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Invited Review

Nutrition in Clinical Practice


Volume 00 Number 0
Methods of Enteral Nutrition Administration in Critically Ill xxx 2018 1–6

C 2018 American Society for

Patients: Continuous, Intermittent, Cyclic, and Bolus Feeding Parenteral and Enteral Nutrition
DOI: 10.1002/ncp.10105
wileyonlinelibrary.com

Satomi Ichimaru, PhD, RD, CNSC

Abstract
There are several methods of enteral nutrition (EN) administration, including continuous, cyclic, intermittent, and bolus techniques,
which can be used either alone or in combination. Continuous feeding involves hourly administration of EN over 24 hours assisted
by a feeding pump; cyclic feeding involves administration of EN over a time period of <24 hours generally assisted by a feeding
pump; intermittent feeding involves administration of EN over 20–60 minutes every 4–6 hours via pump assist or gravity assist;
and bolus feeding involves administration of EN over a 4- to 10-minute period using a syringe or gravity drip. In practice, pump-
assisted continuous feeding is generally acceptable for critically ill patients to prevent EN-related complications. However, a limited
number of studies have been conducted to support this practice. In addition, regarding muscle protein synthesis and gastrointestinal
hormone secretion, intermittent or bolus feeding may be more beneficial than continuous EN feeding for critically ill patients.
For medically stable patients with feeding tubes terminating in the stomach, bolus feeding is favored with respect to practical
factors, such as cost, convenience, and patient mobility. However, few studies have shown whether intermittent or bolus feeding is
beneficial in a critical care setting at present. Additional randomized controlled studies comparing intermittent with bolus feeding
are required. (Nutr Clin Pract. 2018;00:1–6)

Keywords
cost and cost analysis; critical illness; enteral nutrition; nutrition support; patient safety; protein synthesis; respiratory aspiration;
tube feeding

Introduction Continuous Feeding


Enteral nutrition (EN) is defined as nutrition provided Continuous feeding provides EN by electric enteral feeding
through the gastrointestinal (GI) tract via a tube, catheter, pump over 24 hours, which is generally initiated at a rate of
or stoma that delivers nutrients distal to the oral cavity.1 20–50 mL/h and advanced to goal rate by 10–25 mL/h every
The modes of EN administration include continuous, cyclic, 4–24 hours.4 This method is selected for patients who are
intermittent, and bolus techniques, which can be used either critically ill, who have been intubated for respiratory failure,
alone or in combination. To determine the most appropriate who are fed through a postpyloric tube, or who cannot
method of administration, the clinician should consider tolerate intermittent or bolus feedings.5
numerous factors such as patient’s age, preexisting and Although continuous feeding is preferred by most ICUs,
current medical condition, nutrition status and requirement, it is supported by only a few relatively outdated studies.
enteral route for feeding (gastric vs small bowel), GI tol- A study on 76 adult burn patients reported that patients
erance, formula type used, patient mobility, feeding pump who received continuous feeding had lower stool frequency
availability, and cost. Continuous feeding seems to be the and reached their nutrition goals sooner than those who
standard in the intensive care unit (ICU)2 ; however, there received bolus feeding.6 In adult patients with neurological
is currently insufficient data to choose the best method
to improve patient outcomes of critically ill patients. This From the Department of Nutrition Management, Osaka Saiseikai
narrative review summarizes EN administration methods, Nakatsu Hospital, Osaka, Japan.
their advantages and disadvantages, and the indications of Financial disclosure: None declared.
intermittent and/or bolus feeding in critically ill patients. Conflicts of interest: None declared.
This article originally appeared online on xxxx 0, 0000.
Methods of EN Administration Corresponding Author:
Satomi Ichimaru, PhD, RD, CNSC, Department of Nutrition
The 4 methods of EN administration include continu- Management, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata
ous, cyclic, intermittent, and bolus feedings as shown in Kitaku, Osaka 530-0012, Japan.
Figure 1.3 Email: satomi.ichimaru@gmail.com
2 Nutrition in Clinical Practice 00(0)

Figure 1. Methods of delivering enteral tube feeding. (Reprinted by permission from Springer Nature: Diet and Nutrition in
Critical Care, Intermittent and Bolus Methods of Feeding in Critical Care, Ichimaru S and Amagai T, Springer Science+Business
Media New York 2015)

impairment who received continuous feeding, aspiration Bonten et al17 and Tamowicz et al18 hypothesized
was observed less frequently (1/17) than in those who that cyclic feeding beneficially affected gastric acidity and
received intermittent feeding (3/17).7 In a study of 18 bacterial colonization of the stomach and respiratory tract,
postoperative patients, continuous feeding groups showed thereby helping to prevent ventilator-associated pneumonia
improved cumulative nitrogen balance for 5 days compared (VAP). In these studies, a significant decrease in gastric
with cyclic feeding groups.8 Whether continuous feeding pH was observed when EN was discontinued in the cyclic
provides better glycemic control than intermittent/bolus feeding groups. However, only the study by Tamowicz
feeding remains controversial.9-11 et al18 showed reduced rate of gastric colonization, and the
Continuous feeding is frequently interrupted in the incidence of VAP was relatively similar between the cyclic
ICU.12 The most common reasons for discontinuation of and continuous feeding groups in both studies.
feeding include surgery (27%) and diagnostic procedures With regard to mortality in the ICU, the cyclic and con-
(15%), and minor reasons for EN interruptions include tinuous feeding groups showed no significant differences.17
mechanical feeding tube problems (8%), pharmacy delivery In 1 study, the length of hospital stay was found to be
delay (4%), and miscellaneous factors (3%). Because of the significantly shorter in patients receiving cyclic feeding than
frequency with which enteral feeds are interrupted in the in those receiving continuous feeding.19
hospital setting, resulting in delivery of only 50%–60% of
prescribed EN volume on a daily basis,13 some institutions Intermittent Feeding
have implemented a volume-based feeding protocol to en-
Intermittent EN feeding is usually delivered over 20–60
sure that the volume of EN prescribed to their patients is
minutes by infusion pump or by the gravity drip method. In
actually provided.14-16
the gravity drip method, formula flows out from a feeding
bag and into a feeding tube by gravity. The rate of infusion
is regulated by adjusting a roller clamp.5 Usually, the gravity
Cyclic Feeding drip feeding is tolerated when infused into the stomach.1 In
Cyclic feeding involves feeding by electric enteral feeding intermittent feeding, a volume of 240–720 mL of feeding is
pump over a period of <24 hours, in which the goal infusion administered 4–6 times per day depending on the patient’s
rate is determined by dividing the desired formula volume nutrition needs.5 This feeding method is more physiological
by the number of hours of administration. The infusion than continuous/cyclic feeding because it permits greater
time may vary between 24 and 8 h/day depending on the patient mobility between feedings. If tolerated, the volume
patient’s volume tolerance. This method can be used for of each feeding can be increased and the total number of
patients with feeding tubes terminating in the stomach or feeds can be decreased to improve quality of life.5 According
small bowel. During the course of recovery, patients may to old studies, intermittent feeding has been believed to
transition from the continuous feeding to nocturnal cyclic have some disadvantages, such as risk for aspiration7 and
feeding to stimulate patient’s appetite during the day. It also diarrhea20 ; however, in a recent study of ICU patients
increases patients’ mobility by freeing them from a feeding receiving intermittent or continuous feeding, there was no
set or pump.5 difference in outcomes, including the rate of aspiration
Ichimaru 3

and diarrhea.21 In 1 study, intermittent and continuous pulsatile increase in intramuscular leucine concentration,
feeding groups of critically ill trauma patients showed no and an increase in the rate of MPS. MPS has been found
significant differences in mortality in the ICU or incidence to peak at 90 minutes, decrease thereafter, and return to
of pneumonia.22 In 2 studies that compared intermittent baseline at 180 minutes.38 In a study using neonatal pigs,
and 16-hour cyclic feeding in elderly patients, no significant significant increases in intramuscular AKT and mTOR, as
differences were noted between the groups in mortality, well as increased MPS, were observed with bolus compared
incidence of diarrhea, or pneumonia.23,24 with continuous feeding.39
After the intake of a meal, several hormones, such as
Bolus Feeding glucagon-like peptide-1, gastric inhibitory peptide, chole-
cystokinin, ghrelin, and peptide YY, are secreted from the
Bolus feeding is administered via syringe or gravity drip
enteroendocrine cells lining the lumen of the GI tract. These
over a short period, usually 4–10 minutes. Generally, the
hormones regulate GI motility, gallbladder contraction,
patient is fed a volume of 240 mL of feeding 3–6 times
pancreatic function, and nutrient absorption40 ; most of
daily.5 Feeding provided by this rapid infusion method may
these hormones are secreted within minutes of feeding,
result in diarrhea and/or aspiration.5,6,25 Therefore, bolus
rise transiently, and decline to basal levels after feeding.
feeding is usually reserved for the medically stable patients
In continuous tube feeding, this enterohormonal response
with feeding tubes ending in the stomach.1 For patients with
to nutrition is almost completely absent.41-44 Furthermore,
a gastrostomy tube, not only commercial liquid formulas
bolus feeding may stimulate small-intestinal growth. In a
but also blended food or viscosity-thickened formula can
study using neonatal pigs, greater small-intestinal mucosal
be administered in the bolus feeding.26,27 One advantage
weight and ileal protein mass have been observed fed via bo-
of bolus feeding is that medication can be separately ad-
lus feeding compared with continuous feeding.45 Although
ministered from feeding. Furthermore, this method closely
the studies introduced earlier are conducted in non-ICU
resembles normal eating patterns, increases the time away
settings, we cannot deny the possibility that those results
from feeding, and provides freedom of movement and a
may be applicable to ICU patients. Thus, regarding MPS
more normal life.
and GI hormone secretion, intermittent or bolus feeding
To the best of our knowledge, no study has evaluated
may be more beneficial than continuous EN feeding for
the outcomes of mortality or length of hospital stay be-
critically ill patients. Further randomized controlled studies
tween patients receiving bolus and continuous feeding. The
comparing continuous with intermittent and bolus feeding
bolus feeding group showed improved nitrogen balance in
are required to confirm this hypotheses.
1 study,28 whereas the continuous feeding group showed
significantly improved body weight and arm circumference
in another study.29 Respiratory quotient, resting energy Intermittent vs Bolus Feeding
expenditure, and blood sugar were comparable between
Several studies have been conducted to compare the out-
cyclic and bolus feedings in head-injured patients with
comes of feeding methods in the ICU; however, to our
mechanical ventilation.30
knowledge, no study has compared intermittent with bolus
Table 1 shows the advantages, disadvantages, and indica-
feeding. One reason for this could be that pump-assisted
tions for each method.3
continuous feeding is generally considered acceptable for
patients in the ICU to prevent EN intolerance.2,46 Another
Potential Advantages of Intermittent/ reason could be that intermittent and bolus feeding are often
Bolus Feeding treated as the same feeding method because of the lack of a
Muscle Protein Synthesis and GI Hormone clear definition of them.
Currently, no clinical guidelines strongly recommend
Secretion a specific method of feeding for either critically ill or
In ICU patients, muscle breakdown often exceeds muscle stable patients. According to the Canadian Critical Care
synthesis, and skeletal muscle wasting leads to functional Nutrition Guidelines in 2015, there are insufficient data to
impairment in most survivors of critical illness.31-33 Insulin make recommendations on whether EN should be given
and leucine enhance muscle protein synthesis (MPS) by continuously or via other methods in critically ill patients.47
activating AKT/protein kinase B and the mammalian target The American guidelines of Nutrition Support Therapy
of rapamycin (mTOR).34-36 The continuous infusion of in the Adult Critically Ill Patient in 2016 suggest that
amino acids for 30–60 minutes has been found to lead for high-risk patients or those intolerant to bolus gastric
to stimulated MPS; however, after 120 minutes, MPS was EN, the delivery of EN should be switched to continuous
found to have declined to baseline despite continuation infusion.2 The National Institute for Health and Care
of the amino acid infusion.37 An oral whey protein bolus Excellence Clinical Guidelines recommend that EN should
has been found to cause a pulsatile release of insulin, a usually be continuously administered over 16–24 hours daily
4 Nutrition in Clinical Practice 00(0)

Table 1. Advantages, Disadvantages, and Indications of Each Feeding Method.

Feeding Method Advantages Disadvantages Indications

Continuous May improve tolerance Feeding pump required Initiation of feeding in


May reduce risk of aspiration May restrict ambulation critically ill patients
Increased time for nutrient absorption More expensive Promote tolerance
Compromised gastric
function
Feeding into small bowel
Intolerance to other
feeding methods
Cyclic Facilitates transition of support to oral diet Feeding pump required Transitioning from EN to
Allows daytime ambulation May require high oral nutrition (enhance
Encourages patient to eat normal meals and infusion rates appetite during the day)
snacks May promote intolerance Supplement inadequate
oral intake
Free patient from enteral
feedings during the day
Intermittent Feeding pump may not be required Increased risk for Intolerance to bolus
May enhance quality of life aspiration administration
Allows greater mobility between feedings Gastric distention Initiation of EN without
More physiological Delayed gastric emptying feeding pump
May be better tolerated than bolus feeding
Bolus More physiological Increased risk of Recommended for gastric
Feeding pump not required aspiration feeding
Inexpensive and easy administration Hypertonic, high-fat, or Normal gastric function
Limits feeding time high-fiber formulas
Patient is free to move about, participate in may delay gastric
rehabilitation therapies, and live a emptying or result in
relatively normal life osmotic diarrhea
More likely patient will receive all of formula

EN, enteral nutrition.


Reprinted by permission from Springer Nature: Diet and Nutrition in Critical Care, Intermittent and Bolus Methods of Feeding in Critical Care,
Ichimaru S and Amagai T, Springer Science+Business Media New York 2015.

for patients in the ICU, and if insulin administration is The major points of this review are summarized as
required, continuous feeding over 24 hours is safe and more follows:
practical.48
r There are 4 methods of EN administration: continu-
ous, cyclic, intermittent, and bolus feedings.
Application of Intermittent and/or Bolus r At present, there is no evidence that suggests that any
Feeding to Other Conditions particular feeding method is superior to others.
In the administration of EN at a lower acuity hospital
r In the ICU, pump-assisted continuous feeding is
unit, a long-term care facility, or the home, it is important generally acceptable to prevent EN-related complica-
to address practical factors, such as cost, convenience, tions.
and patient mobility. Compared with other methods, bolus
r Regarding MPS and GI hormone secretion, inter-
feeding is inexpensive because it requires less equipment mittent or bolus, rather than continuous, EN feeding
such as feeding bags, administration sets, and pumps. In may be favorable even for critically ill patients.
addition, bolus feeding requires the least amount of time,
r In a lower acuity hospital unit, a long-term care fa-
and it is easy to perform for caregivers at home. In patients cility, or the home, bolus feeding is preferred because
who frequently tug and dislodge nasogastric tubes, bolus it is inexpensive, easy to perform, requires the least
feeding may be safer than intermittent feeding. Especially amount of time, and mimics normal eating patterns.
for alert and active patients, bolus feeding can allow them to
r Further research is required to determine whether in-
live a relatively normal life, because of shorter feeding time termittent or bolus feeding is beneficial for critically
and freedom from mechanical devices between feedings. ill patients.
Ichimaru 5

Statement of Authorship 16. Declercq B, Deane AM, Wang M, Chapman MJ, Heyland DK.
Enhanced Protein-Energy Provision via the Enteral Route Feeding
S. Ichimaru contributed to conception/design of the manu-
(PEPuP) protocol in critically ill surgical patients: a multicentre
script; S. Ichimaru contributed to acquisition, analysis, or prospective evaluation. Anaesth Intensive Care. 2016;44:93-98.
interpretation of the data; S. Ichimaru drafted the manuscript; 17. Bonten MJ, Gaillard CA, van der Hulst R, et al. Intermittent enteral
S. Ichimaru critically revised the manuscript; S. Ichimaru agrees feeding: the influence on respiratory and digestive tract colonization in
to be fully accountable for ensuring the integrity and accuracy mechanically ventilated intensive-care-unit patients. Am J Respir Crit
of the work; and S. Ichimaru read and approved the final Care Med. 1996;154:394-399.
manuscript. 18. Tamowicz B, Mikstacki A, Grzymislawski M. The influence of
the Feeding Therapy Model on pulmonary complications in pa-
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