Routine Gastric Residual Checks In Critically Ill Children

Key Takeaways

• No routine assessment was noninferior for survival and days free of mechanical ventilation at 30 days in the randomized comparison.
• Early nutrition delivery was modestly higher, and time with no enteral feed was shorter, in the group without routine assessment.
• Vomiting-related feed stoppage, target calorie or protein timing, NEC in infants younger than 12 months, ventilator-associated pneumonia, other healthcare-acquired infections, and length of stay were similar, and 3 serious adverse events were reported overall.

Among ventilated children receiving enteral feeds, a multicenter randomized trial compared no routine gastric residual volume assessment with usual care that included checks at least every 6 hours. Energy attainment at 72 hours was 80.3% without routine checks and 76.8% with usual care, for an adjusted mean difference of 3.24 percentage points. The clinical co-primary outcome was also noninferior at 30 days in this 4700-child trial across 23 UK pediatric intensive care units and 1 Swiss site.

Investigators conducted a pragmatic, unblinded, multicenter, parallel-group, noninferiority randomized clinical trial across 23 UK pediatric intensive care units and 1 site in Switzerland. The trial enrolled 4700 children aged 0 to 16 years who were receiving invasive ventilation and starting enteral feeds. Children were assigned 1:1 to no routine assessment guided by clinical signs alone or to usual care with gastric residual volume checks at least every 6 hours. Enteral feeding otherwise followed local protocols, and staff in the no-routine group could still assess residuals before procedures, with vomiting, or during clinical deterioration. Co-primary outcomes were survival and days free of ventilation at 30 days and estimated energy attainment by 72 hours.

For the clinical co-primary outcome of survival and days free of ventilation at 30 days, both groups had a median of 25 days, and the adjusted OR was 0.95 (95% CI, 0.86-1.05), meeting noninferiority. By 72 hours, energy attainment averaged 80.3% without routine assessment and 76.8% with usual care, a 3.24-point adjusted mean difference (95% CI, 1.29-5.19; P < .001). Time with no enteral feed was 20.7 versus 22.7 hours, a -1.7-hour adjusted difference (95% CI, -3.1 to -0.4; P < .001), and feed stoppage due to gastric residual volume assessment was 4.0% versus 19.3%.

No significant between-group differences were seen for vomiting leading to feed stoppage, target calorie or protein timing, necrotizing enterocolitis in infants younger than 12 months, ventilator-associated pneumonia, other healthcare-acquired infections, or length of stay. Vomiting-related stoppage occurred in 10.2% versus 9.0%, and necrotizing enterocolitis in infants younger than 12 months in 2.6% versus 2.5%.

Three serious adverse events were reported overall: ischemic colitis and transverse colon perforation in the no-routine group, and cecal perforation with usual care.