Abstract
BackgroundEarly start of enteral feeding is an established treatment strategy in intubated patients in intensive care since it reduces invasive bacterial infections and length of hospital stay. There is equipoise whether early enteral feeding is also beneficial in non-intubated patients with cerebral malaria in resource poor settings. We hypothesized that the risk of aspiration pneumonia might outweigh the potential benefits of earlier recovery and prevention of hypoglycaemia.Method and FindingsA randomized trial of early (day of admission) versus late (after 60 hours in adults or 36 hours in children) start of enteral feeding was undertaken in patients with cerebral malaria in Chittagong, Bangladesh from May 2008 to August 2009. The primary outcome measures were incidence of aspiration pneumonia, hypoglycaemia and coma recovery time. The trial was terminated after inclusion of 56 patients because of a high incidence of aspiration pneumonia in the early feeding group (9/27 (33%)), compared to the late feeding group (0/29 (0%)), p = 0.001). One patient in the late feeding group, and none in the early group, had hypoglycaemia during admission. There was no significant difference in overall mortality (9/27 (33%) vs 6/29 (21%), p = 0.370), but mortality was 5/9 (56%) in patients with aspiration pneumonia.ConclusionsIn conclusion, early start of enteral feeding is detrimental in non-intubated patients with cerebral malaria in many resource-poor settings. Evidence gathered in resource rich settings is not necessarily transferable to resource-poor settings.Trial RegistrationControlled-Trials.com ISRCTN57488577
Highlights
Even with optimal antimalarial treatment with parenteral artesunate, mortality of severe malaria remains 15% in adults and 9% in children [1,2]
In conclusion, early start of enteral feeding is detrimental in non-intubated patients with cerebral malaria in many resource-poor settings
On advice of the committee the trial was stopped on 2nd September 2009, because of the high incidence of aspiration pneumonia in the study group receiving early enteral feeding
Summary
Even with optimal antimalarial treatment with parenteral artesunate, mortality of severe malaria remains 15% in adults and 9% in children [1,2]. In resource poor settings more technically demanding interventions, such as mechanical ventilation and renal replacement therapy, will only be feasible in a minority of patients Other treatments, such as enteral feeding via a nasogastric tube, are easier to achieve. Studies on enteral feeding in the intensive care setting are performed in patients with an airway protected by endotracheal intubation This does not prevent aspiration pneumonia [13], aspiration pneumonia is a rare complication, especially with the use of post-pyloric enteral feeding tubes [14,15,16,17,18] and avoidance of supine positioning of patients by elevating the head of the bed by at least 30o [18,19]. Incidences of aspiration pneumonia, hypoglycaemia and coma recovery time were the primary outcome measures
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