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, Cyclic, Intermittent, 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
through the gastrointestinal (GI) tract via a tube, catheter,
or stoma that delivers nutrients distal to the oral cavity.1
The modes of EN administration include continuous, cyclic,
intermittent, and bolus techniques, which can be used either
alone or in combination. To determine the most appropriate
method of administration, the clinician should consider
numerous factors such as patient’s age, preexisting and
current medical condition, nutrition status and requirement,
enteral route for feeding (gastric vs small bowel), GI tol-
erance, formula type used, patient mobility, feeding pump
availability, and cost. Continuous feeding seems to be the
standard in the intensive care unit (ICU)2 ; however, there
is currently insufficient data to choose the best method
to improve patient outcomes of critically ill patients. This
narrative review summarizes EN administration methods,
their advantages and disadvantages, and the indications of
intermittent and/or bolus feeding in critically ill patients.
Methods of EN Administration
The 4 methods of EN administration include continu-
ous, cyclic, intermittent, and bolus feedings as shown in
Figure 1.3
Continuous feeding provides EN by electric enteral feeding
pump over 24 hours, which is generally initiated at a rate of
20–50 mL/h and advanced to goal rate by 10–25 mL/h every
4–24 hours.4 This method is selected for patients who are
critically ill, who have been intubated for respiratory failure,
who are fed through a postpyloric tube, or who cannot
tolerate intermittent or bolus feedings.5
Although continuous feeding is preferred by most ICUs,
it is supported by only a few relatively outdated studies.
A study on 76 adult burn patients reported that patients
who received continuous feeding had lower stool frequency
From the Department of Nutrition Management, Osaka Saiseikai
Nakatsu Hospital, Osaka, Japan.
This article was modified on 2018-06-25 after initial online publication
to correct the article title and to make some other editing changes.
Financial disclosure: None declared.
Conflicts of interest: None declared.
This article originally appeared online on xxxx 0, 0000.
Corresponding Author:
Satomi Ichimaru, PhD, RD, CNSC, Department of Nutrition
Management, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata
Kitaku, Osaka 530-0012, Japan.
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)
and reached their nutrition goals sooner than those who
received bolus feeding.6 In adult patients with neurological
impairment who received continuous feeding, aspiration
was observed less frequently (1/17) than in those who
received intermittent feeding (3/17).7 In a study of 18
postoperative patients, continuous feeding groups showed
improved cumulative nitrogen balance for 5 days compared
with cyclic feeding groups.8 Whether continuous feeding
provides better glycemic control than intermittent/bolus
feeding remains controversial.9-11
Continuous feeding is frequently interrupted in the
ICU.12 The most common reasons for discontinuation of
feeding include surgery (27%) and diagnostic procedures
(15%), and minor reasons for EN interruptions include
mechanical feeding tube problems (8%), pharmacy delivery
delay (4%), and miscellaneous factors (3%). Because of the
frequency with which enteral feeds are interrupted, resulting
in delivery of only 50%–60% of prescribed EN volume on a
daily basis,13 some institutions have implemented a volume-
based feeding protocol to ensure that the volume of EN
prescribed to their patients is actually provided.14-16
Cyclic Feeding
Cyclic feeding involves feeding by electric enteral feeding
pump over a period of <24 hours, in which the goal infusion
rate is determined by dividing the desired formula volume
by the number of hours of administration. The infusion
time may vary between 24 and 8 h/day depending on the
patient’s volume tolerance. This method can be used for
patients with feeding tubes terminating in the stomach or
small bowel. During the course of recovery, patients may
transition from the continuous feeding to nocturnal cyclic
feeding to stimulate patient’s appetite during the day. It also
increases patients’ mobility by freeing them from a feeding
set or pump.5
Bonten et al17 and Tamowicz et al18 hypothesized
that cyclic feeding beneficially affected gastric acidity and
bacterial colonization of the stomach and respiratory tract,
thereby helping to prevent ventilator-associated pneumonia
(VAP). In these studies, a significant decrease in gastric
pH was observed when EN was discontinued in the cyclic
feeding groups. However, only the study by Tamowicz
et al18 showed reduced rate of gastric colonization, and the
incidence of VAP was relatively similar between the cyclic
and continuous feeding groups in both studies.
With regard to mortality in the ICU, the cyclic and con-
tinuous feeding groups showed no significant differences.17
In 1 study, the length of hospital stay was found to be
significantly shorter in patients receiving cyclic feeding than
in those receiving continuous feeding.19
Intermittent Feeding
Intermittent EN feeding is usually delivered over 20–60
minutes by infusion pump or by the gravity drip method. In
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
drip feeding is tolerated when infused into the stomach.1 In
intermittent feeding, a volume of 240–720 mL of feeding is
administered 4–6 times per day depending on the patient’s
nutrition needs.5 This feeding method is more physiological
than continuous/cyclic feeding because it permits greater
patient mobility between feedings. If tolerated, the volume
of each feeding can be increased and the total number of
feeds can be decreased to improve quality of life.5 According
to old studies, intermittent feeding has been believed to
have some disadvantages, such as risk for aspiration7 and
diarrhea20 ; however, in a recent study of ICU patients
receiving intermittent or continuous feeding, there was no
difference in outcomes, including the rate of aspiration
Ichimaru
and diarrhea.21 In 1 study, intermittent and continuous
feeding groups of critically ill trauma patients showed no
significant differences in mortality in the ICU or incidence
of pneumonia.22 In 2 studies that compared intermittent
and 16-hour cyclic feeding in elderly patients, no significant
differences were noted between the groups in mortality,
incidence of diarrhea, or pneumonia.23,24
Bolus Feeding
Bolus feeding is administered via syringe or gravity drip
over a short period, usually 4–10 minutes. Generally, the
patient is fed a volume of 240 mL of feeding 3–6 times
daily.5 Feeding provided by this rapid infusion method may
result in diarrhea and/or aspiration.5,6,25 Therefore, bolus
feeding is usually reserved for the medically stable patients
with feeding tubes ending in the stomach.1 For patients with
a gastrostomy tube, not only commercial liquid formulas
but also blended food or viscosity-thickened formula can
be administered in the bolus feeding.26,27 One advantage
of bolus feeding is that medication can be separately ad-
ministered from feeding. Furthermore, this method closely
resembles normal eating patterns, increases the time away
from feeding, and provides freedom of movement and a
more normal life.
To the best of our knowledge, no study has evaluated
the outcomes of mortality or length of hospital stay be-
tween patients receiving bolus and continuous feeding. The
bolus feeding group showed improved nitrogen balance in
1 study,28 whereas the continuous feeding group showed
significantly improved body weight and arm circumference
in another study.29 Respiratory quotient, resting energy
expenditure, and blood sugar were comparable between
cyclic and bolus feedings in head-injured patients with
mechanical ventilation.30
Table 1 shows the advantages, disadvantages, and indica-
tions for each method.3
Potential Advantages of Intermittent/
Bolus Feeding: Muscle Protein Synthesis
and GI Hormone Secretion
In ICU patients, muscle breakdown often exceeds muscle
synthesis, and skeletal muscle wasting leads to functional
impairment in most survivors of critical illness.31-33 Insulin
and leucine enhance muscle protein synthesis (MPS) by
activating AKT/protein kinase B and the mammalian target
of rapamycin (mTOR).34-36 The continuous infusion of
amino acids for 30–60 minutes has been found to lead
to stimulated MPS; however, after 120 minutes, MPS was
found to have declined to baseline despite continuation
of the amino acid infusion.37 An oral whey protein bolus
has been found to cause a pulsatile release of insulin, a
pulsatile increase in intramuscular leucine concentration,
3
and an increase in the rate of MPS. MPS has been found
to peak at 90 minutes, decrease thereafter, and return to
baseline at 180 minutes.38 In a study using neonatal pigs,
significant increases in intramuscular AKT and mTOR, as
well as increased MPS, were observed with bolus compared
with continuous feeding.39
After the intake of a meal, several hormones, such as
glucagon-like peptide-1, gastric inhibitory peptide, chole-
cystokinin, ghrelin, and peptide YY, are secreted from the
enteroendocrine cells lining the lumen of the GI tract.
These hormones regulate GI motility, gallbladder con-
traction, pancreatic function, and nutrient absorption40 ;
most of these hormones are secreted within minutes of
feeding, rise transiently, and decline to basal levels after
feeding. In continuous tube feeding, this enterohormonal
response to nutrition is almost completely absent.41-44
Furthermore, bolus feeding may stimulate small-intestinal
growth. In a study using neonatal pigs, greater small-
intestinal mucosal weight and ileal protein mass have been
observed fed via bolus feeding compared with continuous
feeding.45
Although the studies introduced earlier are conducted
in non-ICU settings, we cannot deny the possibility that
those results may be applicable to ICU patients. Thus,
regarding MPS and GI hormone secretion, intermittent
or bolus feeding may be more beneficial than continuous
EN feeding for critically ill patients. Further randomized
controlled studies comparing continuous with intermittent
and bolus feeding are required to confirm this hypotheses.
Intermittent vs Bolus Feeding
Several studies have been conducted to compare the out-
comes of feeding methods in the ICU; however, to our
knowledge, no study has compared intermittent with bolus
feeding. One reason for this could be that pump-assisted
continuous feeding is generally considered acceptable for
patients in the ICU to prevent EN intolerance.2,46 Another
reason could be that intermittent and bolus feeding are often
treated as the same feeding method because of the lack of a
clear definition of them.
Currently, no clinical guidelines strongly recommend
a specific method of feeding for either critically ill or
stable patients. According to the Canadian Critical Care
Nutrition Guidelines in 2015, there are insufficient data to
make recommendations on whether EN should be given
continuously or via other methods in critically ill patients.47
The American guidelines of Nutrition Support Therapy
in the Adult Critically Ill Patient in 2016 suggest that
for high-risk patients or those intolerant to bolus gastric
EN, the delivery of EN should be switched to continuous
infusion.2 The National Institute for Health and Care
Excellence Clinical Guidelines recommend that EN should
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 Summary

required, continuous feeding over 24 hours is safe and more
practical.48 The major points of this review are summarized as follows:

r There are 4 methods of EN administration: continu-

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

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