Enteral Feeding Via Nasogastric Tube .16

Enteral Feeding via Nasogastric Tube.
Effectiveness of continuous versus intermittent administration for

greater tolerance in adult patients in Intensive Care
Enteral Feeding via Nasogastric Tube.

Effectiveness of continuous versus
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intermittent administration for greater

tolerance in adult patients in Intensive
Care
PROTOCOL
The Spanish Centre for Evidence Based Nursing: Collaborating Centre of the Joanna Briggs
Institute
Enteral Feeding via Nasogastric Tube. Effectiveness of continuous versus intermittent administration for
Review title
Enteral Feeding via Nasogastric Tube. Effectiveness of continuous versus intermittent
administration for greater tolerance in adult patients in Intensive Care: A systematic review
Conductive Centre of the Revision

The Spanish Centre for Evidence Based Nursing: Collaborating Centre of the Joanna Briggs
Institute
Review Authors
a
Aguilera-Martínez, Rosa . RN, M Sc. Cuidados Intensivos. Hospital Universitario de Sant Joan
d'Alacant.
a
Ramis-Ortega, Emília . RN, M Sc. Endocrinología y Nutrición. Hospital Universitario de Sant
Joan d'Alacant.
a
Carratalá-Munuera, Concha . RN, MSc, PhD. Universidad Miguel Hernández. Campus de San
Juan.
a
Fernández-Medina, José Manuel . RN. Urgencias. Hospital de Manacor.
a
Saiz-Vinuesa, Mª Dolores RN. Cuidados Intensivos. Hospital Universitario de Albacete.
a
Barrado-Narvión, Mª Jesús . RN, M Sc. Cuidados Intensivos. Hospital Royo Villanova de
Zaragoza.
a. The Spanish Centre for Evidence Based Nursing: Collaborating Centre of the Joanna Briggs
Institute.
Contact for Review

Name: Aguilera-Martínez, Rosa
Phone: + 34649092389
Fax:
Email: rosa_aguileram@hotmail.com
Commencement date: March 2011

Expected Completion date: February 2012
Review Questions/Objectives
The Review objective is to synthesise the best available evidence on the effectiveness of
continuous versus intermittent enteral feeding in adult patients with nasogastric tube admitted to
the ICU, in respect to their nutritional status, digestive tolerance and complications
Background
Nutrition via enteral tube in adults suffering from a critical condition is a controversial topic due
to the great variability in nutritional support in different Intensive Care Units (ICUs) and in the
performance of registered nurses. Studies researching nursing care have not reached a conclusion
about which is the optimal way to administer enteral feeding 1-7 (EF).
In our clinical practice, we find critically ill patients that often need parenteral or enteral feeding
due to the impossibility of feeding them orally 8-10.
Nowadays, evidence shows that, when possible, EF via nasogastric tube should be first choice
versus parenteral feeding, in critically ill patients with preserved digestive function that are
unable to be fed orally 1,2,5,6,10.
Parenteral feeding should only be used in situations where the digestive tract is not working or
4,8,9
when the enteral route would not cover all the nutritional requirements of the patient .
Nevertheless, the multi-pathological situation of these patients, their treatments and the multiple
complications associated with EF lead us to slow down or even suspend their programmed
feeding supply, thus their clinical condition deteriorates 7,9, 10,11.
EF hast two main aims. The first one is to meet nutritional needs and the second one is to
preserve the intestinal barrier and prevent infectious complications resulting from a bacterial
translocation. Many clinical studies have suggested that EF preserves the structure and function
of the gastrointestinal mucosa by maintaining its barrier effect, preventing or reducing bacterial
translocation, diminishing the catabolic response and reducing the rate of infection in critically
ill patients 9-15.
The optimal time, after the patient’s admission, for starting EF has not been clearly established,
although EF is considered early if applied within the first 48 hours. Early EF plays an important
role in caring for these patients to ensure optimal recovery 2,4, 9-15.
The nasogastric tube is the most used way for administering EF to critically ill patients because
of its easier and physiological access 10,12.
However, in these patients, feeding via nasogastric tube is accompanied by numerous treatments,
difficult clinical situations, as well as their underlying condition. All this can have an adverse
effect on gastrointestinal motility, though it is difficult to assess which factor by itself is
contributing to each of the complications. The few studies that have addressed this problem have
not been able to pinpoint the actual weight of each of these factors because of the complexity of
these patients 9-15.
In intensive care units (ICUs), continuous EF is the most widely used method for administering
EF (once every 24 hours) and is recommended in clinical practice guidelines that are based on
1-4
systematic reviews and in other guides that are based on the advice of experts, such as the
16,17
one of the Spanish Society of Parenteral and Enteral Nutrition . Whilst the discontinuous,
intermittent or bolus administration, which apparently follows a more physiological pattern, is
discarded because it is attributed poor tolerance and increased frequency of bronchoaspiration.
However, studies published in this regard do not conclude that continuous administration system
is better than intermittent18-24.
The most frequent gastrointestinal complications include increased gastric residue, constipation,
abdominal distension, vomiting and regurgitation.
19
According to a narrative review by Wiesen et al , diarrhoea in critically ill patients is less
associated with continuous that with intermittent administration, and interrupting enteral feeding
during diarrhoea is not justified. It is advisable to treat the diarrhoea, as well as using high-fibre
nutrition and administer prebiotics and probiotics as a novel treatment which has yet been little
studied 13-15,19,25.
Chen et al 20, of the Taipei Veterans General Hospital Nursing Department, in Taiwan, conducted
a randomized clinical trial which compares intermittent versus continuous EF. A total of 107
participants were randomly assigned to receive continuous (51 patients) or intermittent (56
patients) EF. Gastric emptying and pulmonary aspiration were analysed during the first 7 days,
presenting a lower risk of aspiration pneumonia in the group of intermittent EF (OR: 0.146, CI
95%: 0.062-0.413 p 0.000)), this group also had a higher volume of nutrients on the seventh day
and were extubated on day 21 (p =0.002). Patients treated with high doses of dopamine were
almost 3 times (OR: 2.95) more likely to develop aspiration pneumonia than those receiving a
low dose of dopamine, (CI 95%: 1.076-8.107, p= 0.035), regardless of the form of
administration of EF. There were no significant differences in the length of hospital stay between
the two groups 20.
A randomized clinical trial conducted by MacLeadet al 22 with 164 patients of over 18 years age
admitted to the ICU, analysed the effectiveness of continuous versus intermittent EF, through a
strict protocol. The outcome variables were nutritional volume, and number of days to reach
100% of the caloric needs in the first 10 days of their stay in ICU. The results show no
significant differences in the complications of EF and emphasise that patients in the intermittent
group reached more quickly (by the seventh day), the objectives described above, than patients
with continuous EF. ( χ 2 = 6.01, p= 0.01).
Existing studies on EF study different types of intervention and focus on ways to reduce
22
gastrointestinal complications, bronchoaspiration and how to reach the nutritional goal .
Increased gastric residuals, vomiting and regurgitation increase the risk of bronchoaspiration.
13,14,22,26,27
.
Today, studies are trying to define a wider volume of gastric residue, with the aim of increasing
the patients’ nutritional supply without increasing the risk of bronchoaspiration 13, 14-23,26,27.
There are studies comparing 3,12,21 enteral with parenteral nutrition as well as the different access
10,12-15 1-
routes for EF and the use of prokinetic agents to improve gastrointestinal tolerance
3,11,13,15 15,21,28,29
. Other studies analyse transpyloric versus gastric administration and whether
complications resulting from an increased gastric residue can be reduced through EF by
1,27,28,29
transpyloric tube . However, placing and caring for these tubes is more complex and the
results, when it comes to an increase of calorie supply, are not conclusive 28,29.
A meta-analysis conducted by Heyland et al 3, analysed eleven studies comparing gastric versus

post-pyloric nutrition and the results, in those that refer to the nutritional requirements
administrated, emphasize a major nutritional contribution in the group fed post-pylorically.
28
To the contrary, Marik et al , in another meta-analysis, found no differences in energy intake
between the post-pyloric and the gastric nutrition group (RR 5.22; 95% CI; 7,53-17,97; p=0,4).
Transpyloric access for EF remains controversial. Therefore, only in cases of previously proven
gastric intolerance or due to a pathology that prevents feeding through the stomach or when there
are several risk factors for intolerance (mechanical ventilation, deep sedation, muscle relaxation,
high doses of pressor amines) should feeding begin with the transpyloric tube 15.
Numerous studies have analysed early versus late EF, and parenteral feeding as support to EF 1-
3,13-15,21,25
.
The form of nutritional intervention in ICU patients will depend on their clinical situation and is
geared to prevent nutritional deficiencies, avoid complications related to administering nutrition
and reduce disruption, in order to produce faster recoveries, fewer hospital and ICU stays and,
possibly, a lower morbidity-mortality rate 1-4,6,10.
Currently, there are many primary studies, using small samples of patients to analyse which
method of EF is more effective, but do not provide sufficient evidence of which one is better,
continuous or intermittent, nor of the advantages or disadvantages each one. This favours
variability in their use by health professionals, although, in most studies, the trend is to favour
continuous EF.
Given this situation, it is considered necessary to conduct a systematic review to assess the
effectiveness of continuous versus intermittent enteral feeding in adult patients admitted to the
ICU, in order to obtain results that facilitate decision making for nursing professionals.
We performed a search of Cochrane Library of Systematic Reviews, JBI Library of Systematic

Reviews, CRD DARE database and Medline and no existing systematic review (completed or in
progress) or existing systematic review protocols to assess the effectiveness of continuous versus
intermittent enteral feeding in adult patients admitted to the ICU was identified.
For the purpose of this systematic review we’ll use the following definitions:
Intensive Care Unit (ICU) refers to hospital units providing continuous surveillance and care to
acutely ill patients.
Continuous enteral feeding is defined as administering nutrition through gravity systems or

infusion pumps, without interruption, for a minimum period of twelve hours a day.
Intermittent enteral feeding is defined as non continuous administration of nutrition that can be
done through: bowls, gravity systems or infusion pumps, repeating the operation several times a
day, depending on the total volume to infuse.
A nasogastric tube is a tube that is inserted through the nose until it reaches the stomach and
which allows the administration of enteral nutrition directly to the gastric cavity.
Patient’s nutritional status is the balance of the nutrient intake and requirements.
Digestive tolerance is defined as the capacity of the digestive system for digesting food.
Bronchoaspiration refers to the inhalation of oropharyngeal or gastric contents into the lower
respiratory tract.
Length of hospital stay is expressed/measures as number of days in the hospital from admission
till discharge or death.
Length of intensive care unit ICU stay refers to refers to number of days in the ICU, from
admission till discharge from the ICU or death.
Duration of enteral feeding is the period of time from the first EF administration to the last EF
administration, due to the completion of the treatment or cessation because of complications.
Inclusion Criteria
Types of participants
Patients of nineteen years of age or more, carrying a nasogastric tube, enteral feeding recipients
and who were admitted to an intensive care unit, with either a medical or a surgical pathology,
and that received enteral feeding during their stay in the Intensive Care Unit.
Types of interventions
Intervention: Continuous enteral feeding.
Comparator: Intermittent enteral feeding.
Types of outcomes
Studies must include at least one of the following primary outcomes:
Primary outcome:
1.-Patient’s nutritional status.

2.-Digestive tolerance.
3.-Bronchoaspiration.
The following secondary outcomes, will also be considered:
1. Start day and duration of enteral feeding.

2. Length of hospital stay and ICU stay.

3. Causes of interruption of enteral feeding because of complications.
Types of studies
Randomised clinical trials, clinical trials without randomization and before and after studies that
compared continuous versus intermittent enteral feeding.
Search strategy
The search aims to identify both unpublished and published studies written in Spanish, Catalan,
English, French, Portuguese and Italian languages, published from database inception until 2011.
Searches will be conducted in both Spanish and English separately, depending on the database
language, by each component of PICO format (Population, Intervention, Comparison, Outcome)
and then combined using Boolean operators.
An electronic systematic search will be conducted in the following databases:
• Cochrane Library (Cochrane Central Register of Controlled Trials, CENTRAL); 1996 to

2011
• MEDLINE; from 1966 to January 2011
• EMBASE; from 1974 to January 2011
• AMED (Allied and Alternative Medicine Database); from 1985 to January 2011
• CINAHL (Cumulative Index to Nursing and Allied Health Literature); from 1982 to
January 2011
• Database DARE Centre for Reviews and Dissemination; from 1996 to January 2011
• National Research Register; from 1998 to January2011
• Cuiden: Index de enfermería; from 1987 to January 2011
• Lilacs, Base de datos Latinoamericana; from 1982 to January 2011
• IME, Índice Medico Español; from 1970 to January 2011
The search for grey literature will be conducted in:
• Google Scholar
• OpenSIGLE (System for Information on Grey Literature in Europe)
• Database for Spanish Dissertations: TESEO, from 1976 to January 2011.
• Dissertation Abstracts International

• Proceedings First Database
• National Library of Medicine Gateway
• Grey Literature Report (through New York Academy of Medicine website)
• AHRQ: Agency for Health Care Research and Quality
• CURRENT CONTENTS
• EXPANDED ACADEMIC INDEX
Will include papers presented at conferences and seminars sponsored by scientific societies of
intensive care and nutrition: Sociedad Española de Medicina Intensiva, Crítica y Unidades
Coronarias (SMICYUC), Sociedad Española de Nutrición Parenteral y Enteral (SENPE), FC:
Metabolismo y Nutrición y American Society for Parenteral and Enteral Nutrition (ASPEN). If
necessary experts will be contacted.
A manual search will be conducted in the Journals that are most specialised in the topic of this
review:
• Nutrición Hospitalaria
• FC: Metabolismo y Nutrición
• Journal Parenteral and Enteral Nutrition
• Nutrition in Clinical Practice
• Critical Care Medicine
• Nutrition Journal
Both controlled and natural languages will be used, through the most relevant descriptors for
each of the databases searched. A methodological filter will be used for each database used in
this review.
MeSH terms will be adapted and combined according to the rules of each database.
Descriptors or key words (MesH):
• Enteral Nutrition
• Nutrition status
• Critical care
• Critical Illness
• Feeding Methods
• (Continuous next feeding) AND (Intermittent OR bolus).
Two reviewers will carry out an independent and blind eligibility check of the title and abstract
using the eligibility check list described in Appendix I; where it is not clear there will be
necessary to follow the same process with the full article. Disagreements will be resolved by
consensus with a third reviewer. Duplicate works will be excluded.
Assessment of methodological quality
Selected articles will be evaluated by two independent reviewers.
The methodological quality will be assessed using the standardised criteria for critical appraisal
of the Joanna Briggs Institutes Meta Analysis of Statistics Assessment and Review Instrument
for experimental studies (JBI-MAStARI) (Appendix II).
Studies will be classified, according to their quality, as high, medium and low methodological
quality. Studies of low methodological quality will be taken into account separately in the
analysis.
Disagreement between reviewers will be resolved by discussion; when no agreement is reached

there will be resorting to a blind third reviewer.
Data Collection
Data will be extracted by two independent and blinded reviewers to assess whether they reach
the same results. Data will be extracted from the articles included in the review using a data
extraction standardized tool JBI-MASTARI (Appendix III) to reduce extraction error. The data
extracted will include specific details about the interventions, populations, study methods and
outcomes of significance to the review question and specific objectives.
Data Synthesis
Quantitative papers will, where possible, be pooled in statistical meta-analysis using JBI-
MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio
(for categorical data) and weighted mean differences (for continuous data) and their 95%
confidence intervals will be calculated for analysis modify text as appropriate. Heterogeneity
will be assessed statistically using the standard Chi-square, with statistical significance if p<0.05;
because the low power of the test to detect heterogeneity the I2 index will also be used,
considering the values of 0%, 25%, 50% and 75% as none, low, moderate and high
heterogeneity. If Studies are heterogeneous, data will be pooled with using an aleatory effect
model.
If possible, subgroups analysis will be conducted (studies with common features) according to
primary and secondary outcomes.
The presence of publication bias will be assessed through funnel plot analysis.
Where statistical pooling is not possible the findings will be presented in narrative form
including tables and figures to aid in data presentation where appropriate.
Acknowledgements
To the following nurses:
Mª Dolores Espinosa Pérez. RN, MSc, Educación Terapéutica en Endocrino y Nutrición

Hospital Universitario de Sant Joan d’Alacant.
Raquel Ramírez Guillem. RN, MSc, Cuidados Intensivos. Hospital Universitario de Sant Joan
d'Alacant.
Esther Santoro Sánchez. RN, MSc, Atención Primaria Centro de Salud Muchamiel (Alicante).
Conflict of interest
Authors declare no conflicts of interest in the review conducted.
References
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ill adults: part I Intensive Crit Care Nurs. 2004;20:330-343.
2. Williams TA, Leslie GD. A review of the nursing care of enteral feeding tubes in critically
ill adults: part II Intensive Crit Care Nurs.2005;21:5-15.
3. Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P. Canadian clinical practice
guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN
J Parenter Enteral Nutr. 2003 Sep-Oct;27(5):355-73.
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practice guidelines for nutrition support in mechanically ventilated, critically ill adult
patients: results of a prospective observational study. Crit Care Med. 2004
Nov;32(11):2260-6.
5. Marshall AP, West SH. Enteral feeding in the critically ill: Are nursing practices
contributing to hypocaloric feeding? Intensive Crit Care Nurs 2006;22:95-105.
6. Marshall A, West S. Nutritional intake in the critically ill: improving practice through
research. Aust Crit Care. 2004 February;17(1):6-15.
7. Quenot JP, Plantefeve G, Baudel JL, Camilatto I, Bertholet E, Cailliod R, Reignier J, Rigaud
JP. Bedside adherence to clinical practice guidelines for enteral nutrition in critically ill
patients receiving mechanical ventilation: a prospective, multi-centre, observational study.
Crit Care. 2010;14:R37.
8. Ortiz Leyba C, Montejo Gonzalez JC, Jiménez Jiménez FJ, Lopez Martinez J, García de
Lorenzo y Mateos A, Grau Carmona T, Acosta Escribano J, Mesejo Arizmendi A,
Fernandez Ortega F, Ordoñez Gonzalez FJ, Bonet Saris A, Blesa Malpica A; Grupo de
Trabajo de Metabolismo y Nutricion de la SEMICYUC. [Recommendations for nutritional
assessment and specialized nutritional support of critically ill patients]. Nutr Hosp. 2005
Jun;20 Suppl 2:1-3.
9. Webster NR, Galley HF. Nutrition in the critically ill patient. J R Coll Surg Edinb. 2000
Dec;45(6):373-9.
10. Álvarez Hernández J, Peláez Torres N, Muñoz Jiménez A. Utilización clínica de la
Nutrición Enteral. Nutr Hosp. 2006;21:87-99.
11. Ilari S. Nutrición en el paciente crítico. Causas de la inadecuación entre lo indicado y lo
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http://revistas.um.es/eglobal/article/view/464/447.
12. García de Lorenzo y Mateos A, Acosta Escribano J, Rodríguez Montes JA. Importancia
clínica de la translocación bacteriana. Nutr Hosp. 2007;22:49-54.
13. Montejo González JC, Estébanez Montiel B. Complicaciones gastrointestinales en el
paciente crítico. Nutr Hosp. 2007;22(Supl. 2):56-62.
14. Montejo JC. Enteral nutrition-related gastrointestinal complications in critically ill patients.
A multicenter study. The Nutritional and Metabolic Working Group of the Spanish Society
of Intensive Care Medicine and Coronary Units. Crit Care Med. 1999;27:1447-53.
15. Mesejo A, Juan M, García-Simón M. Enteral access and intestinal function assessment in
the critically ill patient. Nutr Hosp. 2007 May;22 (Suppl 2):37-49.
16. Sociedad Española de Nutrición Parenteral y Enteral (SENPE). Protocolos para la
prescripción de Nutrición Parenteral y Enteral. 1998; 2-A-EP:12-32.
prescripción de Nutrición Parenteral y Enteral. 1998; 2-B-C-EP:1-41.
18. Hiebert JM, Brown A, Anderson RG, Halfacre S, Rodeheaver GT, Edlich RF. Comparison
of continuous vs intermittent tube feedings in adult burn patients JPEN Nutr parenteral
enteral J. 1981 Jan-Feb;5(1):73-5.
19. Wiesen P, Van Gossum A, Preiser JC. Diarrhoea in the critically ill. Curr Opin Crit Care.
2006 Apr;12(2):149-54.
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preventing aspiration pneumonia in ventilated critically ill patients. J Nurs Res. 2006
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Prospective randomized control trial of intermittent versus continuous gastric feeds for
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Appendices
Appendix I
Eligibility Check list

Study Identification: ________________________ Language:___________________
Record number:_________________________ Year of publication:_________________
Títle: ___________________________________________________________________
Authors: _______________________________________________________________
Complete reference:
 INCLUSION CRITERIA*
1. Type of study:
a. Randomized clinical trials: YES / NO
b. Clinical trials without randomization: YES / NO
c. Before and After study: YES / NO
2. Type of intervention:
Continuous enteral feeding vs Intermittent enteral feeding: YES/ NO
3. Participants:
ICU patients; YES / NO
Nineteen years of age or more: YES / NO
4. Outcome measures:
a. 1.-Patient’s nutritional status.

b. 2.-Digestive tolerance.
c. 3.-Bronchoaspiration.
* Exclude the study if criteria 1, 2, 3 and 4 are not fulfillled. Specify the reason for exclusion
Selected_____________________ Excluded____________________________
Reviewer 1_________________________ Date _____________________

Reviewer 2_________________________ Date _____________________
Reviewer 3**_________________________ Date _____________________
** Only if disagreement between reviewers.

Appendix II
JBI Critical Appraisal Form for experimental studies
Reviewer_________________ Date____________________
Author____________ Year____________
Record Number__________________
Was the assignment to treatment groups truly random?

Yes No Unclear
Were participants blinded to treatment allocation?
Yes No Unclear
Was allocation to treatment groups concealed from the allocator?
Yes No Unclear
Were the outcomes of people who withdrew described and included in the analysis?
Yes No Unclear
Were those assessing outcomes blind to the treatment allocation?
Yes No Unclear
Were the control and treatment groups comparable at entry?
Yes No Unclear
Were groups treated identically other than for the named interventions?
Yes No Unclear
Were outcomes measured in the same way for all groups?
Yes No Unclear
Were outcomes measured in a reliable way?
Yes No Unclear
Was appropriate statistical analysis used?
Yes No Unclear
Overall appraisal: Include ___ Exclude ___ Seek further info ___
Comments (Including reasons for exclusion)

________________________________________________________________
________________________________________________________________
________________________________________________________________
Appendix III
JBI Data extraction Form for Experimental/Observational studies
Author/s __________________________________________Year ___________
Journal _________________________________________________________
Title____________________________________________________________
Record Number/Article Reference No: ________________________
Reviewer: _________________________________
Study design: _____________________________________________________
Setting __________________________________________________________
Total Participants
Intervention 1 Intervention 2 Control or placebo
Outcome Measure 1
Outcome Measure 2
Outcome Measure 3
Outcome Measure 4
Outcome Measure 5
Dichotomous Data
Outcome Intervention 1 Intervention 2 Control or placebo P value
Number/ Number/ Number/

total number total numer total number
________________________________________________________________
Continuous Data
Outcome Intervention 1 Intervention 2 Control or placebo P value
Mean & SD Mean & SD Mean & SD

(n) (n) (n)
________________________________________________________________
Authors Conclusion
________________________________________________________________
Reviewer’s conclusion
________________________________________________________________

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Enteral Feeding via Nasogastric Tube.

Effectiveness of continuous versus intermittent administration for

Enteral Feeding via Nasogastric Tube.

intermittent administration for greater

Conductive Centre of the Revision

Contact for Review

Commencement date: March 2011

A meta-analysis conducted by Heyland et al 3, analysed eleven studies comparing gastric versus

We performed a search of Cochrane Library of Systematic Reviews, JBI Library of Systematic

Continuous enteral feeding is defined as administering nutrition through gravity systems or

Intervention: Continuous enteral feeding.

Comparator: Intermittent enteral feeding.

Studies must include at least one of the following primary outcomes:

1.-Patient’s nutritional status.

The following secondary outcomes, will also be considered:

1. Start day and duration of enteral feeding.

2. Length of hospital stay and ICU stay.

An electronic systematic search will be conducted in the following databases:

• Cochrane Library (Cochrane Central Register of Controlled Trials, CENTRAL); 1996 to

The search for grey literature will be conducted in:

• Dissertation Abstracts International

Descriptors or key words (MesH):

• (Continuous next feeding) AND (Intermittent OR bolus).

Assessment of methodological quality

Selected articles will be evaluated by two independent reviewers.

Disagreement between reviewers will be resolved by discussion; when no agreement is reached

Mª Dolores Espinosa Pérez. RN, MSc, Educación Terapéutica en Endocrino y Nutrición

Eligibility Check list

Continuous enteral feeding vs Intermittent enteral feeding: YES/ NO

a. 1.-Patient’s nutritional status.

Reviewer 1_________________________ Date _____________________

** Only if disagreement between reviewers.

JBI Critical Appraisal Form for experimental studies

Was the assignment to treatment groups truly random?

Comments (Including reasons for exclusion)

JBI Data extraction Form for Experimental/Observational studies

Author/s __________________________________________Year ___________

Record Number/Article Reference No: ________________________

Study design: _____________________________________________________

Intervention 1 Intervention 2 Control or placebo

Outcome Intervention 1 Intervention 2 Control or placebo P value

Number/ Number/ Number/

Outcome Intervention 1 Intervention 2 Control or placebo P value

Mean & SD Mean & SD Mean & SD

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Reviewer 1_____ Date _

Author/s ________________________________Year _