Gastric vs small-bowel feeding in critically ill children receiving mechanical ventilation: a randomized controlled trial.

STUDY OBJECTIVES To determine the effect of feeding tube position (gastric vs small bowel) on adequacy of nutrient delivery and feeding complications, including microaspiration, in critically ill children. DESIGN Randomized controlled trial. SETTING Pediatric ICU in a university teaching hospital. PATIENTS Seventy-four critically ill patients < 18 years of age receiving mechanical ventilation were randomized to receive gastric or small-bowel feeding. INTERVENTIONS All feeding tubes were inserted at the bedside. Color, pH, and bilirubin concentration of the feeding tube aspirates were used to guide placement. Final tube position was confirmed radiographically. Continuous feedings were advanced to achieve a caloric goal based on age and body weight. Tracheal secretions were collected daily and tested for gastric pepsin by immunoassay. MEASUREMENTS AND RESULTS Thirty-two patients were randomized to the gastric group, and 42 patients were randomized to the small-bowel group. Twelve patients exited the study because a small-bowel tube could not be placed at the bedside, leaving 30 patients in the small-bowel group. Gastric and small-bowel groups were similar at baseline in age, sex, percentage of ideal body weight, serum prealbumin concentration, and pediatric risk of mortality score. The percentage of daily caloric goal achieved was less in the gastric group compared to the small-bowel group (30 +/- 23% vs 47 +/- 22%, p < 0.01). No difference was found in the proportion of tracheal aspirates positive for pepsin between the gastric and small-bowel groups (50 of 146 aspirates vs 50 of 172 aspirates, respectively; p = 0.3). No differences were found in the frequency of feeding tube displacement, abdominal distension, vomiting, or diarrhea between groups. CONCLUSIONS Small-bowel feeds allow a greater amount of nutrition to be successfully delivered to critically ill children. Small-bowel feeds do not prevent aspiration of gastric contents.