3.1 Prevalence and Epidemiology
YP with ED requiring NG were often medically unstable on admission9,18,20,22,23,25,39 and NG feeding was implemented as standard practice.22,23,26,39 NG was also implemented due to acute refusal of food or inability to meet oral intake, without significant medical instability, in five studies.9,10,18,31,43 In 13 studies (3 high risk of bias 28,35,47) in which NG was not implemented as standard protocol for all patients, the percentage of ED YP administered NG feeding in all contexts (due to medical instability or inadequate oral diet) varied between 6% − 66%.9,18,29,31,36,37,41−44
Two studies,37,43 found NG feeding was more likely to be required in: patients of a lower age at admission (14.3 years compared to 15.3 yrs old, P < 0.0537 and 20% in early onset AN compared to 0% in adult onset AN P < 0.0543). Clausen46 described NG as the most frequently used involuntary measure in psychiatric practice and is most commonly used in 15–17 year olds. Studies included both male and female patients, however, out of 25 patient focused studies, most had a female majority and 6 studies 20,26,37,39,43,44 were conducted on female only cohorts. 2 studies21,47 examined male only cohorts but both were high risk of bias. 1 study39 included only Caucasian participants however the majority of studies were conducted in affluent, Caucasian majority countries; 31% of the studies included were set in Australia, 14% in the USA, 10% in Canada. There were no studies from Asia, South America or Africa. In Australian based studies, NG was given due to refusal of oral intake in 2 studies9,10 as well as to treat medical instability.26 Globally studies from North America18,21,39,41 and Turkey36 focused on medical instability in YP with ED. In the UK, three studies described NG use during medical instability after oral intake was refused27,28,40 and one where oral intake was inadequate.31
3.2 Reported Weight Gain
Four studies reported weight gain primarily in the context of ED YP with medical instability.24,25,26,44 2 of these studies 24,26 for the first 24–72 hours started with continuous NG feeding, using higher than standard calorie protocols, 2400–3000 kcal per day prevented any initial drop in weight. Between admission and discharge, Parker et al24 reported a mean overall weight gain of 7.4kgs, Kezelman 201826 reported a mean overall increase of 3.04kg/m2 BMI; Madden et al25 reported a mean weight gain of 2.79 kgs during medical instability using continuous NG feeding at 2400 kcals per day. Skrik Liever et al44 reported 27% required NG feeding and linked this to a faster weight gain but gave no information related to NG feeding protocols.
3 Studies reported weight gain in the context of inadequate oral intake9,18,39. Maginot et al, 201718 and Whitelaw et al, 20109 reported NG bolus feeding in 13.8% and 15% in order to supplement oral diet with a mean weight gain of 3.1kgs and 2.6kgs respectively but did not report if this was specific to NG feeding. Robb et al39 compared nocturnal NG feeding to supplement oral diet (maximum 3255 kcals /d) with oral intake (max 2508 kcals/d) reporting nocturnal NG feeding weight gain of 5.4kgs versus 2.4kgs in the oral diet only group.
1 Study reported on weight gain where NG is routinely started on all ED YP regardless of context.23 Agostino et al23 compared a higher calorie (1500-1800kcal/d) continuous NG fed cohort to lower calorie oral bolus cohort (1000-1200kcal/d, divided 6 times per day), results showed mean weight gain was greater in the continuous NG fed group (1.22 kgs per week) than the oral bolus fed group (0.08 kgs per week) over the first 2 weeks.
3.3 Patient And Staff Experience Of Nasogastric Feeding
Five studies used qualitative methods to analyse patient, parent and professional opinions on NG feeding.10,20,40,45,48 A survey of dietitians found 82% considered NG feeding a necessary procedure if oral diet is inadequate.10 Psychiatric nursing assistant’s views centred around: NG being an unpleasant practice, becoming sensitized or desensitized, and the importance of developing coping mechanisms to manage the distress.
An Australian study45 (conducted in a paediatric unit) found YP viewed being NG fed as: an unpleasant experience, a necessary intervention, a psychological signifier of illness, and an emphasis in an underlying struggle for control. Some described NG feeds as easier than eating as it “disguised” the amount due to not swallowing; others felt it was a form of punishment for not gaining enough weight. Conversely the YP in Paccagnella and colleagues20 research stated NG was helpful, particularly initially when an oral diet was challenging to manage.
3.4 Feeding Regime And Calorie Intake
A variety of different feeding regimes were identified in this review which are summarised in Table 2. Refeeding protocols daily calorie intake varied greatly between studies particularly as many studies were evaluating the outcome of higher calorie refeeding protocols.9,18,22,24,31 Most studies tailored the calorie requirements to the individual patient, accounting for initial weight for height percentage and signs of medical instability. The majority commenced on daily intake of less than 2000kcal and increased periodically.
Table 2
Nasogastric Feeding Protocol and Complications Identified in Studies Included in this Systematic Review.
Study | Risk of Bias | Setting | Method and Reason for Implementation of NG | Feeding Regime | Complications |
Whitelaw et al, 20109 | Medium | Medical Ward | Oral intake supplemented with bolus NG feeding if oral RDI not met | Minimum of 1900kcals on day 1 and increased by 300kcal per day | 38% developed HP. HP was associated with lower %IBW on admission |
Rocks et al, 201410 | Medium | MH and Medical Wards | High energy supplements and NG feeds were commonly used to meet RDI. | The initial calorie intake recommended was between 800-1750kcals | Not discussed |
Maginot et al, 201718 | Medium | Medical Ward | Bolus NG feeds supplemental to oral intake if RDI not met | Average of 1185kcal average which increased to an average of 1781 kcals (range 1500–3000 kcals) | Hypomagnaemia and HP reported, HP was more likely in those under 80% %IBW |
Paccagnella et al, 200620 | Medium | Unknown | Continuous NG feeding until medically stable | 15.9-19.7kcal/kg/day; increased to 30kcal/kg/day after 24 hours. | No patient developed nausea, vomiting, or worsened abdominal symptoms; 2 developed lower limb oedema despite slow infusion. |
Silber et al, 200421 | High | MH Ward | Routine nocturnal NG feeding to supplement daily oral intake vs oral refeeding only (control) | Nocturnal NG feeding regime patients were prescribed calories individually (max 4350kcal) and 3400 in the oral refeeding group (control). | Epistaxis, nasal irritation. |
Madden et al, 201522 | Low | Medical Ward | Continuous NG feeding until medically stable; followed by oral intake with supplemental nocturnal NG feeding until biomarkers stabilised. | NG feeding continuously for 1–2 days. Weight gain aim for 1kg per week. Weaning to oral diet occurred as soon as medically stable – average 14 days on NG with feed of 2400-3000kcal per day | Not discussed |
Agostino et al, 201323 | Medium | Medical Ward | Routine continuous NG feeding at a higher calorie intake compared to lower calorie standard oral intake. | Starting range for NG cohort 1200-2000kcal increased by 200kcal/day vs. oral diet of 800-1200kcal increased by 150kcal/day. NG fed for 7 days then weaned over 3 days with kcal via NG reducing as meals replaced | Oral cohort 51% lost weight initially compared to 6% in the NG high kcal cohort. 2 cases of Hypokalaemia (although both were abusing laxatives), HP. |
Parker et al, 201624 | Medium | MH Ward | Continuous NG feeding or combination of oral intake with supplemental overnight NG feeding, or oral intake alone. | Start feed 2400kcal increasing to 2400-3400kcal/day at 100ml per hour | Peripheral oedema (4%), hypomagnaemia (7%), hypokalaemia (2%), HP (1%). No incidence of RS or delirium. |
Madden et al, 201525 | Low | Medical Ward | Continuous NG feeding until medically stable; followed by oral intake with supplemental nocturnal NG feeding until biomarkers stabilised. Average %IBW at initiation was 78 | 2400-3000kcal to meet weekly target of weight gain of 1kg/week. In the first week average weight gain was 2.79kg. | Stated none developed RS or HP |
Kezelman et al 201826 | Medium | Medical Ward | Continuous NG until medically stable followed by oral intake supplemented by nocturnal NG feeding | 2400 kcal/day for 24hrs or until medically stable, changed to oral diet starting ~ 1800kcal increasing to a maximum of 3800kcal with nocturnal NG top up feeds stopped when BMI > 18.5 | Not discussed |
Fuller et al, 201927 | Medium | MH Ward | Results from questionnaire showed non-specialist psychiatric units gave 73% NG as syringe bolus, 27% as enteral pump. Specialist ED units gave 85% as syringe bolus, 15% as enteral pump. | Volume of bolus feed ranged from 330-1000ml average 564ml per feed. Bolus feed time ranged between 10–40 minutes average being 20 minutes. If delivered by pump it was > 1 hour. | Not discussed |
Street et al, 201628 | High | Medical Ward | Bolus NG feeding if medically unstable and oral intake not met | NG feeds were higher in calories than meals to motivate eating. | Not discussed |
Couturier and Mahmood, 200929 | Medium | MH Ward | Bolus NG feeding if patient failed to gain 1kg/week or acute refusal of meals | Not discussed | Nausea, odynophagia, self-harm, epistaxis, anxiety, sadness, 38.4% patients experienced mild HP |
Falcoski et al, 202030 | High | MH Ward | Oral calories supplemented with bolus NG feeds, single bolus of high calorie NG feeding, and 3 smaller single boluses. | Starting feed 1200kcal, increased by 200kcal per day to 2000kcal. 1 NG feed per day under restraint. Also described 1 bolus feed of 2000kcal due to no oral intake for 20 hours | Distress described during the procedure requiring Lorazepam |
O’Connor et al, 201631 | Low | Medical Ward | Supplemental bolus NG feeding if patients failed to meet 80% RDI. At initiation %IBW was < 78% | Compared 500kcal starting diet with 1200kcal | HP (28%) |
Akgul et al, 201635 | High | MH Ward | Not discussed | Initiated at 750kcal per day and increased by 220kcal per day | HP described in 2 cases (unable to determine if this was in those requiring NG) |
Akgul et al, 201636 | Medium | Medical Ward | Not discussed, the majority of young people were under 80% %IBW | Started on an average of 975kcal. Average duration of NG was 2.5 days | HP described in 2 cases (not stated if this was in those requiring NG) |
Robb et al, 200239 | Medium | Medical Ward | Nocturnal NG feeding to supplement daily oral intake during medical instability | Starting NG feed at 600 kcal. Ratio oral kcal to NG was approximately 2:1. NG feed via pump at 40 cc per hour for 4 hours then 60 cc per hour for 4 hours. Increases to 1200kcal NG feed over 3 nights. Weaned when the young person is 95%IBW. | Epistaxis (11.5%), anxiety (3.8%) treated with Lorazepam, removal of NG tube (5.8%), nasal irritation (28.8%). |
Neiderman et al, 200140 | High | Medical Ward | Not discussed | Not discussed | Removal of tube (55%). |
Key: BMI = Body Mass Index; NG = nasogastric; MH = mental health; RDI = recommended daily intake; HP = hypophosphataemia; RS = refeeding syndrome; %IBW = percentage ideal bodyweight. |
No study discussed in detail the strategy used to transition from NG feeds back to an oral diet. Those studies where NG was used for medical stabilisation often described a short period of NG before a quick transition back to an oral diet.22,23,36 In studies where continuous NG was provided, YP were sometimes not given the option of an oral diet so that their calorie intake could be closely monitored.22–24, 31 These studies discussed ceasing NG feeds after the risk of RS had reduced; most gave a time frame between 2–14 days.24,44 Studies using bolus feeds stated that oral intake was encouraged and it was only when this was not fully achieved that supplementary NG was used.39 This appeared to be either after each meal, at set times during the day or once in the evening.27 For nocturnal feeds, oral diet was encouraged during the day. In most studies the NG feed supplemented any deficit in oral intake but occasionally also provided additional calories above those prescribed in the oral meal plan.22,25,39
<Table 2>
3.5 Length Of Time Receiving Ng Feeding
There was a wide variety in length of time receiving NG for medical instability. Agostino and colleagues23 delivered nutrition on a medical ward solely via NG for 14 days before commencing oral diet in addition to NG feeding. The average length of time on NG feeding in this study was 20.7 days; NG was terminated as YP accepted more than 50% oral caloric quota compared to theoretical reported quota. Madden et al22 RCT determined the duration of NG feeding was a minimum of 14 days, using biochemical markers of medical instability in a hospital setting. Conversely, Akgul and colleagues36 described a much shorter average time, 2.5 days, that YP required NG before transitioning to an oral diet. Conversely, in MH wards, if NG has to be given under restraint, it may be required for a significant duration; in one study46 the average was 170 days. Neiderman et al40 qualitative study describes patients time receiving NG varying from 1 to 476 days (methods not explained).
2 studies examined therapeutic interventions to reduce the need for NG or length of time on it in medically stable YP.29, 41 Couturier and Mahmood29 highlighted that meal support therapy reduced the requirement for NG feeding from 66.7–11.1%, criteria for NG feeding was the same in both groups throughout and oral intake was encouraged. Gusella and colleagues41 compared parent led therapy (PLT) to non-specific therapy (psychologist led talking therapy). PLT was based on FBT and included parents reducing child exercise and increasing oral intake. Results demonstrated that YP receiving PLT had a significantly reduced requirement for NG (P < 0.05).
3.6 Complications Associated With Ng Feeding
Complications associated with NG feeding found in this review are summarised in Table 2, with the most frequently described being nasal irritation or epistaxis, anxiety related to the procedure and electrolyte disturbance (which occurred with both oral and NG refeeding). Overall, this review found 5 studies9,18,23,24,29 reported some incidence of electrolyte disturbance, 2 studies29,39 described epistaxis and 1 study39 described behavioural problems associated with the procedure. A number of YP in MH wards required restraint to NG feed with one study reporting this was required for 66% of YP.24 NG under restraint was described as causing distress and risk of injury to both staff and YP.48 No study reported a YP developed RS. Nehring and colleagues37 concluded that NG feeding had no impact on growth, recovery or development of psychiatric co-morbidities.
Kezelman and colleagues (Australia) 201826 assessed the impact on anxiety, depression and ED symptoms when using NG in adjunct to oral intake as part of a rapid refeeding regime. Changes in these symptoms were not attributed to the rate of weight restoration suggesting a rapid refeeding schedule would not exacerbate psychiatric symptoms.
3.7 Length Of Stay Associated With Ng Feeding
Length of stay was reported in studies from medical and MH ward settings, however, the specific package of treatment YP received in each study was different depending on the country of origin. For example, in Australian studies medical wards tended to include high levels of psychiatric treatment alongside medical treatment.26 Agostino and colleagues23 demonstrated that YP on medical wards having NG feeds had a mean LOS of 33.8 days compared to those in the same setting having an oral diet who had a mean of 50.9 days, however, the oral diet was lower in calories therefore taking longer for weight recovery and medical stabilisation. Conversely any hospital admission was significantly longer (P < 0.0001) for a YP requiring NG feeding compared to those managing an oral diet in a German retrospective cohort study.37 However, this study does not discuss the reasons NG was implemented. Maginot et al study18 in a medical ward (where NG was implemented due to insufficient oral intake) discussed NG feeding in the context of YP with more severe medical problems, (such as intractable vomiting and superior mesenteric artery syndrome) which therefore took longer to transition to oral diet, resulting in a longer admission.
Strik Lievers and colleagues44 concluded that, amongst others, requirement for NG feeding when NG was implemented due to medical instability was a factor affecting LOS on a psychiatric ward. In this study the mean LOS was significantly increased: 117 days for YP managing oral intake compared to 180 days for those requiring NG. They concluded that the requirement for NG was an indication of severity and resistance to oral feeding.44