Continuous vs intermittent feeding: Which is better for critically ill patients?

Continuous feeding appears to be more effective than intermittent feeding in reducing the rate of mortality in critically ill patients in the intensive care unit (ICU), reveals a study.

“However, according to the GRADE framework, the certainty of evidence was … low,” the researchers said. “Trial sequential analysis (TSA) also indicated insufficient data to reach a firm conclusion.”

A comprehensive search with no language restrictions was conducted using the databases of PubMed, Embase, and Cochrane Library from inception to 29 December 2022. The research team included randomized controlled trials (RCTs) comparing the clinical efficacy and safety of continuous feeding and intermittent feeding in critically ill patients in the ICU.

Thirteen RCTs, involving a total of 785 patients, met the eligibility criteria. Continuous feeding correlated with a lower mortality rate (relative risk [RR], 0.68, 95 percent confidence interval [CI], 0.47‒0.98; p=0.04) but a higher constipation risk (RR, 1.57, 95 percent CI, 1.02‒2.43; p=0.04). [Eur J Clin Nutr 2023;77:1026-1033]

Additionally, TSA for mortality rate revealed a cumulative Z-curve crossing the traditional boundary, but this curve failed to reach the TSA boundary for benefit.

No significant between-group differences were observed in the aspiration/pneumonia rate (RR, 1.19, 95 percent CI, 0.51‒2.75; p=0.69), diarrhoea rate (RR, 0.82, 95 percent CI, 0.58‒1.16; p=0.26), or increased gastric residual volumes (RR, 1.05, 95 percent CI, 0.58‒1.90; p=0.86).

There was moderate heterogeneity seen in the pooled results for the aspiration/pneumonia rate, which might be explained by the various diagnostic approaches or criteria used. Most studies used diagnoses based on the results of X-ray, blue-dye test, or clinical observation. [Aust Crit Care 2014;27:188-193; Saudi J Anaesth 2011;5:195-201; J Nurs Res 2006;14:167-180; Nutr Clin Pract 2002;17:118-122]

“It is worth mentioning that we are the first article to observe the potential benefits of continuous feeding on the reduction of mortality rates,” the researchers said.

These findings were consistent with the recommendations of the ESPEN and ASPEN guidelines, which endorse continuous feeding for ICU patients because it increases feeding volume and decreases the rate of diarrhoea. [Clin Nutr 2019;38:48-79; J Parenter Enteral Nutr 2016;40:159-211]

“According to the ASPEN guidelines, continuous feeding has shown the ability to achieve greater volume with fewer interruptions in delivery of enteral nutrition, which may be reasonably accounted for the difference,” the researchers said.

In contrast, previous meta-analyses found no significant mortality benefit with continuous feeding, which could have been driven by methodological differences and flawed search strategies. [Int J Nurs Stud 2021;113:103783; Crit Care 2022;26:325]

“[T]his study provides updated information and compelling evidence on the use of continuous feeding relative to the previous ones. However, the results of this meta-analysis should be interpreted with caution,” the researchers said.

“The results of TSA neither support nor oppose the administration of continuous feeding. In other words, this study may have false-positive errors, and future large-scale rigorous randomized trials with other designs are warranted to provide more certainty regarding the clinical efficacy of various feeding modalities,” they added.