Timing of enteral feeding in cerebral malaria in resource-poor settings: a randomized trial

Richard J Maude, Gofranul Hoque, Mahtab Uddin Hasan, Abu Sayeed, Shahena Akter, Rasheda Samad, Badrul Alam, Emran Bin Yunus, Ridwanur Rahman, Waliur Rahman, Romal Chowdhury, Tapan Seal, Prakaykaew Charunwatthana, Christina C Chang, Nicholas J White, M Abul Faiz, Nicholas P J Day, Arjen M Dondorp, Amir Hossain, Richard J Maude, Gofranul Hoque, Mahtab Uddin Hasan, Abu Sayeed, Shahena Akter, Rasheda Samad, Badrul Alam, Emran Bin Yunus, Ridwanur Rahman, Waliur Rahman, Romal Chowdhury, Tapan Seal, Prakaykaew Charunwatthana, Christina C Chang, Nicholas J White, M Abul Faiz, Nicholas P J Day, Arjen M Dondorp, Amir Hossain

Abstract

Background: Early start of enteral feeding is an established treatment strategy in intubated patients in intensive care since it reduces invasive bacterial infections and length of hospital stay. There is equipoise whether early enteral feeding is also beneficial in non-intubated patients with cerebral malaria in resource poor settings. We hypothesized that the risk of aspiration pneumonia might outweigh the potential benefits of earlier recovery and prevention of hypoglycaemia.

Method and findings: A randomized trial of early (day of admission) versus late (after 60 hours in adults or 36 hours in children) start of enteral feeding was undertaken in patients with cerebral malaria in Chittagong, Bangladesh from May 2008 to August 2009. The primary outcome measures were incidence of aspiration pneumonia, hypoglycaemia and coma recovery time. The trial was terminated after inclusion of 56 patients because of a high incidence of aspiration pneumonia in the early feeding group (9/27 (33%)), compared to the late feeding group (0/29 (0%)), p = 0.001). One patient in the late feeding group, and none in the early group, had hypoglycaemia during admission. There was no significant difference in overall mortality (9/27 (33%) vs 6/29 (21%), p = 0.370), but mortality was 5/9 (56%) in patients with aspiration pneumonia.

Conclusions: In conclusion, early start of enteral feeding is detrimental in non-intubated patients with cerebral malaria in many resource-poor settings. Evidence gathered in resource rich settings is not necessarily transferable to resource-poor settings.

Trial registration: Controlled-Trials.com ISRCTN57488577.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Consort flow diagram of the…
Figure 1. Consort flow diagram of the study.

References

    1. SEAQUAMAT study group. Artesunate versus quinine for treatment of severe falciparum malaria: a randomised trial. Lancet. 2005;366:717–725.
    1. Dondorp AM, Fanello CI, Hendriksen I, Gomes E, Seni A, et al. Artesunate versus quinine in the treatment of severe falciparum malaria in African children (AQUAMAT): an open-label, randomized trial. Lancet. 2010;376:1647–1657.
    1. Marik PE, Zaloga GP. Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med. 2001;29:2264–2270.
    1. Moore FA, Moore EE, Jones TN, McCrosky BL, Peterson VM. TEN versus TPN following major abdominal trauma reduced septic morbidity. J Trauma. 1989;29:916–923.
    1. Chiarelli A, Enzi G, Casadei A, Baggio B, Valerio A, et al. Very early enteral nutrition supplementation in burned patients. Am J Clin Nutr. 1990;51:1035–1039.
    1. Beier-Hogersen R, Boesby S. Influence of postoperative enteral nutrition on postsurgical infections. Gut. 1996;39:833–835.
    1. Kompan L, Krežar R, Gadžijev E, Prošek M. Effects of early enteral nutrition on intestinal permeability and the development of multiple organ failure after multiple injury. Intensive Care Med. 1999;25:157–161.
    1. Marik PE, Zaloga GP. Early enteral nutrition in acutely ill patients: A systematic review. Crit Care Med. 2001;29:2264–2270.
    1. Gianotti L, Alexander JW, Nelson JL, Fukushima R, Pyles T, et al. The role of early enteral feeding and acute starvation on postburn bacterial translocation and host defense: prospective randomized trials. Crit Care Med. 1994;22:265–272.
    1. White NJ, Warrell DA, Chanthavanich P, Looareesuwan S, Warrell MJ, et al. Severe hypoglycemia and hyperinsulinemia in falciparum malaria. N Engl J Med. 1983;309:61–66.
    1. Walsh AL, Phiri AJ, Graham SM, Molyneux EM, Molyneux ME. Bacteremia in febrile Malawian children: clinical and microbiologic features. Pediatr Infect Dis J. 2000;19:312–318.
    1. Hadfield RJ, Sinclair DG, Houldsworth PE, Evans TW. Effects of enteral and parenteral nutrition on gut mucosal permeability in the critically ill. Am J Respir Crit Care Med. 1995;152:1545–1548.
    1. Jacobs S, Chang RW, Lee B, Bartlett FW. Continuous enteral feeding: a major cause of pneumonia among ventilated intensive care unit patients. JPEN J Parenter Enteral Nutr. 1990;14:353–356.
    1. Bosscha K, Nieuwenhuijs VB, Vos A, Samsom M, Roelofs JM, et al. Gastrointestinal motility and gastric tube feeding in mechanically ventilated patients. Crit Care Med. 1998;26:1510–1517.
    1. Kearns PJ, Chin D, Mueller L, Wallace K, Jensen WA, et al. The incidence of ventilator-associated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: a randomized clinical trial. Crit Care Med. 2000;28:1742–1746.
    1. Heyland DK, Drover JW, MacDonald S, Novak F, Lam M. Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial. Crit Care Med. 2001;29:1495–1501.
    1. Davies AR, Froomes PRA, French CJ, Bellomo R, Gutteridge GA, et al. Randomized comparison of nasojejunal and nasogastric feeding in critically ill patients. Crit Care Med. 2002;30:586–590.
    1. Metheny NA, Davis-Jackson J, Stewart BJ. Effectiveness of an aspiration risk-reduction protocol. Nurs Res. 2010;59:18–25.
    1. Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomized trial. Lancet. 1999;354:1851–1858.
    1. World Health Organisation Malaria Treatment Guidelines. 2 Available: . Accessed 2010 December.
    1. World Health Organisation. Management of severe malnutrition: a manual for physicians and other senior health workers. 1999;2 Available: . Accessed 2010 December.
    1. Doig GS, Heighes PT, Simpson F, Sweetman EA, Davies AR. Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a meta-analysis of randomised controlled trials. Intensive Care Med. 2009;35:2018–2027.
    1. Woo SH, Finch CK, Broyles JE, Wan J, Boswell R, et al. Early vs. delayed enteral nutrition in critically ill medical patients. Nutr Clin Pract. 2010;25:205–211.
    1. Marik PE, Zaloga GP. Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med. 2001;29:2264–2270.
    1. Bozza FA, Salluh JI. An urban perspective on sepsis in developing countries. Lancet Infect Dis. 2010;10:290–291.
    1. Metheny NA, Clouse RE, Chang YH, Stewart BJ, Oliver DA, et al. Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: frequency, outcomes, and risk factors. Crit Care Med. 2006;34:1007–1015.
    1. Mentec H, Dupont H, Bocchetti M, Cani P, Ponche F, et al. Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications. Crit Care Med. 2001;29:1955–1961.
    1. Metheny NA, Schallom L, Oliver DA, Clouse RE. Gastric residual volume and aspiration in critically ill patients receiving gastric feedings. Am J Crit Care. 2008;17:512–519.

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