CI: Timing of Enteral Nutrition (2006)


Yanagawa T, Bunn F, Roberts I, Wentz R, Pierro A. Nutritional support for head-injured patients (Cochrane Review). Cochrane Database Syst Rev. 2002; (3): CD001530. Review.

PubMed ID: 12137627
Study Design:
Meta-analysis or Systematic Review
M - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:
To determine the effect of timing (early vs. delayed) of nutrition support (enteral and parenteral) in patients suffering from acute traumatic brain injury.
Inclusion Criteria:
  • Randomized Clinical Control Trials (RCT) comparing early vs. delayed nutritional support
  • Trials containing patients of all ages suffering from acute traumatic brain injury of any severity were included.
Exclusion Criteria:
  • Trials other than RCT
  • Trials of patients not suffering from acute traumatic brain injury.
Description of Study Protocol:
  • Trials for this review were identified through computerized searches of the Injuries Group, specialized register, Cochrane Controlled Trials Register, MEDLINE, EMBASE and BIDS Index to Scientific and Technical Proceedings
  • Additional studies cited by researchers of trials identified through the computerized search were also included
  • Two independent reviewers reviewed the articles and scored them based on a quality scale used by Schulz; C being the poorest quality and A being the best.
Data Collection Summary:
  • Death and disability following care
  • Length of hospital stay (LOS)
    • Grahm (1989)
    • Minard (2000)
    • Taylor (1999)
  • Frequency of infections
    • Grahm (1989)
    • Hadley (1986)
    • Minard (2000)
    • Sacks (1995)
    • Taylor (1999)
    • Young (1987).

List of comparison reviewed in study:

  • Timing of intervention (early vs. delayed)
  • Route of intervention (parenteral vs. enteral)
  • Enteral nutrition (jejunal vs. gastric) [not reviewed in worksheet]
Description of Actual Data Sample:
  • Seven RCT dealing with timing of nutritional support (TPN and EN) in head-injured patients
  • 284 total patients included
  • Seven trials dealt with the route of nutritional support (N=222 patients)
  • Three of the trials were in both comparisons (early vs. late feeding) and TPN vs. EN.
Summary of Results:
  • Timing of nutritional support (early vs. delayed) parenteral and enteral combined
  • The RR for mortality with early support was 0.67 (95% CI 0.41-1.07). 
Length of Hospital Stay
  • Early enteral vs. delayed enteral
    • Grahm: Median length of ICU stay was seven days for early and 10 days for late feeding groups 
    • Minard: 19.3 days in earlyg roup vs. 11.7 in the lategroup 
    • Taylor: Early fed group was discharged earlier than the late, 30 days vs. 46.  
  • Early Enteral vs. Delayed Enteral
    • Grahm: Three patients had infections in the early group. Delayed group had 14 infections
    • Minard: Six patients developed pneumonia in the early group while seven did in the late group
    • Taylor: 44% of patientsdeveloped pneumonia in the early group, while 63% did in the late. 
  • Early TPN vs. Late Enteral Feeding
    • Hadley: TPN group had a total of 17 infections, the enteral group developed 15 infections
    • Young: TPN group 26.1% of patients developed UTI, and 26.1% developed pneumonia.  In the EN group 10.7% had sepsis, 25% had a UTI and 32.1% had pneumonia. 
  • Early TPN vs. Late TPN
    • Sacks: Early TPN three patients developed an infection, in the delayed group four patients developed an infection.
Author Conclusion:
  • Research supports that nutrition support initiated early after injury may result in a trend towards improved survival and reduced disability
  • The type of feeding employed influences timing of nutrition support. Trend towards improved survival and reduced disability with early support. The data from trials comparing parenteral and enteral feedings imply that there is a trend towards improved outcomes with parenteral feedings.
  • Two trials showed an increased trend with infections with TPN compared with EN 
  • Evidence is lacking, overall quality of most of the studies was poor
  • The majority of the articles reviewed were limited and had inadequate or unclear allocation concealment
  • Intention to treat was lacking in most trial.
Funding Source:
John Wiley & Sons
Foundation associated with industry:
Reviewer Comments:
  • Was not able to examine infection due to methodological differences in trails, not able to perform RR analysis
  • Review was adequately performed with two independent reviewers analyzing material
  • Reviewers report that Hadley article compares early TPN vs. delayed enteral feeding. In the Hadley study, researchers compared TPN to enteral feeding and both were started within 48 hours.     
Quality Criteria Checklist: Review Articles
Relevance Questions
  1. Will the answer if true, have a direct bearing on the health of patients? Yes
  2. Is the outcome or topic something that patients/clients/population groups would care about? Yes
  3. Is the problem addressed in the review one that is relevant to dietetics practice? Yes
  4. Will the information, if true, require a change in practice? Yes
Validity Questions
  1. Was the question for the review clearly focused and appropriate? Yes
  2. Was the search strategy used to locate relevant studies comprehensive? Were the databases searched and the search termsused described? Yes
  3. Were explicit methods used to select studies to include in the review? Were inclusion/exclusion criteria specified andappropriate? Wereselectionmethods unbiased? Yes
  4. Was there an appraisal of the quality and validity of studies included in the review? Were appraisal methodsspecified,appropriate, andreproducible? Yes
  5. Were specific treatments/interventions/exposures described? Were treatments similar enough to be combined? Yes
  6. Was the outcome of interest clearly indicated? Were other potential harms and benefits considered? Yes
  7. Were processes for data abstraction, synthesis, and analysis described? Were they applied consistently acrossstudies and groups? Was thereappropriate use of qualitative and/or quantitative synthesis? Was variation in findings among studies analyzed? Were heterogeneity issued considered? If data from studies were aggregated for meta-analysis, was the procedure described? Yes
  8. Are the results clearly presented in narrative and/or quantitative terms? If summary statistics are used, are levels ofsignificance and/or confidence intervals included? Yes
  9. Are conclusions supported by results with biases and limitations taken into consideration? Are limitations ofthe review identified anddiscussed? Yes
  10. Was bias due to the review's funding or sponsorship unlikely? Yes