Bolus versus continuous nasogastric feeding for infants hospitalised with bronchiolitis: a randomised clinical trial

Bolus versus continuous nasogastric feeding for infants hospitalised with bronchiolitis: a randomised clinical trial

Background: Viral bronchiolitis is the leading reason for hospitalisation in infants with around 13, 500 children admitted to hospital with bronchiolitis each year in Australia. Nasogastric feeding is the preferred method for their fluid supplementation. Infants with moderate to severe respiratory distress are commonly commenced on continuous nasogastric feeds to potentially decrease splinting of the diaphragm. No published evidence could be found to support this anecdotal practice. Guidelines are inconsistent as evidence is lacking for either bolus or continuous regimens, with practices being largely based on physician or institution preference.

Aims: To determine whether continuous nasogastric feeding prolongs length of stay (LOS) for infants admitted with bronchiolitis when compared to bolus nasogastric feeds. Secondary objectives were to determine whether bolus nasogastric feeding was associated with an increased risk of pulmonary aspiration or number of paediatric intensive care admissions.

Methods: This randomised, open, parallel-group, superiority clinical trial recruited throughout two bronchiolitis seasons from May 2018 to October 2019. Infants less than 12 months corrected age hospitalised with bronchiolitis and requiring supplemental nasogastric feeding were recruited from a children's hospital providing quaternary care in Australia. Patients were randomly assigned to continuous or bolus nasogastric feeding regimens.

LOS measured in hours was the primary outcome measure, with a clinically significant difference defined as 24 hours. Secondary outcome measures included the adverse event of pulmonary aspiration and rate of escalation of care by admission to the paediatric intensive care unit (PICU).

Descriptive statistics were presented for continuous data using mean and standard deviation or median and inter-quartile range (IQR) if data were not-normally distributed. Differences in demographics and baseline clinical characteristics were assessed between groups using a Mann-Whitney test for age and Chi-square test (or Fisher's exact test, where appropriate) for all other categorical data. To assess the efficacy of bolus feeding compared to continuous nasogastric feeding for length of stay, the groups were compared using a non-parametric Mann-Whitney test. LOS was analysed using the Kaplan-Meier method and compared between groups using a log-rank test where appropriate.

Results: 242 patients were assessed for eligibility; 189 patients were included in the intention to treat analysis (98 in the bolus group and 91 in the continuous group). There was no significant difference in LOS between the bolus or continuous nasogastric feeding arms in the intention-to-treat analysis (median LOS of the bolus group was 54.25 hours [inter-quartile range [IQR] 40.25 – 82 hours] and 56 hours [IQR 38 – 78.75] in the continuous group). There was a higher proportion of admissions to PICU in the continuous nasogastric feeding group (28.57% [26/91] of the continuous group versus 11.22% [11/98] of the bolus group). There were no pulmonary aspirations. There was no significant difference between groups in vital signs within six hours of allocated feed initiation.

Conclusions and Relevance: Bolus and continuous nasogastric feeding regimens for fluid supplementation are clinically equivalent in infants hospitalised with bronchiolitis. There was no significant difference in LOS or aspiration events however a higher proportion of PICU admissions was noted in the continuous feeding group.

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