Small bowel feeding versus gastric feeding in critically ill adults: more attention should be paid to specific populations

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As all of us are well aware, there are a lot of unanswered questions in the nutrition support of patients, especially in the care of critically ill adults. Despite extensive studies, however, the optimal route (small bowel feeding versus gastric feeding) of enteral nutrition remains debated. In recent issues of Critical Care, three meta-analyses focus on the topic [1-3]. Deane and colleagues [1] and Alhazzani and colleagues [2] both concluded that small intestinal feeding was superior to gastric feeding in reducing the risk of pneumonia in critically ill patients. We performed a subgroup analysis based on the analysis by Deane and colleagues [1], and the results suggested that small bowel feeding was associated with a reduction in the incidence of pneumonia in trauma patients (relative risk (RR) 0.67, 95% confidence interval (CI) 0.52 to 0.87; P = 0.003) but no reduction in the medical or surgical ICU population or both (RR 0.86, 95% CI 0.58 to 1.26; P = 0.43). Moreover, in another meta-analysis focusing on patients with severe acute pancreatitis, the authors suggested that small intestinal feeding was not superior to gastric feeding [3]. As implied above, what is noteworthy is that the effects of small bowel versus gastric feeding on clinical outcomes may vary in different population groups. In this case, we were unable to demonstrate a clinical benefit from small bowel versus gastric feeding in a mixed group of critically ill patients. More attention should be paid to specific populations, such as medical or surgical ICU patients (or both), patients with severe acute pancreatitis, and trauma patients.