutrition is associated with improved outcomes in mechanically ventilated patients with septic shock: a retrospective review. J Intensive Care Med. 2016;31:471–477.
    1. Ichimaru S. Methods of enteral nutrition administration in critically ill patients: continuous, cyclic, intermittent, and bolus feeding. Nutr Clin Pract. 2018;33:790–795.
    1. Windsor AC, Kanwar S, Li AG, Barnes E, Guthrie JA, Spark JI, et al. Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis. Gut. 1998;42:431–435.
    1. Taylor SJ, Fettes SB, Jewkes C, Nelson RJ. Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med. 1999;27:2525–2531.
    1. Kudsk KA, Croce MA, Fabian TC, Minard G, Tolley EA, Poret HA, et al. Enteral versus parenteral feeding. Effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg. 1992;215:503–511.
    1. Saito H, Trocki O, Alexander JW, Kopcha R, Heyd T, Joffe SN. The effect of route of nutrient administration on the nutritional state, catabolic hormone secretion, and gut mucosal integrity after burn injury. JPEN. 1987;11:1–7.
    1. Harvey SE, Parrott F, Harrison DA, Bear DE, Segaran E, Beale R, et al. Trial of the route of early nutritional support in critically ill adults. N Engl J Med. 2014;371:1673–1684.
    1. Reignier J, Boisramé-Helms J, Brisard L, Lascarrou JB, Ait Hssain A, Anguel N, et al. Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2) Lancet. 2018;391:133–143.
    1. Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38:48–79.
    1. Rhoney DH, Parker D, Jr, Formea CM, Yap C, Coplin WM. Tolerability of bolus versus continuous gastric feeding in brain-injured patients. Neurol Res. 2002;24:613–620.
    1. Marik PE. Feeding critically ill patients the right 'whey': thinking outside of the box. A personal view. Ann Intensive Care. 2015;5:51.
    1. Bear DE, Hart N, Puthucheary Z. Continuous or intermittent feeding: pros and cons. Curr Opin Crit Care. 2018;24:256–261.
    1. Johnston JD, Ordovás JM, Scheer FA, Turek FW. Circadian rhythms, metabolism, and chrononutrition in rodents and humans. Adv Nutr. 2016;7:399–406.
    1. Ma Y, Cheng J, Liu L, Chen K, Fang Y, Wang G, et al. Intermittent versus continuous enteral nutrition on feeding intolerance in critically ill adults: a meta-analysis of randomized controlled trials. Int J Nurs Stud. 2021;113:103783.
    1. Tatsumi H. Enteral tolerance in critically ill patients. J Intensive Care. 2019;7:30.
    1. Kocan MJ, Hickisch SM. A comparison of continuous and intermittent enteral nutrition in NICU patients. J Neurosci Nurs. 1986;18:333–337.
    1. Bonten MJ, Gaillard CA, van der Hulst R, de Leeuw PW, van der Geest S, Stobberingh EE, et al. Intermittent enteral feeding: the influence on respiratory and digestive tract colonization in mechanically ventilated intensive-care-unit patients. Am J Respir Crit Care Med. 1996;154:394–399.
    1. Chen YC, Chou SS, Lin LH, Wu LF. The effect of intermittent nasogastric feeding on preventing aspiration pneumonia in ventilated critically ill patients. J Nurs Res. 2006;14:167–180.
    1. Evans DC, Forbes R, Jones C, Cotterman R, Njoku C, Thongrong C, et al. Continuous versus bolus tube feeds: does the modality affect glycemic variability, tube feeding volume, caloric intake, or insulin utilization? Int J Crit Illn Inj Sci. 2016;6:9–15.
    1. Maurya I, Pawar M, Garg R, Kaur M, Sood R. Comparison of respiratory quotient and resting energy expenditure in two regimens of enteral feeding: continuous vs. intermittent in head-injured critically ill patients. Saudi J Anaesth. 2011;5:195–201.
    1. Gowardman J, Sleigh J, Barnes N, Smith A, Havill J. Intermittent enteral nutrition: a comparative study examining the effect on gastric pH and microbial colonization rates. Anaesth Intensive Care. 2003;31:28–33.
    1. MacLeod JBA, Lefton J, Houghton D, Roland C, Doherty J, Cohn SM, et al. Prospective randomized control trial of intermittent versus continuous gastric feeds for critically ill trauma patients. J Trauma Inj Infect Crit Care. 2007;63:57–61.
    1. McNelly AS, Bear DE, Connolly BA, Arbane G, Allum L, Tarbhai A, et al. Effect of intermittent or continuous feed on muscle wasting in critical illness: a phase II clinical trial. Chest. 2020 doi: 10.1016/j.chest.2020.03.045.
    1. Nasiri M, Farsi Z, Ahangari M, Dadgari F. Comparison of intermittent and bolus enteral feeding methods on enteral feeding intolerance of patients with sepsis: a triple-blind controlled trial in intensive care units. Middle East J Dig Dis. 2017;9:218–227.
    1. Shahriari M, Rezaei E, Bakht LA, Abbasi S. Comparison of the effects of enteral feeding through the bolus and continuous methods on blood sugar and prealbumin levels in ICU inpatients. J Educ Health Promot. 2015;4:95.
    1. Serpa LF, Kimura M, Faintuch J, Ceconello I. Effects of continuous versus bolus infusion of enteral nutrition in critical patients. Rev Hosp Clin Fac Med Sao Paulo. 2003;58:9–14.
    1. Spilker CA, Hinthorn DR, Pingleton SK. Intermittent enteral feeding in mechanically ventilated patients: the effect on gastric pH and gastric cultures. Chest. 1996;110:243–248.
    1. Steevens EC, Lipscomb AF, Poole GV, Sacks GS. Comparison of continuous vs intermittent nasogastric enteral feeding in trauma patients: perceptions and practice. Nutr Clin Pract. 2002;17:118–122.
    1. de Araujo VMT, Gomes PC, Caporossi C. Enteral nutrition in critical patients; should the administration be continuous or intermittent? Nutr Hosp. 2014;29:563–567.
    1. van Nieuwkoop MM, Ramnarain D, Pouwels S. Enteral nutrition interruptions in the intensive care unit: a prospective study. Nutrition. 2021;96:111580.
    1. Patel JJ, Rosenthal MD, Heyland DK. Intermittent versus continuous feeding in critically ill adults. Curr Opin Clin Nutr Metab Care. 2018;21:116–120.
    1. Gazzaneo MC, Suryawan A, Orellana RA, Torrazza RM, El-Kadi SW, Wilson FA, et al. Intermittent bolus feeding has a greater stimulatory effect on protein synthesis in skeletal muscle than continuous feeding in neonatal pigs. J Nutr. 2011;141:2152–2158.
    1. Atherton PJ, Etheridge T, Watt PW, Wilkinson D, Selby A, Rankin D, et al. Muscle full effect after oral protein: time-dependent concordance and discordance between human muscle protein synthesis and mTORC1 signaling. Am J Clin Nutr. 2010;92:1080–1088.
    1. Compher C, Chittams J, Sammarco T, Nicolo M, Heyland DK. Greater protein and energy intake may be associated with improved mortality in higher risk critically ill patients: a multicentre, multinational observational study. Crit Care Med. 2017;45:156–163.
    1. Martindale RG, Heyland DK, Rugeles SJ, Wernerman J, Weijs PJ, Patel JJ, et al. Protein kinetics and metabolic effects related to disease states in the intensive care unit. Nutr Clin Pract. 2017;32:21s–s29.
    1. Phillips SM, Dickerson RN, Moore FA, Paddon-Jones D, Weijs PJ. Protein turnover and metabolism in the elderly intensive care unit patient. Nutr Clin Pract. 2017;32:112s–s120.
    1. Stoll B, Puiman PJ, Cui L, Chang X, Benight NM, Bauchart-Thevret C, et al. Continuous parenteral and enteral nutrition induces metabolic dysfunction in neonatal pigs. JPEN. 2012;36:538–550.
    1. Shulman RJ, Redel CA, Stathos TH. Bolus versus continuous feedings stimulate small-intestinal growth and development in the newborn pig. J Pediatr Gasteroenterol Nutr. 1994;18:350–354.

Source: PubMed

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