Bolus vs Continuous Nasogastric

Feeds in Mechanically Ventilated

Pediatric Patients :
A Pilot Study
Journal Presentation
 Background

Increases the risk of

poor healing,
> 30% children in hospital-acquired Optimization
PICU are infections, enteral nutrition
malnourished prolonged length of (EN)
stay, >> healthcare
costs need

Continuous
ASPEN (continuous
Reduced gastric feeding
guidelines
morbidity and [C-GF]) or Bolus
suggest Gastric (bolus gastric
mortality
feeding feeding [B-GF])
methods.
Cont…
Gut disfunction

The Evaluate C-GF vs B-

purpose GF on the attainment
>> risk for intolerance, inadequate intake
of prescribed energy
and protein nutrition
goals
C-GF reduce the risk of intolerance and
Compare trajectories of aspiration
acute lung injury
between groups
May not best physiologic delivery mode
Characterize the
frequency and types of
feedingi nterruptions
and intolerance events Bolus feeding

Reduce feeding interruptions, as procedures

can be performed during the rest periods
• B-GF feeds > C-GF

Hypothesized Insufficient evidence to support either

delivery mode
 Methods
prospective, randomized, comparative effectiveness
Design intervention

23-bed PICU in a freestanding pediatric teaching

Sample hospital, upper age limit was 12 years

21 Institutional Review Board approval ,Written consent

Ethic from the parents/guardians

Inclusion patients with 1 month corrected gestational age to 12 years,

intubated within 24 hours of admission to the PICU, and EN
criteria started within 48 hours of admission

Exclusion primary gastrointestinal pathology or surgery, EN not started

within 48 hours, or EN started prior to PICU, percutaneous
criteria gastric tubes
Cont…

• Distributing subject, identification numbers, disrupting

Procedures events, goal

• A nasogastric (NG) tube was inserted by radiographic confirmation

Feeding • Guidance by nutritionist in kcal/kg/d and g/kg/d
protocols • Based WHO or ASPEN guidelines

• 1) Any emesis (regardless of volume)

Feeding • 2) GRV 50% of the infused volume × 2 consecutive measurements
intolerance • 3) GRV 50% of the infused volume × 1 measurement and abdominal
interruption girth >10% above baseline for the current 24- hour feeding period
criteria

Oxygenation
saturation • Aspiration and acute lung injury assessment per 3 hours
index (OSI)
 Data Management and Analysis
• A FileMaker Pro 11 Advanced
Study data entering (FileMaker Inc, Filemaker )
database.

SPSS 22 (SPSS, Inc., International • Data analysis  mean ±

Business Machines.) standard deviation

The delivered/prescribed nutrition

• Independent t-test
ratio

Time-to-full EN prescription and

• Independent t-test
total intolerance events

The incidence of elevated GRV • χ2

The time to first feeding intolerance

event, along with the duration of • Independent t-test
feeding interruptions
 Result

• A total of 842 PICU patients 

28 subjects were enrolled, and
25 were included in the final
Enrollment analysis (B-GF group n = 11;
October 2013 C-GF group n = 14)
- April 2014. • The study enrollment flowchart
(Figure 1)  the screening
and enrollment process
Sample Characteristics
Nutrition Delivery
Feeding Interruptions
OSI
 CONCLUSION
Improved
delivery of There would be
energy and improved Delivery of both energy and protein
protein intake gastric motility > the B-GF group in the first 24
via B-GF > C-GF following a hours of feeding with a continued
feeding period of trend despite attrition at 48 hours.
methods at 24 nonfeeding.
hours

Mehta et al  Mikhailov et al
Decreased reduced  a lower
Martinez et al 
mortality, mortality when mortality rate
critically ill
utilizing the EN delivery was when delivery of
children have
methods to most increased from 25% of target EN
delayed gastric
rapidly deliver the first to occurred within
emptying
goal feeds second tertile the first 48
(33.3% to 66.6%) hours.
 Cont…
Only the B-GF group achieved the second tertile for target energy
delivery  in half the time (median)
Further study to elucidate the impact of B-GF vs C-GF is important,
as increased nursing resources are required for B-GF
Current clinical guidelines  best protocols and implementation
practices for the delivery of early EN for its critical protective effect
to the PICU patient, including reduction in mortality

The recent 2017 ASPEN guidelines  achieving delivery of at least

two-thirds of the prescribed daily energy requirement by the end
of the first week in the PICU.
Further study is needed to ascertain the benefit of early vs later
attainment of EN goals.
Cont…
Feeding intolerance in the adult and pediatric population
has been predicated on GRV and abdominal girth
• emesis is a major risk factor for aspiration and new or worsened lung
injury
• no increased risk associated with lung injury with emesis, with increases
in GRV alone, or with increased GRV plus increased abdominal girth 
The OSI did not change

OSI
• validated scoring
• need for further invasive monitoring(placement of an arterial catheter)

Both feeding methods

• excellent safety profile in this critically ill, mechanically ventilated
population  but a larger sample size is needed to strengthen this finding
 Limitations/Recommendations for
FutureResearch
Small sample size
Innovations in noninvasive
ventilation in pediatric
patients with respiratory
failure significantly
diminished the pool of
eligible subject
The incidence of critical
illness is lower in children
compared with adults
Plan to expand our study by
linking with national
networks to build an
adequate sample to be able
to generalize result
A multicenter replication is
needed to provide evidence
regarding optimal delivery
modalities  deliver the
benefits of early EN 
lower the risk of mortality
and other hospital
A single center
morbidities
Several practice changes
may be warranted, pending
confirmation of study
findings to improve the
delivery of critical nutrition
intake to the mechanically
ventilated child