Enteral Feeding:

Continuous vs.
Intermittent
GROUP B: AIMEE A., ANTONIO S., ASHLEY H., DOUG T.,
DUYEN P., HOLLY Z., JANET D., MELISSA D., RUTHLYN K.

Introduction and Overview

Enteral nutrition is often favored for high-acuity patients with a still
functioning gastrointestinal tract who cannot take in oral nutrition due
to their disease process.
Enteral nutrition for high-acuity patients can be administered through a
continuous or intermittent (bolus) feeding method.
Enteral nutrition contributes trophic effects by prohibiting gut villi
atrophy, helps lower intestinal permeability, contributes to intestinal
perfusion and helps protect gut immunity.
Complications that can result from enteral nutrition include GI,
metabolic, pulmonary and mechanical issues.

PICOT Question
In high acuity patients, how does bolus versus
continuous enteral feedings influence patient
outcomes over the course of the patients admission
to the high acuity care unit?

Summary of Current Practice

Carondelet Health
Gastric Feeding:
Standard formulas start of 50 ml/hr advanced by 25 ml/hr every 4-8
hours until the goal rate is met.
Elemental formulas start at 25 ml/hr for the first 12 hours advance
by 25 ml/hr every 6-12 hours until reaching goal rate
2 kcal/ml formulas started at 25ml/hr advanced as elemental
formulas
Bolus feeding may be used with gastric feeding

Summary of Current Practice

Jejunal or duodenal feeding:
Standard or elemental feedings start at 25 ml/hr for the first 12 hours
advance by 25 ml/hr every 6-12 hrs until reaching goal rate.
Do not use bolus feeding method with jejunal or duodenal feeding!
When to Hold Feedings:
30 mins. prior to procedures requiring the Trendelenberg position
6 hours prior to general anesthesia for non-intubated patients
Intubated patients having either airway surgery or planned
reintubation (a minimum of 6 hours)
Intubated patients having planned surgery on the GI tract (NPO from
midnight)

Summary of Current Practice

American Society for Parenteral and Enteral Nutrition:
Bolus/gravity feeding are tolerated when infused into the stomach. The
feedings may be initiated 3-8 times per day, with increases of 60-120
mL (every 8-12 hours as tolerated up to the goal volume.)
For people in intensive care, enteral feedings should usually be
delivered continuously 10-40 mL/hr and advanced to the goal rate by
10-20 mL/hr every 8-12 hours as tolerated.
(Isotonic, high-osmolality or elemental formulas are recommended for
both method)

Current Literature Synopsis

Literature included 9 studies that compared continuous enteral feeds to
intermittent enteral feeds
Studies focused on high acuity patients
Most populations in the studies are ICU patients
General consensus of these studies:
No significant difference between bolus and continuous feeds
Focus on patient outcomes:
GI complications, aspiration, aspiration pneumonia
Nutrition: gastric resudial, caloric goals

Strengths and Limitations of

Literature
Strengths
All of the studies are randomized clinical studies
All of the studies consisted of high acuity patients
Generalize to a larger population
Limitations
Different patient conditions, comorbidities, and demographics
Small sample sizes
Limited time frame of the clinical studies

Evidence-Based Recommendations
There was no significant difference between continuous vs.
intermittent feeding.
With bolus feeding, it was found that there was an increased risk for
GI issues.
Currently, there is no national recommendation on whether
intermittent or continuous feeding is preferred.
The evidence based recommendation is:
The provider will determine whether continuous or intermittent
enteral feeding is appropriate on a case-by-case basis based on
patient indicators, such as GI status, acuity, and nutritional needs.

Application and Implementation

No statistically significant difference between 2 groups was found regarding the provision
of caloric needs and in the variables vomiting, abdominal distension or diarrhea
No clinically significant difference in respiratory quotient (RQ), resting energy expenditure
(REE), and random blood sugar (RBS) when enteral feedings are either intermittent or
continuous on head injury patients on mechanical ventilation
Patients in multiple studies developed aspiration pneumonia, which is a major concern
with patients receiving enteral feeds.
The researchers concluded that there are no clinically relevant differences in glycemic
variability, insulin use, tube feeding volume or caloric intake between the two groups.
In conclusion, these studies allow the provider to choose more freely which enteral
nutrition form of delivery will best fit the clinical status of the patient and the procedures
adopted at any given moment. Therefore, no timeline of implementation is needed, as
there is no deviation from the currently recommended practice.

Cost Analysis
Most patients at Carondelet use Jevity for enteral nutrition.
There are four basic types of enteral formula: polymeric, modular, elemental, and
specialty.
Direct cost
Tube insertion = $26
After an enteral tube is inserted, verification of tube placement by X-ray film
examination needs to occur before the patient receives the first enteral feeding.
Indirect cost
Jevity 1.2 Cal Ready-to-Hang - 1000 mL = $35/bottle
Run at 40 ml/hr and tubing has to be changed every 24 hours
1 bottle per day per patient

Cost Analysis
Kangaroo pump cost $620
Feeding pump set $130
Additional costs
Costs to verify the correct placement of the NG-tube, chest x-ray
Costs for accidental tube removal
If the patient has a metabolic disorder or other diagnosis (obese, DM,
Cardiac disorders), which may necessitate a different or more formula,
this may come at an increased cost

Hospital Expenses for NG tube

per week
Expenses

Cost per item

Needed amount
per week

Total cost

Tube formula

$ 35

7 bottles

$ 245

Feeding pump

$ 620

1 pump

$ 620

Costs NG-tube

$26 for an NG tube

$ 26

Costs PEG tube

$110 for a PEG

tube

1( replace every 2
w)

$ 110

Feeding tube

$ 10

$ 70

Total amount NG
per week

$ 961

Total amount PEG

per week

$ 1045

Risk-Benefit Analysis
Benefits:
No significant clinical difference between the two
techniques was found overall; but each study had
varying short term results.
Ex: nutritional intake may have differed at first in
some studies, but equalized by the third day.

Risk-Benefit Analysis
Benefits:
Technique can be up to the physicians discretion
without high risk of one or the other.
Patients on intermittent feeds were extubated
earlier, and had a lower risk of aspiration
pneumonia. (aspiration pneumonia linked to high
doses of dopamine) (Yu-Chih et al, 2006)

Risk-Benefit Analysis
Risks:
Incidence of aspiration warrants further
investigation.
Staff prefer continuous feeding over intermittent.
(Steevens et al, 2002)
Continuous: nurse may not be as vigilant as
with intermittent feeding
Intermittent: gives the nurse extra nursing care
to keep track of

Risk-Benefit Analysis
Risks:
There may still be risk that is unknown and the
limitations of the studies and the differences in patient
conditions and possible comorbidities have prevented
us from isolating specific complications.
Risk for aspiration pneumonia is associated with
feedings at night and supine position.
Intermittent feeds increase the patients
gastrointestinal complications, including diarrhea.

Evaluation and SMART Outcome

Evaluation: Given the data from the articles that our group
researched, there were no notable clinical significant differences
between bolus or intermittent feedings.
SMART Outcome: The patient started on enteral feeding will not
experience an adverse event, such as gastrointestinal
complications or aspiration, during the course of their stay in
the high acuity care unit.

Summary of Literature
Current clinical recommendations allow the physician to decide
which type of feeding is best for the patient, either intermittent
(bolus) or continuous.
After reviewing 9 different studies, no statistical difference or
benefit was found between implementing either an intermittent
or continuous feeding regimen.
Given our findings after reviewing the literature, our
recommendation is to continue with the current national clinical
recommendations regarding enteral feedings.

References
Evans, D. C., Forbes, R., Jones, C., Cotterman, R., Njoku, C., Thongrong, C., ... & Stawicki, S. P. (2016).
Continuous versus bolus tube feeds: Does the modality affect glycemic variability, tube feeding
volume, caloric intake, or insulin utilization?. International Journal of Critical Illness and Injury Science,
6(1), 9.
Kadamani, I., Itani, M., Zahran, E., & Taha, N. (2014). Incidence of aspiration and gastrointestinal
complications in critically ill patients using continuous versus bolus infusion of enteral nutrition: A
pseudo-randomised controlled trial. Australian Critical Care, (27) 4, 188-193. doi:
http://dx.doi.org/10.1016/j.aucc.2013.12.001
Lee, J.S.W., Kwok, T., Chui, P.Y., Ko, F.W.S., Lo, W.K., Kam, W.C.,...Woo,J. (2010). Can continuous pump
feeding reduce the incidence of pneumonia in nasogastric tube-fed patients? A randomized controlled
trial. Clinical Nutrition, 29, 453-458. doi:10.1016/j.clnu.2009.10.003
MacLeod, J. B., Lefton, J., Houghton, D., Roland, C., Doherty, J., Cohn, S. M., & Barquist, E. S. (2007).
Prospective randomized control trial of intermittent versus continuous gastric feeds for critically ill
trauma patients. The Journal of Trauma, 63(1), 57-61. doi:10.1097/01.ta.0000249294.58703.11 [doi]

References

Maurya, I., Pawar, M., Garg, R., Kaur, M., & Sood, R. (2011). Comparison of respiratory quotient and resting energy
expenditure in two regimens of enteral feeding continuous vs. intermittent in head-injured critically ill patients.
Saudi Journal of Anaesthesia, 195-201. doi:10.4103/1658-354X.82800
Serpa, Letcia Faria, Kimura, Miako, Faintuch, Joel, & Ceconello, Ivan. (2003). Effects of continuous versus bolus
infusion of enteral nutrition in critical patients. Revista do Hospital das Clnicas, 58(1), 9-14. Retrieved March 04,
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Steevens, E. C., Lipscomb, A. F., Poole, G. V., & Sacks, G. S. (2002). Comparison of continuous vs intermittent
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Yu-Chih, C., Shin-Shang, C., Li-Hwa, L., Li-Fen, W., (2006). The Effect of Intermittent Nasogastric Feeding on
Preventing Aspiration Pneumonia in Ventilated Critically Ill Patients. The Journal of Nursing Research, 14(3), 167180.