COntinuous vs BOlus Nasogastric Feeding in Mechanically Ventilated Pediatric Patients 2

Dietary Modification Clinical Trial

— COBO2  

Official title:

COntinuous vs BOlus Nasogastric Feeding in Mechanically Ventilated Pediatric Patients 2

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02566070
• Other study ID #: 150311
• Status: Completed
• Phase: N/A
• Start date: November 2015
• Est. completion date: December 2018

Study information

• Verified date: January 2020
• Source: Akron Children's Hospital
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

This multi-center, prospective, randomized comparative effectiveness intervention study will evaluate continuous feeding (CGF) and bolus gastric feeding (BGF) protocols and their effect on delivery of prescribed nutrition and feeding intolerance in mechanically ventilated critically ill children for up through 12 hours post achievement goal feeds or exclusion from feeding protocol, whichever comes first, to a maximum of 10 days.

Description:

A significant number of children (>30%) are malnourished upon admission to the Pediatric Intensive Care Unit (PICU). In addition, critically ill children are at risk to develop new or worsened malnutrition during their PICU stay. Adequate nutritional support of critically ill children reduces mortality and morbidities, such as hospital acquired health care infections. Inadequate nutrition during hospitalization results in poor healing, increased risk for hospital acquired conditions, and prolonged length of stay, all of which contribute to increased health care costs. Even previously healthy children experiencing critical illness are at high risk for malnourishment because of increased protein and/or caloric needs at a time when oral intake is inadequate to meet their metabolic needs. A gap in the literature exists regarding the effectiveness of 2 delivery modes for gastric enteral nutrition: continuous gastric (stomach) feeding (CGF), the steady infusion of liquid nutrition is delivered at an hourly volume via an infusion pump, and bolus gastric feeding (BGF), whereby nutrition is intermittently delivered over a prescribed period of time, followed by a period of rest.

Enteral nutrition (EN, or tube feeding) in the PICU is commonly given via continuous gastric feeding. However, feeding by bolus or intermittent methods better mimics normal body function and may minimize interruptions to feedings improving nutritional intake. This study proposes to address the gap in the literature regarding the best method to deliver EN to achieve prescribed nutritional goals and avoid feeding interruptions in the mechanically ventilated, critically ill pediatric population.

This multi-center, prospective, randomized, controlled study includes children 1-month to 12-years who are on a ventilator and have EN started within 48-hours of admission. Subjects are randomized to CGF or BGF. Feeding volume is advanced in a weight-based manner every 3-hours to target volume; caloric density is then increased to goal. Feeding intolerance measures are assessed every 3-hours. Study sites are assigned to follow one of two feeding intolerance criteria to better define the measures and thresholds necessary to halt and resume feeds for safety purposes. Incidence, duration and category of feeding interruptions are recorded. Statistical significance is defined as p < 0.05. The findings will be submitted for oral and poster presentation and manuscripts submitted for publication.

As the focus of nursing remains not on disease and cure, rather on healing and health, nutrition is embedded in this philosophy. Our vision of nursing is to put the patient in the best position to heal him or herself. Mitigating existing malnutrition and/or avoiding newly acquired nutritional deficits decreases the risk of mortality and hospital acquired adverse events in this population. This study seeks to optimize delivery of nutrition as therapy as imperative to optimize clinical and functional outcomes in the critically ill child.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 147
• Est. completion date: December 2018
• Est. primary completion date: December 2018
• Accepts healthy volunteers: No
• Gender: All
• Age group: 1 Month to 12 Years

Eligibility

Inclusion Criteria:

• all medical patients hospitalized in the Pediatric Intensive Care Unit (PICU)

• aged 1 month through 12 years of age

• mechanically ventilated within the first 24 hours of admission

• patients with an anticipated duration of mechanical ventilation greater than 48 hours

Exclusion Criteria:

• diagnosis of acute or chronic gastrointestinal pathology

• primary cardiac surgery or other surgical service patients

• enteral nutrition initiated greater than 48 hours post PICU admission, or

• enteral nutrition was initiated prior to admission to PICU

Related Conditions & MeSH terms

• Dietary Modification

Intervention

Other:
• Continuous Gastric Feeding

• Bolus Gastric Feeding

Locations

Country	Name	City	State
United States	Children's Hospital Medical Center of Akron	Akron	Ohio
United States	Shands Children's Hospital	Gainesville	Florida
United States	Dartmouth-Hitchcock Medical Center	Lebanon	New Hampshire
United States	Children's Hospital of Wisconsin	Milwaukee	Wisconsin
United States	The Children's Hospital at Oklahoma University Medical Center	Oklahoma City	Oklahoma
United States	Children's Hospital of Philadelphia	Philadelphia	Pennsylvania

Sponsors (1)

Lead Sponsor	Collaborator
Akron Children's Hospital

Country where clinical trial is conducted

United States, 

References & Publications (25)

Brown A-M, Forbes ML, Vitale VS, Tirodker UH, Zeller R. Effects of a gastric feeding protocol on efficiency of enteral nutrition in critically ill infants and children. ICAN: Infant, Child, & Adolescent Nutrition. 2012;4(3):175-180.

Brown A-M. A Comparison of Two Gastric Feeding Approaches in Mechanically Ventilated Pediatric Patients. Akron, OH: The University of Akron; 2014:159.

Chen YC, Chou SS, Lin LH, Wu LF. The effect of intermittent nasogastric feeding on preventing aspiration pneumonia in ventilated critically ill patients. J Nurs Res. 2006 Sep;14(3):167-80. — View Citation

Cooper VB, Haut C. Preventing ventilator-associated pneumonia in children: an evidence-based protocol. Crit Care Nurse. 2013 Jun;33(3):21-9; quiz 30. doi: 10.4037/ccn2013204. — View Citation

Horn D, Chaboyer W, Schluter PJ. Gastric residual volumes in critically ill paediatric patients: a comparison of feeding regimens. Aust Crit Care. 2004 Aug;17(3):98-100, 102-3. — View Citation

Horn D, Chaboyer W. Gastric feeding in critically ill children: a randomized controlled trial. Am J Crit Care. 2003 Sep;12(5):461-8. — View Citation

Hurt RT, McClave SA. Gastric residual volumes in critical illness: what do they really mean? Crit Care Clin. 2010 Jul;26(3):481-90, viii-ix. doi: 10.1016/j.ccc.2010.04.010. — View Citation

Khorasani EN, Mansouri F. Effect of early enteral nutrition on morbidity and mortality in children with burns. Burns. 2010 Nov;36(7):1067-71. doi: 10.1016/j.burns.2009.12.005. Epub 2010 Apr 18. — View Citation

Larsen BM, Goonewardene LA, Field CJ, Joffe AR, Van Aerde JE, Olstad DL, Clandinin MT. Low energy intakes are associated with adverse outcomes in infants after open heart surgery. JPEN J Parenter Enteral Nutr. 2013 Mar;37(2):254-60. doi: 10.1177/0148607112463075. Epub 2012 Oct 11. — View Citation

Lee JS, Auyeung TW. A comparison of two feeding methods in the alleviation of diarrhoea in older tube-fed patients: a randomised controlled trial. Age Ageing. 2003 Jul;32(4):388-93. — View Citation

Lee JS, Kwok T, Chui PY, Ko FW, Lo WK, Kam WC, Mok HL, Lo R, Woo J. Can continuous pump feeding reduce the incidence of pneumonia in nasogastric tube-fed patients? A randomized controlled trial. Clin Nutr. 2010 Aug;29(4):453-8. doi: 10.1016/j.clnu.2009.10.003. Epub 2009 Nov 12. — View Citation

Mehta NM, Bechard LJ, Cahill N, Wang M, Day A, Duggan CP, Heyland DK. Nutritional practices and their relationship to clinical outcomes in critically ill children--an international multicenter cohort study*. Crit Care Med. 2012 Jul;40(7):2204-11. doi: 10.1097/CCM.0b013e31824e18a8. — View Citation

Mehta NM, Compher C; A.S.P.E.N. Board of Directors. A.S.P.E.N. Clinical Guidelines: nutrition support of the critically ill child. JPEN J Parenter Enteral Nutr. 2009 May-Jun;33(3):260-76. doi: 10.1177/0148607109333114. — View Citation

Mehta NM, McAleer D, Hamilton S, Naples E, Leavitt K, Mitchell P, Duggan C. Challenges to optimal enteral nutrition in a multidisciplinary pediatric intensive care unit. JPEN J Parenter Enteral Nutr. 2010 Jan-Feb;34(1):38-45. doi: 10.1177/0148607109348065. Epub 2009 Nov 10. — View Citation

Mikhailov TA, Kuhn EM, Manzi J, Christensen M, Collins M, Brown AM, Dechert R, Scanlon MC, Wakeham MK, Goday PS. Early enteral nutrition is associated with lower mortality in critically ill children. JPEN J Parenter Enteral Nutr. 2014 May;38(4):459-66. doi: 10.1177/0148607113517903. Epub 2014 Jan 8. — View Citation

Mohr F, Steffen R. Physiology of gastrointestinal motility. In: Wyllie R, Hyams JS, Kay M, eds. Pediatric Gastrointestinal and Liver Disease. 4th ed. Philadelphia, PA: Elsevier/Saunders; 2011:39-49.

Poulard F, Dimet J, Martin-Lefevre L, Bontemps F, Fiancette M, Clementi E, Lebert C, Renard B, Reignier J. Impact of not measuring residual gastric volume in mechanically ventilated patients receiving early enteral feeding: a prospective before-after study. JPEN J Parenter Enteral Nutr. 2010 Mar-Apr;34(2):125-30. doi: 10.1177/0148607109344745. Epub 2009 Oct 27. — View Citation

Reignier J, Mercier E, Le Gouge A, Boulain T, Desachy A, Bellec F, Clavel M, Frat JP, Plantefeve G, Quenot JP, Lascarrou JB; Clinical Research in Intensive Care and Sepsis (CRICS) Group. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA. 2013 Jan 16;309(3):249-56. doi: 10.1001/jama.2012.196377. — View Citation

Schindler CA, Mikhailov TA, Kuhn EM, Christopher J, Conway P, Ridling D, Scott AM, Simpson VS. Protecting fragile skin: nursing interventions to decrease development of pressure ulcers in pediatric intensive care. Am J Crit Care. 2011 Jan;20(1):26-34; quiz 35. doi: 10.4037/ajcc2011754. — View Citation

Skillman HE. How you can improve the delivery of enteral nutrition in your PICU. JPEN J Parenter Enteral Nutr. 2010 Jan-Feb;34(1):99-100. doi: 10.1177/0148607109344725. — View Citation

Skillman HE. Monitoring the efficacy of a PICU nutrition therapy protocol. JPEN J Parenter Enteral Nutr. 2011 Jul;35(4):445-6. doi: 10.1177/0148607111409046. Epub 2011 Jun 1. — View Citation

Thomas NJ, Shaffer ML, Willson DF, Shih MC, Curley MA. Defining acute lung disease in children with the oxygenation saturation index. Pediatr Crit Care Med. 2010 Jan;11(1):12-7. doi: 10.1097/PCC.0b013e3181b0653d. — View Citation

Tume L, Carter B, Latten L. A UK and Irish survey of enteral nutrition practices in paediatric intensive care units. Br J Nutr. 2013 Apr 14;109(7):1304-22. doi: 10.1017/S0007114512003042. Epub 2012 Aug 1. — View Citation

Ukleja A. Altered GI motility in critically Ill patients: current understanding of pathophysiology, clinical impact, and diagnostic approach. Nutr Clin Pract. 2010 Feb;25(1):16-25. doi: 10.1177/0884533609357568. Review. — View Citation

Weckwerth JA. Monitoring enteral nutrition support tolerance in infants and children. Nutr Clin Pract. 2004 Oct;19(5):496-503. — View Citation

* Note: There are 25 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Time to goal feeds (TTGF) is decreased in a bolus compared to continuous gastric feeding protocol.	TTGF defined as time to attain goal feeds	12 to 48 hours post enteral feeding
Secondary	Feeding interruptions	measured by minutes feeds are withheld.	12 to 48 hours post enteral feeding
Secondary	Gastric residual volumes	measured in milliliters	12 to 48 hours post enteral feeding
Secondary	Rate of ventilator associated infections (VAI)	as reported by Infection Control Department.	12 to 48 hours post enteral feeding
Secondary	Oxygen Saturation Index	as calculated by [(FiO2 x Mean Airway Pressure)/SpO2]	12 to 48 hours post enteral feeding
Secondary	Emesis	as a binary yes/no event	12 to 48 hours post enteral feeding
Secondary	Abdominal girth	measured in centimeters	12 to 48 hours post enteral feeding