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Background Nutrition guidelines recommend enteral nutrition in the form of gastric feedings for critically ill children and acknowledge a lack of evidence describing an optimal method for providing these feedings. Objective To determine the state of the science regarding the efficacy of bolus (intermittent) or continuous gastric feedings to improve nutrition delivery in critically ill children receiving mechanical ventilation. Methods Five hundred seventy-nine abstracts met the inclusion criteria and were screened by 2 reviewers according to prespecified criteria. Full-text reviews were performed on 28 articles; 11 studies were selected for detailed analysis. Because of the small number of eligible studies, broader searches were conducted. Results Only 5 studies with a collective enrollment of fewer than 200 children closely addressed the specific research question. These 5 studies did not report any similarity in feeding regimens, nor did they report nutritional outcomes. Two of the articles described findings from the same study population. Although 4 of the 5 studies randomized children to bolus versus continuous feedings, only 3 studies described attainment of nutrient delivery goals in both the intervention and the control groups; the remaining study did not report this outcome. The heterogeneity in methodology and outcomes among the 5 studies did not allow for a meta-analysis. Conclusions The dearth of evidence regarding best practices and outcomes related to bolus versus continuous gastric feedings in critically ill children receiving mechanical ventilation requires additional rigorous investigation.

The purpose of this study was to (1) define medical and sociodemographic factors related to maternal milk feedings and (2) explore relationships between maternal milk feeding and early neurobehavioral outcome. Ninety-two preterm infants born ≤ 32 weeks gestation had maternal milk feeding and breastfeeding tracked in this retrospective analysis. At 34 to 41 weeks postmenstrual age (PMA), neurobehavior was assessed with the NICU Network Neurobehavioral Scale. Maternal milk feeding was often delayed by the use of total parenteral nutrition, administered for a median of 11 (7-26) days, impacting the timing of gastric feeding initiation. Seventy-nine (86%) infants received some maternal milk during neonatal intensive care unit (NICU) hospitalization. Twenty-one (27%) infants continued to receive maternal milk at 34 to 41 weeks PMA, with 10 (48%) of those receiving maternal milk exclusively. Among mothers who initiated maternal milk feeds, 20 (25%) put their infants directly at the breast at least once during hospitalization. Mothers who were younger (P = .02), non-Caucasian (P < .001), or on public insurance (P < .001) were less likely to provide exclusive maternal milk feedings by 34 to 41 weeks PMA. Infants who received maternal milk at 34 to 41 weeks PMA demonstrated better orientation (P = .03), indicating they had better visual and auditory attention to people and objects in the environment. Our findings demonstrate a relationship between maternal milk feedings and better neurobehavior, which is evident before the infant is discharged home from the NICU.

Gastrostomy tubes, placed either endoscopically or laparoscopically, are the most widely used method to deliver enteral feeding to patients unable to be fed by mouth. Tube gastrostomy is quick and low cost and allows the health care professionals for a convenient route to deliver enteral nutrition to their patients. Nevertheless, bearing an indwelling gastric tube could not be as convenient for patients. Complications, such as bowel perforation, tube dislodgement, peristomal infection or bleeding occur in up to 17% of patients, and some other drawbacks of gastric tubes, such as peristomal pain, are often understated. We present our technique for laparoscopic creation of a tubularized continent gastrostomy, originally conceived for the emergency treatment of patients with a dislodged percutaneous endoscopic gastrostomy, to provide them with a reliable new route for gastric feeding. After healing, this gastrostomy does not need an indwelling tube to stay patent, requires only a light gauze dressing and can be used by intermittent catheterization at conventional feeding times during the day. Laparoscopic tubularized continent gastrostomy can be offered to patients as a reliable alternative to tube gastrostomy.

The principal purpose of critical care nutrition is to arrest the loss of lean body mass and to maintain and restore energy-dependent homeostatic functions. There is no well-validated tool that evaluates the nutritional status of the critically ill patient, so opinion-based clinical evaluation of nutritional status is preferred. There is no evidence that parenteral nutrition (PN) is superior to enteral nutrition (EN) during the first 7 days of critical illness and vice versa. Moreover, early EN and early PN feeding do not appear to improve outcomes compared with delayed or hypocaloric nutrition. Parenteral nutrition should probably be delayed for up to 7 days for well-nourished patients. Adding PN to EN early in critical illness to achieve energy goals does not improve outcomes. The status of PN in malnourished or undernourished patients is unclear. PN is not associated with elevated infection risk. EN is associated with gastrointestinal complications, principally vomiting, probably clinically insignificant. EN is safe to administer to patients receiving vasoactive drugs after the initial shock period. For the majority of patients, gastric feeding should be attempted, and this usually results in achieving nutritional goals. It is probably unnecessary to routinely check gastric residual volumes. EN is superior to PN in patients with acute pancreatitis. In conclusion, there is currently no evidence that administration of a patient’s full estimated energy requirements improves outcomes in early critical illness. Consequently, trophic or hypocaloric feeding is a reasonable approach in the first 7 days.

Large burns are associated with a dramatic increase in metabolic demand, and adequate nutrition is vital to prevent poor wound healing and septic complications. However, enteral nutrition (EN) support is frequently withheld perioperatively, risking nutritional deficits. We retrospectively examined the safety and feasibility of continuing EN during surgery in patients with an established airway, and estimated the impact of perioperative fasting on overall caloric intake.Mechanically ventilated patients admitted to our urban, verified burn center between January 2012 and July 2017 with greater than 20% total body surface area (TBSA) burns were included in this retrospective analysis. The total volume of EN received by the patient during each 24-h period and goal EN volume as determined by a clinical dietitian were collected.A total of 45 patients met criteria with mean TBSA of 44% (range 20-84%). Most patients had a gastric feeding tube (86%). Each patient underwent a median of 4 operations (range 1-33) for a total of 249 operative days and 991 non-operative days. There were no aspiration events. On non-operative days, patients met 85% of estimated caloric needs. EN was held on 170 operative days (69%), and on these days, only 34% of total caloric needs were met. EN was continued on 77 operative days (31%), and on these days, 95% of total caloric needs were met (p0.001). Patients who had EN held for at least 50% of operative procedures (n=30) met only 69% of caloric goals while intubated. By comparison, patients who had EN continued for a majority of procedures (n=15) met 81% of caloric goals (p=0.002).Continuing EN intraoperatively in patients with an established airway appears to be a safe and efficacious way to meet patients' nutritional needs, including when feeding is delivered via a gastric route. This is particularly important given that placement of nasojejunal feeding tubes can be difficult, particularly in resource-poor settings where endoscopic or fluoroscopic-guided placement may not be practical.

BACKGROUND Malnutrition increases the risk of mortality and morbidity in the pediatric intensive care unit (PICU). Barriers to adequate delivery of enteral nutrition (EN) include hemodynamic instability, feeding interruptions and intolerance, and lack of standardized feeding protocols. The most recent guidelines on nutrition support for the critically ill child describe a paucity of evidence around the best method to deliver EN. There is an untested clinical assumption that bolus gastric feeding (B-GF) in intubated patients is associated with aspiration events, lung injury, and associated morbidity compared with continuous gastric feeding (C-GF). This study compared the effectiveness and safety of C-GF vs B-GF in intubated pediatric patients. METHODS We enrolled randomized patients aged 1 month-12 years who were intubated within 24 hours and received EN starting within 48 hours of admission to a C-GF or B-GF group. Goal-directed EN volume and caloric density were increased every 3 and 12 hours, respectively, to target. Feeding interruptions and intolerance events were recorded. RESULTS Twenty-five subjects were enrolled (B-GF = 11; C-GF = 14). At 24 hours, B-GF was associated with higher energy and protein delivery (P

Background: Dietary protein is required to attenuate the loss of muscle mass and to support recovery during a period of hospitalization. Jejunal feeding is preferred over gastric feeding in patients who are intolerant of gastric feeding. However, the impact of gastric vs. jejunal feeding on postprandial dietary protein digestion and absorption kinetics in vivo in humans remains largely unexplored. Objective: We compared the impact of gastric vs. jejunal feeding on subsequent dietary protein digestion and amino acid (AA) absorption in vivo in healthy young men. Methods: In a randomized crossover study design, 11 healthy young men (aged 21 +/- 2 y) were administered 25 g specifically produced intrinsically L-[1-C-13] phenylalanine-labeled intact casein via a nasogastric and a nasojejunal tube placed similar to 30 cm distal to the ligament of Treitz. Protein was provided in a 240-mL solution administered over a 65-min period in both feeding regimens. Blood samples were collected during the 7-h postprandial period to assess the increase in plasma AA concentrations and dietary protein-derived plasma L-[1-C-13] phenylalanine enrichment. Results: Jejunal feeding compared with gastric feeding resulted in higher peak plasma phenylalanine, leucine, total essential AA (EAA), and total AA concentrations (all P

Objective: Enteral nutrition (EN) has well-established benefits in critically ill children. Optimally, full nutritional support should be achieved expeditiously. The authors hypothesized that a protocolized continuous gastric EN (GEN) approach would decrease time to goal feeding rate and calories (TTG). Design: 96 patients were enrolled, divided equally into control (pre) and treatment (post) groups. Patients were monitored every 4 hours for 5 signs of feeding intolerance. Significance was defined as P < .05. Setting: 23-bed multidisciplinary pediatric intensive care unit (PICU). Subjects: PICU patients

BACKGROUND: Jejunal feeding is preferred instead of gastric feeding in patients who are intolerant to gastric feeding or at risk of aspiration. However, the impact of gastric feeding compared with that of jejunal feeding on postprandial circulating plasma glucose and amino acid concentrations and the associated endocrine response in vivo in humans remains largely unexplored. OBJECTIVE: We compared the impact of administering enteral nutrition as either gastric feeding or jejunal feeding on endocrine responses in vivo in humans. DESIGN: In a randomized, crossover study design, 12 healthy young men (mean +/- SD age: 21 +/- 2 y) received continuous enteral nutrition that contained noncoagulating proteins for 12 h via a nasogastric tube or a nasojejunal tube placed 30-40 cm distal to the ligament of Treitz. Blood samples were collected during the 12-h postprandial period to assess the rise in plasma glucose, amino acid, and gastrointestinal hormone concentrations. RESULTS: No differences were observed in the postprandial rise in circulating plasma amino acid and glucose concentrations between regimens. Jejunal feeding resulted in higher peak plasma insulin concentrations than did gastric feeding (392 +/- 53 compared with 326 +/- 54 pmol/L, respectively; P < 0.05). The postprandial rise in plasma cholecystokinin, peptide YY (PYY), glucagon-like peptide 1 (GLP-1), and glucagon-like peptide 2 (GLP-2) concentrations was greater after jejunal feeding than after gastric feeding, with higher peak concentrations and a greater postprandial incremental AUC for GLP-1 and cholecystokinin (all P < 0.05). Plasma ghrelin concentrations did not differ between regimens. CONCLUSIONS: Enteral nutrition with gastric or jejunal feeding in healthy young men results in similar postprandial plasma amino acid and glucose concentrations. However, the endocrine response differs substantially, with higher peak plasma cholecystokinin, PYY, GLP-1, and GLP-2 concentrations being attained after jejunal feeding. This effect may result in an improved anabolic response, greater insulin sensitivity, and an improved intestinotropic effect. Nevertheless, it may also lead to delayed gastric emptying. This trial was registered at trialregister.nl as NTR2801.

Background and Aims: Intolerance of gastric enteral feeding (GEN) commonly occurs in surgical Intensive Care Unit (SICU). A liquid containing sugar could prolong gastric emptying time. This study was to propose a method for prediction of nonsuccess GEN using gastric volume after loading (GVAL) following gradual sucrose gastric loading. Materials and Methods: Mechanical ventilator supported and hemodynamically stable patients in SICU were enrolled. About 180-240 min before the GEN starting, a sucrose solution (12.5%; 450 mosmole/kg, 800 mL) was administered via gastric feeding tube over 30 min with 45° head upright position. GVAL was measured at 30, 60, 90, and 120 min after loading. GEN success status using clinical criteria was assessed at 72 h after the starting GEN protocol. The receiving operating characteristic (ROC) and c statistic were used for discrimination at each time point of GVAL. Results: A total of 32 patients were enrolled and completed the protocol. 14 patients (43.7%) were nonsuccessful GEN. The nonsuccess group was found to have significantly more GVAL than the other group at all-time points during the test (P < 0.05). The most discriminating point of GVAL for the prediction of nonsuccess was 150 mL at 120 min after loading with a sensitivity of 92.3%, specificity of 88.9%, positive predictive value of 85.7%, negative predictive value of 94.1%, and ROC area 0.97 (95% confidence interval 0.91–1.00). Conclusion: A high GVAL following sucrose gastric loading test might be a method to predict nonsuccess GEN in critically ill surgical patients.

The trafficking of dietary fat was assessed in obesity-prone (OP) and obesity-resistant (OR) male and female rats. Test meals containing [1-14C]palmitate were delivered through gastric feeding tubes while rats consumed a high-carbohydrate diet (HCD) or after 5 days of a high-fat diet (HFD). Over the subsequent 24 h, the appearance of14C was followed in the GI tract, skeletal muscles (SM), liver, adipose tissues (AT), and expired CO2. There was no difference in the production of14CO2between OP and OR rats consuming a HCD. However, after 5 days on HFD, OR rats produced significantly more14CO2after the test meal than OP rats ( P < 0.001 females, P = 0.03 males). The differential oxidation of dietary fat between OP and OR rats on HFD was not due to differences in absorption but rather was associated with preferential disposition of tracer to AT in OP rats. Measurements of lipoprotein lipase in part explained increased tracer uptake by AT in OP rats but were not consistent with increased SM tracer uptake in OR rats. Surprisingly, female rats oxidized more tracer than male rats irrespective of phenotype or diet. These results are consistent with the notion that differences in the partitioning of dietary fat between storage in AT and oxidation in SM and liver that develop shortly after the introduction of a HFD may in part underlie the differential tendency for OR and OP rats to gain weight on this diet.

In veterinary patients, postgastric feeding is indicated for uncontrollable gastric vomiting, gastroparesis, biliary tract disease, pancreatitis, and for patients at increased risk for aspirating secondary to decreased mentation, prolonged recumbency, or an unprotected airway. Postgastric feeding may be implemented via the placement of a jejunal feeding tube. These tubes can be placed surgically (jejunostomy tubes) or with fluoroscopic or endoscopic guidance. This article will focus on methods of jejunal feeding-tube placement, advantages and disadvantages of the methods described, and complications associated with jejunal feeding.

The "pancreatic rest" concept is entrenched in the management of acute pancreatitis. As a result, "nonstimulatory" feeding has been widely advocated in patients with this disease, being parenteral nutrition 2-3 decades ago and jejunal tube feeding in the past decade. However, accumulating clinical evidence from the fields of acute pancreatitis and critical care medicine suggests that gastric feeding is as safe and effective as jejunal feeding in most patients. This has paved the way for a new conceptual framework called "gut rousing." Acute pancreatitis management now requires consideration of gut function. Enteral nutrition is a gut-directed therapy, and avoiding stimulation of the pancreas in patients with acute pancreatitis need not overshadow the main goal of maintaining or restoring gut function.

Objective: To determine whether adding erythromycin to a gastric feeding regimen could render it as effective in meeting nutritional needs as transpyloric feeding. Design: Randomized, controlled study. Setting: University hospital medical, surgical, and neurologic care intensive care units. Patients: Critically ill patients, requiring a projected 96 hrs of enteral feeding, who had no specific indication for tube location (gastric or transpyloric). Eighty patients were randomized. Interventions: Patients were randomized to gastric feeding with erythromycin (200 mg IV) given every 8 hrs or feeding through a transpylorically placed feeding tube. Goal rate and feeding advancement were determined by protocol. Measurements and Main Results: During the 96-hr period, the gastric group received 74% of their goal calories and the transpyloric group received 67%. The only day on which gastric feedings were superior was the first study day, where the gastric group attained 55% of their goal, compared with 44% in the ...

Lipid-laden macrophages (LLM) in tracheal aspirates are reported to be pathognomonic findings in exo- and endogenous lipoid pneumonia in adults. A pilot study was carried out to evaluate the effect of lipid infusion on the LLM index of the tracheal aspirates from ventilated neonates. All intubated infants were eligible for the study. Infants receiving parenteral nutrition had intravenous (IV) lipid introduced by 4–7 days of age; most samples after 7 days were from infants receiving IV lipid. Four infants received minimal gastric feeding; none had evidence of aspiration pneumonia. Tracheal aspirates from 28 infants were analyzed for the LLM index. Alveolar macrophages were graded 0–4 in direct relation to the amount of lipid per cell. One hundred macrophages were graded; the maximum possible LLM index was 400. Two hundred forty-five of 387 tracheal aspirate samples were acceptable for analysis. LLM indices increased during the first week after birth; the mean LLM index then continued in the same range, but with a wide distribution of individual values. The mean LLM index from infants receiving an IV lipid infusion during days 4–7 was 87.9 (SD = 44.8), and was significantly higher compared to 58.7 (SD = 40.8) in infants receiving no IV lipid (P 100. These observations invalidate the use of the LLM index >100 as proof of aspiration pneumonia in this group of infants. Pediatr Pulmonol. 1999; 28:101–108. © 1999 Wiley-Liss, Inc.

Despite considerable efforts to define energy requirements for critically ill patients, no single method has been found to be precise and unbiased for all patients. As a result, clinicians have used various methods that may overestimate energy requirements for some patients. Provision of target caloric intake without regard to the complications of overfeeding, such as hyperglycemia, hypercapnia, or gastric feeding intolerance, could result in overall detrimental clinical outcome. Inadequate nutrition support is also associated with adverse clinical outcomes that necessitate optimization of delivery and tolerance of the nutrition regimen. A pivotal paper by Krishnan and colleagues published in 2003 brought these issues to the forefront of clinical practice. Key papers that support or refute the practice of "permissive underfeeding" are reviewed. Further research is necessary to determine the minimum amount of nutrition required to achieve a therapeutic benefit as well as to ascertain at what amount of additional nutrition intake offers no further improvement in clinical outcome.

Although parenteral nutrition is frequently administered to children undergoing treatment for malignancy, the use of naso-gastric feeding had been little studied. A randomized, controlled trial of supplementary naso-gastric feeding in children with newly diagnosed malignancy was therefore performed. Results showed that, contrary to popular belief, naso-gastric feeding is acceptable to and tolerated by children with malignancy even shortly after diagnosis and is welcomed by their parents. Naso-gastric feeding increased energy intake, promoted improvement in nutritional status as measured by mid-upper arm circumference and appeared to increase general well-being. Further studies are being undertaken to determine whether naso-gastric supplementary feeding is also of objective benefit.

Post-pyloric feeding via a surgical jejunostomy allows for enteral nutrition in patients that cannot receive oral or gastric feeding. Regardless of the technique used to create a jejunostomy, complications such as tube dislodgement, jejunostomy closure, or bowel obstruction can occur. We present a simple and efficient jejunostomy technique that does not require a sewn anastomosis and employs an easily exchangeable feeding button.

Feeding into the small bowel is often recommended to improve nutrient delivery for critically ill patients, and thus improve outcome and reduce complications associated with enteral feeding. Risks and benefits of gastric feeding, use of motility agents, postpyloric feeding, and obtaining small bowel access are discussed here. Randomized clinical trials directly comparing postpyloric with gastric feeds are also evaluated. These small, underpowered studies demonstrate small but clinically important differences in important outcomes (pneumonia), but are weakened by significant heterogeneity. Current evidence does not support routine use of postpyloric feeding in the critically ill. A standardized approach to optimizing benefits and minimizing risks with enteral nutrition delivery will help clinicians identify patients who would benefit from small bowel feeding.

Enteral nutrition has been shown to have clinical advantages over parenteral nutrition in critically ill patients. However, delivery of enteral nutrition can be challenging because of intolerance and potential adverse effects. Gastric feeding is more physiologic than post-pyloric feeding, but its use may be limited by intolerance due to gastric dysfunction and by inappropriately low gastric residual volumes. Post-pyloric feeding may help to overcome these disadvantages by making it possible to avoid feeding interruption and potentially reduce the risk of aspiration. Results from studies to date have not shown any advantage of post-pyloric over gastric feeding in regard to outcome. This article focuses on strategies for enteral nutrition delivery in critically ill patients. The selection of site for enteral feeding should be based on risks, patient tolerance, and availability of local expertise. Predetermined feeding protocols may help to optimize the delivery of enteral nutrition. Only sufficient and safe delivery of enteral nutrition will have a positive impact on patient outcome.

Indiscriminate gastric feeding in ICU patients imposes unacceptable risks of aspiration. Believing that a subset of ICU patients can be fed safely via the stomach, we have developed a protocol to identify appropriate patients and guide the bedside clinician in how to safely and effectively feed via the stomach.A literature search was done to identify appropriate medical literature. High grade evidence along with local expert opinions were used to develop a protocol. This protocol has been refined and implemented.Based on perceived risk of aspiration, patients are assigned enteral access (ie, stomach vs. distal post-pyloric). Enteral formula is selected based on patient characteristics. It is then advanced by a standard protocol with specific precautions while monitoring for symptoms of intolerance. Management of intolerance is dictated by the type and severity of intolerance.We have implemented a gastric feeding into a subset of our ICU patients. Gastric feeding requires certain precautions but appears to be safe. With more experience and better understanding of the pathogenesis gastroparesis, we believe that most ICU patients should be able to safely feed into the stomach. This is logistically easier than post-pyloric feeding and offers physiologic advantages.

Post-pyloric feeding has been shown to be beneficial compared to gastric feeding in terms of calories delivered, length of intensive care unit stay and possibly rates of ventilator-associated pneumonia and mortality. It has often been disregarded as taking too long or requiring expensive equipment, but we have established a rapid, safe, cheap and reliable technique for inserting post-pyloric feeding tubes.

To compare outcomes from early post-pyloric to gastric feeding in ventilated, critically ill patients in a medical intensive care unit (ICU).Prospective randomized study. Ventilated patients were randomly assigned to receive enteral feed via a nasogastric or a post-pyloric tube. Post-pyloric tubes were inserted by the bedside nurse and placement was confirmed radiographically.A total of 104 patients were enrolled, 54 in the gastric group and 50 in the post-pyloric group. Bedside post-pyloric tube insertion was successful in 80% of patients. Patients who failed post-pyloric insertion were fed via the nasogastric route, but were analysed on an intent-to treat basis. A per protocol analysis was also performed. Baseline characteristics were similar for all except Acute Physiology and Chronic Health Evaluation II (APACHE II) score, which was higher in the post-pyloric group. There was no difference in length of stay or ventilator days. The gastric group was quicker to initiate feed 4.3 hours (2.9 - 6.5 hours) as compared to post-pyloric group 6.6 hours (4.5 - 13.0 hours) (P = 0.0002). The time to reach target feeds from admission was also faster in gastric group: 8.7 hours (7.6 - 13.0 hours) compared to 12.3 hours (8.9 - 17.5 hours). The average daily energy and protein deficit were lower in gastric group 73 Kcal (2 - 288 Kcal) and 3.5 g (0 - 15 g) compared to 167 Kcal (70 - 411 Kcal) and 6.5 g (2.8 - 17.3 g) respectively but was only statistically significant for the average energy deficit (P = 0.035). This difference disappeared in the per protocol analysis. Complication rates were similar.Early post-pyloric feeding offers no advantage over early gastric feeding in terms of overall nutrition received and complicationsanzctr.org.au:ACTRN12606000367549.

A rise in the fat concentration of human milk within the syringe was noted towards the end of continuous infusion but not with intermittent bolus gastric feeding. The rise in the former was reduced most simply and effectively by using an eccentric nozzle syringe and tilting the pump up at an angle of between 25 degrees and 40 degrees.