Timing of Enteral Nutrition

Author/Year/ Country/Study design/PEDro score/N

 

Methods

 

Outcomes

Chourdakis et al. (2012)

Greece

RCT

PEDro=6

N=59

Population: TBI; Delayed Enteral Feeding (DEF) Group (n=25): Mean Age=33.3yr; Gender: Male=21, Female=4; Mean GCS Score=5.22. Early Enteral Feeding (EEF) Group (n=34): Mean Age=36.13yr; Gender: Male=26, Female=8; Mean GCS Score=5.81.
Treatment: Patients admitted to the Intensive Care Unit were randomly allocated to receive either DEF (2-5d post admission) or EEF (initiated within the first 24-48hr of admission). Measurements were taken on day 1, 6 and 12.
Outcome Measure: Hormone levels, dietary information.

  1. The EEF group began enteral feeding approximately 31 hr post admission and the DEF group began approximately 77 hr post admission.
  2. Kilocalories administration was lower in the DEF group compared to the EEF group (p<0.01).
  3. Several endocrine changes were noted for the groups, with the EEF group showing significant improvements compared to the DEF group (p<0.05).
  4. No differences were noted in mortality and morbidity in either group despite enteral feeding.

Minard et al. (2000)
USA
RCT
PEDro=5
N=27

 

Population: TBI; Time Post-Injury= ≤6hr; Early Group (n=12): Mean Age=30yr; Gender: Male=9, Female=3; Mean GCS Score=7. Late Group (n=15): Mean Age=36yr; Gender: Male=10, Female=5; Mean GCS=7.
Treatment: Patients were randomly assigned to either early (within 60hr of injury) or late enteral feeding. The late group received feeding when tolerated by the patient (i.e. gastroparesis was resolved).
Outcome Measure: Infection rates, Length of stay, ventilator days, instances of pneumonia, mortality.

  1. No significant differences between groups with regard to mortality, Length of stay, ventilator days, number of infections per patient or patients with pneumonia.
  2. Admission GCS score was a good predictor of infection (p<0.003), Length of stay in the intensive care unit (p<0.02), and ventilator days (p<0.007).

Taylor et al. (1999)
UK
RCT
PEDro=4
N=82

 

Population: Head Injury. Intervention Group (n=41): Median Age=34yr. Control Group (n=41): Median Age=28yr.
Treatment: Patients were randomly allocated to receive either the standard Enteral nutrition (EN) or the enhanced EN (intervention). EN was initiated from day 1 in both groups. In the control group, EN was gradually increased from 15mL/hr up to estimated energy and nitrogen requirements. In the intervention group, feeding was administered at a rate that met estimated energy and nitrogen requirements. Follow-up at 3 and 6mo.
Outcome Measure: Neurologic outcome, incidence of major infection, Length of stay.

.

  1. Patients receiving enhanced EN had a significantly higher mean percentage of energy (p=0.0008) and nitrogen (p<0.0001) requirements met over the initial week following injury when compared to the control group. This finding was mostly attributable to improved NG feeding as only 14 intervention patients (34%) had intestinal tubes successfully placed.
  2. The median percentage of energy and nitrogen requirements delivered in control patients remained <60% even by day 7 post injury. 
  3. Neurologic outcome at 6 mo follow-up (intervention, 68% vs. control, 61%; p=0.64) was similar between the groups, but there was a trend toward improved outcome at 3 mo follow-up in favour of the intervention group (61% vs. 39%; p=0.08).
  4. Intervention patients had fewer infections (61% vs. 85%; p=0.02) and earlier discharge (p=0.008).

Taylor and Fettes (1998)
UK
RCT
PEDro=4
N=82

 

Population: Head Injury. Intervention Group (n=41): Median Age=34yr. Control Group (n=41): Median Age=28yr.
Treatment: Patients were randomly assigned to receive either the standard Enteral Nutrition (EN) or the early EN. EN was initiated from day 1; however, in the control group, EN was gradually increased from 15mL/hr up to estimated energy and nitrogen requirements. In the intervention group, feeding was administered at a rate that met estimated energy and nitrogen requirements.
Outcome Measure: Nutritional intake, nitrogen balance, volume of gastric residuals, incidence of pneumonia.

  1. Overall, patients received EN during 57% of the potential feeding time, with the longest interruption to feeding time coming from the rest period (13%).
  2. Patients receiving early EN had a greater energy and nitrogen intake compared to standard EN patients over the initial week following brain injury (p<0.02).
  3. Intervention patients received a higher volume of enteral fluid (p<0.02) but did not have a higher incidence of pneumonia or aspiration.

PEDro = Physiotherapy Evidence Database rating scale score (Moseley et al., 2002).