From the Guidelines
Regurgitation upon initiation of bolus tube feeds occurs in approximately 12-30% of patients, with higher rates observed in critically ill patients and those with impaired gastric emptying. When starting bolus tube feeds, it's recommended to begin with small volumes (typically 60-120 mL) and gradually increase as tolerated while monitoring for signs of regurgitation, as stated in the guidelines for enteral feeding in adult hospital patients 1. Patients with neurological impairments, those in supine positions, or individuals with gastroparesis are at higher risk.
To minimize regurgitation,
- elevate the head of the bed to at least 30 degrees during and for 30-60 minutes after feeding
- verify proper tube placement before each feeding
- consider using continuous rather than bolus feeding in high-risk patients, as continuous infusion may help with diarrhoea or prevent ‘‘dumping’’ in some patients 1. Regurgitation occurs because bolus feeds rapidly deliver large volumes to the stomach, potentially exceeding gastric capacity and relaxing the lower esophageal sphincter, which can lead to reflux of gastric contents. If regurgitation persists, clinicians should consider prokinetic medications like metoclopramide (10 mg IV/PO three to four times daily) or switching to post-pyloric feeding to bypass the stomach entirely, as post pyloric feeding makes aspiration less likely, but does not eliminate the problem 1.
Key considerations for minimizing regurgitation include:
- using iso-osmotic feeds to reduce delayed gastric emptying
- avoiding high osmotic feeds
- utilizing promotility drugs such as metoclopramide or erythromycin to enhance gastric emptying, as these may be helpful in reducing regurgitation 1. By taking these steps, clinicians can help reduce the risk of regurgitation and aspiration in patients receiving bolus tube feeds.
From the Research
Frequency of Gastroesophageal Regurgitation
- The frequency of gastroesophageal regurgitation upon initiation of bolus enteral nutrition is not directly addressed in the provided studies.
- However, a study on bolus vs continuous nasogastric feeds in mechanically ventilated pediatric patients found no aspiration events resulting in additional lung injury in either group 2.
- Another study on the risk of regurgitation and aspiration in patients infused with different volumes of enteral nutrition found that the incidences of regurgitation and aspiration were significantly lower in the treatment group (6.3% and 7.9%, respectively) than in the control group (18.8% and 17.5%, respectively) 3.
- A study on post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults found that post-pyloric feeding was associated with low rates of pneumonia compared with gastric tube feeding (risk ratio 0.65,95% confidence interval 0.51 to 0.84) 4.
- A study on early initiation of enteral feeding after percutaneous endoscopic gastrostomy tube placement found one case of aspiration pneumonia (1.3%) out of 77 patients 5.
Bolus Enteral Nutrition
- A study compared the effectiveness and safety of bolus gastric feeding (B-GF) vs continuous gastric feeding (C-GF) in intubated pediatric patients and found that B-GF was associated with higher energy and protein delivery and faster time to goal volume 2.
- The study also found no significant difference in the risk of aspiration events between the two groups 2.
Enteral Nutrition
- Enteral nutrition by feeding tube is a common and efficient method of providing nutritional support to prevent malnutrition in hospitalized patients who have adequate gastrointestinal function but are unable to eat 6.
- The use of metoclopramide, a prokinetic agent, has been recommended to achieve post-pyloric placement of naso-enteral tubes, but its efficacy is controversial 6.