The Effect of Different Enteral Feeding Protocols on Feeding Tolerance in Critically Ill Children

Objectives: To evaluate different enteral tube Feeding Protocols (FP) on feeding tolerance and achieving the goal feeds (GF) duration in pediatric intensive care unit (PICU) among 2 groups of patients with different risks of feeding intolerance. Design: Prospective randomized study. Settings & Patients: The study is conducted in 20 bed capacity medical/surgical PICU at king Fahad Medical City in Saudi Arabia over 1-year period. We included children from 1 month to 12 years old who are admitted to PICU >48 hours after obtaining informed consent signed by either parent or legal guardian. All patients with medical indication of admission were included except of gastroenterology related illness. Interventions: We categorize PICU patients into either low risk group or high-risk group because we think the severity of illness and medical management in the high-risk group, put them into a higher risk of early development of feeding intolerance. The patients were assigned into the high-risk group if they meet certain criteria that includes 1) need for inotropes/vasopressors >24 hours and/or 2) need for muscle relaxant infusion and/or 3) having severe metabolic acidosis with PH of less than 7.2, HCO3 serum level less than 10 mmol/L at the day of randomization to start the feeding. After assigning the patient into the risk group, then we blindly randomized each patient into one of the two feeding protocols, the continuous versus intermittent enteral NG/ OG tube feeding. Different variables were tracked to monitor the feeding tolerance of the feeding protocol like the frequency of vomiting and change in bowel motion. We determine the duration needed to reach the goal feeds recommended by a registered dietitian and we record any interruptions of the feeding protocol, duration of interruption and the reason. Measurements and Main Results: Total of eighty-five patients were recruited in our study. Sixty-two patients in the low risk group (35 patients fed continuously & 27 fed intermittently) and twenty-three patients in the high-risk group (11 patients fed continuously & 12 intermittently). All patients were fed regular formula for age with goal feeds decided by registered dietitians. No significant differences in patients’ characteristics. 65.7% of the low risk group who were continuously fed reached the goal feeds faster; within 2-3 days from feeding initiation vs 37% of the intermittent feeding group (P-value 0.025). 54.57% of the high-risk group who were continuously fed reached the goal feeds faster within 4-5 days vs 8.3% only of the intermittent feeding group (P-value 0.016). Both feeding protocols, continuous and intermittent feeding in both groups tolerate the feeds with no statistically differences. Feeding interruptions were not significantly different between both groups in each protocol with average interruption days of two days. Conclusion: Implementation of the proposed continuous enteral tube feeding protocol significantly improve the delivery of nutrition in critically ill children in shorter duration than the intermittent boluses feeding protocol with good tolerance of both in different patients’ risk groups. This is the first paper taking in consideration high risk factors because of the substantial risk of feeding intolerance that can affect early decision for feeding.