Intermittent bolus versus continuous feeding in children receiving an enteral formula with food derived ingredients: A national multicentre retrospective study

BACKGROUND AND AIM

A perceived factor believed to have an impact on feed tolerance relates to the mode in which nutrition is delivered regarding intermittent bolus or continuous feeding. Enteral formulas with food derived ingredients have been developed to help address some of the many feeding issues experienced by children who are tube fed. This study aimed to evaluate the tolerance of different feeding modes in children who are fed with an enteral formula with food derived ingredients.

METHODS

Data was collected by paediatric dietitians from dietetic records over a month period on children who had switched to an enteral formula with food derived ingredients. Data was inputted to a Microsoft form to capture the impact of varying modes of feeding (intermittent bolus/continuous/combination) on gastrointestinal and anthropometric outcomes.

RESULTS

Forty-three children were recruited between March 2021 to July 2021 across four National Health Service Trusts. Children who were continuously fed saw the greatest reported improvement in retching, abdominal pain and loose stools. Children who were fed intermittent bolus reported the greatest increase in weight (p-value 0.003). Over 90% of dietitians reported nutritional goals were achieved after switching formula; children who were fed continuously reported the highest achievement to meet dietitian's nutritional goals.

CONCLUSION

Enteral formulas with food derived ingredients are well tolerated and effective in achieving weight gain and meeting dietetic goals whether delivered continuously or as intermittent bolus feed. The clinical situation will determine the most appropriate and effective feeding mode and should be guided by the dietitian and medical team.

Development and implementation of a pneumatic micro-feeder for poorly-flowing solid pharmaceutical materials

Consistent powder micro-feeding (<100 g/h) is a significant challenge in manufacturing solid oral dosage forms. The low dose feeding can well control the content consistency of the dosage forms, which improves drug efficiency and reduces manufacturing waste. Current commercial micro-feeders are limited in their ability to feed < 20 g/h of cohesive (i.e. powders of poor flowability) active pharmaceutical ingredients (API) and excipients (e.g. lubricants) with low fluctuation. To breach this gap, this study presents an advanced micro-feeder design capable of feeding a range of pharmaceutical-grade powders consistently at flow rates as low as 0.7 g/h with <20 % flow rate variation. This was possible due to a novel powder conveying concept utilising particle re-entrainment to minimise flow rate variations. This work details the design of this pneumatic micro-feeder and its excellent micro-feeding performance even for cohesive powders. The experimental studies investigated the influence of the process parameters (air pressure and air flow rate) and equipment configurations (insert size and plug position) on the feeding performance of different pharmaceutical-relevant powders, i.e., microcrystalline cellulose (MCC), croscarmellose sodium (CCS), crospovidone (XPVP) and paracetamol (APAP). It was shown that the system is capable of delivering consistent powder flow rates with good repeatability and stability.

Development of a Controlled Continuous Low-Dose Feeding Process

This paper proposes a feed rate control strategy for a novel volumetric micro-feeder, which can accomplish low-dose feeding of pharmaceutical raw materials with significantly different powder properties. The developed feed-forward control strategy enables a constant feed rate with a minimum deviation from the set-point, even for materials that are typically difficult to accurately feed (e.g., due to high cohesion or low density) using conventional continuous feeders. Density variations observed during the feeding process were characterized via a displacement feed factor profile for each powder. The characterized effective displacement density profile was applied in the micro-feeder system to proactively control the feed rate by manipulating the powder displacement rate (i.e., computing the feed rate from the powder displacement rate). Based on the displacement feed factor profile, the feed rate can be predicted during the feeding process and at any feed rate set-point. Three pharmaceutically relevant materials were used for the micro-feeder evaluation: di-calcium phosphate (large-particle system, high density), croscarmellose sodium (small-particle system, medium density), and barium sulfate (very small-particle <10 μm, high density). A significant improvement in the feeding performance was achieved for all investigated materials. The feed rate deviation from the set-point and its relative standard deviation were minimal compared to operations without the control strategy.

The Effect of Intermittent and Continuous Feeding on Growth and Discharge Time in Very Low Birth Weight Preterm Infants

Objectives

The aim of this study was to determine the effect of intermittent bolus feeding and continuous feeding models on early growth and discharge time in very low birth weight infants.

Methods

The study was designed as a prospective, randomized, and controlled study. Infants born in our hospital with birth weight below 1500 g within a 1 year period were included in the study. The number of samples was determined by power analysis. Babies were randomized according to birth weight and fed with intermittent bolus feeding and continuous feeding models. Demographic characteristics, clinical findings, diagnosis, nutritional status, and length of hospital stay were compared.

Results

The study was conducted with 80 preterm infants, which consisted of continuous feeding (n=41) and intermittent bolus feeding (n=39). There was no significant difference in gender, gestational week, birth weight, height, and head circumference distribution of the babies between groups. The difference between the reach time to birth weight and maximum weight loss rates, parenteral feeding time, transition time to full enteral feeding, transition time to oral feeding, development of feeding intolerance, mechanical ventilation time, and hospitalization time in intensive care unit were not statistically significant. Necrotizing enterocolitis (NEC) Stage I and II developed in 34.1% of babies fed with continuous feeding model and 28.2% of babies fed intermittently; NEC was detected to start in 4.5±2.8 days in the continuous feeding group and in 2.8±5.2 days in the intermittent group. These differences were found to be insignificant between the two groups (p=0.634 and p=0.266, respectively).

Conclusion

There was no difference between growth parameters and discharge time of preterm babies who were applied continuous and intermittent bolus feeding model. Although there was no statistically significant difference on the development of NEC, it was determined that NEC developed earlier in the intermittent bolus feeding model.

Changes in layers of laboratory vermicomposting using spent mushroom substrate of Agaricus subrufescens P

World mushroom production in 2018 was approximately 8.99 million tonnes. The most commonly cultivated species in the Czech Republic are Agaricus spp., which are sold fresh or canned. In 2017, 2018 mushroom production in the Czech Republic was approximately 540 tonnes. Vermicomposting is an easy and less ecologically harmful way to process the spent mushroom substrate. Earthworms, which are referred to as the engine of the process of vermicomposting, and microorganisms, help convert organic waste into fertilizer. This study is concerned with laboratory vermicomposting in a system of continuous feeding of earthworms Eisenia andrei. It compares the differences between variants with and without earthworms. The dry matter percentage was approximately 20% or more in both variants. The variant with earthworms showed a significant decrease in electrical conductivity. The C/N ratio was very low in both variants. The highest total P was recorded in the variant with earthworms, but the highest values of K and Mg were found in the control. Both variants recorded higher content of bacteria than fungi. All values of microorganism contents were higher in the vermicomposter without earthworms, but the bacterial/fungal ratio was higher in the variant with earthworms. The highest content in both variants shows the bacteria especially G-bacteria, on the other side, the lowest content shows the actinobacteria. The highest activity of β-D-glucosidase and acid phosphatase was measured in the vermicomposter with earthworms, but the activity of other enzymes was higher in the control. In both vermicomposters laccase activity was below the detection limit. The method of classical vermicomposting can be used for processing the spent mushroom substrate. However, in terms of higher content of total and available nutrients, there seems to be a better method of processing the substrate without earthworms.

A solution for low-dose feeding in continuous pharmaceutical processes

Continuous feeding of small quantities of powder is increasingly applied in pharmaceutical manufacturing. With that regard, what is crucial is not only the feasibility, but also the accuracy and stability. To enable stable processing, low amounts of various agents, e.g., lubricants, can be used. Even more important is the exact dosage of highly potent active pharmaceutical ingredients (APIs), which require feed rates within the range of grams per hour. Conventional feeders cannot supply powder at such rates, especially when the material properties are challenging. In this work, a novel micro-feeder was integrated into a continuous manufacturing line and its capability to supply API at feed rates down to one gram per hour was tested. The micro-feeder system is based on the principle of active volumetric displacement: a piston pushes the powder out of the cartridge upwards to the end of a plate, where a scraper places it into the process inlet. In this study, a hot melt extrusion process was used, during which the API was dissolved in a polymer matrix. Samples of the strand were analysed with regard to their content by means of HPLC. The results showed that the novel micro-feeder system can feed powder with good accuracy and reproducibility, indicating its high potential for continuous process implementation.

Intermittent versus continuous enteral nutrition on feeding intolerance in critically ill adults: A meta-analysis of randomized controlled trials

OBJECTIVES

Enteral formula delivery strategy is an important part of enteral nutrition. We aimed to synthesize up-to-date studies to clarify the effects of intermittent versus continuous feeding on feeding intolerance during enteral nutrition in critically ill adults.

DESIGN

A meta-analysis of randomized controlled trials.

DATA SOURCES

Embase, PubMed, Information Sciences Institute Web of Science, CINAHL EBSCO, Cochrane Central Register of Controlled Trials, Chinese Biomedical Literature Database, China National Knowledge Infrastructure databases were searched from inception to 17th of June 2020.

REVIEW METHODS

The Cochrane "risk of bias" tool was used to assess the quality of individual studies, and the quality of each outcome was assessed by GRADE approach. Fixed or random effect meta-analysis was used pending the presence of heterogeneity. Dichotomous data synthesis was presented as risk ratio and 95% confidence interval, and quantitative data synthesis was shown as mean difference and 95% confidence interval.

RESULTS

Fourteen trials with 1025 critically ill adults were included in the meta-analysis. We found that intermittent feeding could significantly increase the occurrence of feeding intolerance (risk ratio = 1.64, 95% confidence interval = 1.23 to 2.18, P < 0.001) compared with continuous feeding, as well as the incidence of high gastric volume (risk ratio = 3.62, 95% confidence interval = 1.43-9.12, P = 0.006) and aspiration (risk ratio = 3.29, 95% confidence interval = 1.18-9.16, P = 0.02) in > 1-week trial duration, while constipation rate was reduced in intermittent feeding group (risk ratio = 0.66, 95% confidence interval = 0.45-0.98, P = 0.04). Patients in intermittent feeding group received more calories compared with continuous feeding group (mean difference = 184.81, 95% confidence interval = 56.61-313.01, P = 0.005). The quality of all evidence synthesis was "low" or "very low".

CONCLUSIONS

In critically ill adults, continuous feeding was associated with lower overall incidence of feeding intolerance, especially in high gastric volume and aspiration. However, decreased constipation incidence and more calorie intake were observed in intermittent feeding group. Because quality of the synthesized evidence was "low" or "very low", there is considerable uncertainty about this estimate.

Change in agrochemical and biochemical parameters during the laboratory vermicomposting of spent mushroom substrate after cultivation of Pleurotus ostreatus

Pleurotus ostreatus is one of the most cultivated mushrooms in the Czech Republic. The production of 1 kg of mushrooms generates about 5 kg of spent mushroom substrate. A gentle and fast method for using this substrate is vermicomposting. Vermicomposting of spent mushroom substrate using Eisenia andrei was conducted for seven months. For control purposes, a treatment without earthworms was also prepared. The vermicomposting process used vertical continuous feeding vermicomposters. The agrochemical and biological parameters were analysed. Values of electrical conductivity were very high in both vermicomposters (higher than 2000 μS/cm). During the vermicomposting process the C/N ratio decreased. The number and biomass of earthworms decreased with the age of the layers. The values of total P, K and Mg were higher in the vermicomposter without earthworms. There were also lower microbial phospholipid fatty acids content - than in the vermicomposter with earthworms. However, the fungal phospholipid fatty acids content were two times higher in the vermicomposter without earthworms. The highest hydrolytic enzyme activity was found in lipase, acid phosphatase and β-D-glucosidase. Most hydrolytic enzymes were more active in the vermicomposter without earthworms, with the exception of arylsulphatase. Mn-peroxidase activity was higher in the vermicomposter without earthworms and laccase activity was below the detection limit.

Influence of saturated zone depth and vegetation on the performance of vertical flow-constructed wetland with continuous feeding

The object of this study was to investigate the effect of saturated zone depth (SZD) and plant on the removal of organics and nitrogen in four continuous-feed vertical flow-constructed wetlands (VFCWs). Three VFCWs were planted with Iris pseudacorus and operated at different SZDs (19, 51, and 84 cm), and the other one was non-planted and operated at 51 cm SZD. The VFCWs were operated with an organic loading rate (OLR) of 79 g chemical oxygen demand (COD) m^-2 day^-1, a total nitrogen loading rate (NLR) of 11 g N m^-2 day^-1, and a hydraulic loading rate (HLR) of 0.35 m³ m^-2 day^-1. Simultaneous transformation of ammonium and nitrate occurred in all of the four systems. In the planted bed with 51 cm SZD, suitable conditions for nitrification and denitrification could be created and the best performance for total nitrogen (TN) removal was realized via simultaneous nitrification and denitrification (SND), achieving TN removal efficiency of 67.4-80.3%. Higher ammonium nitrogen (NH₄⁺-N) and COD removal efficiency was obtained in the system operated with 19 cm SZD, whereas higher NO₃^--N removal could be achieved in the bed with 84 cm SZD. With the same SZD of 51 cm, the planted VFCW performed preferable removal of COD, NH₄⁺-N, and TN in comparison with the non-planted one. All the VFCWs showed high removal efficiencies for total phosphorus (> 60.15%). Adsorption of phosphorus was primarily observed in the top and upper-middle layers filled with carbon burn slag. It has been proved that the partially saturated VFCW operated with continuous feed could achieve good performance in removal of organic matter and nitrogen by SZD adjustment to develop appropriate aerobic and anoxic regions.

Production of FucoPol by Enterobacter A47 using waste tomato paste by-product as sole carbon source

Out-of-specification tomato paste, a by-product from the tomato processing industry, was used as the sole substrate for cultivation of the bacterium Enterobacter A47 and production of FucoPol, a value-added fucose-rich extracellular polysaccharide. Among the different tested fed-batch strategies, pH-stat, DO-stat and continuous substrate feeding, the highest production (8.77gL^-1) and overall volumetric productivity (2.92gL^-1d^-1) were obtained with continuous substrate feeding at a constant flow rate of 11gh^-1. The polymer produced had the typical FucoPol composition (37mol% fucose, 27mol% galactose, 23mol% glucose and 12mol% glucuronic acid, with an acyl groups content of 13wt%). The average molecular weight was 4.4×10⁶Da and the polydispersity index was 1.2. This study demonstrated that out-of-specification tomato paste is a suitable low-cost substrate for the production of FucoPol, thus providing a route for the valorization of this by-product into a high-value microbial product.

Antigen administration by continuous feeding enhances oral tolerance and leads to long-lasting effects

The ability to avoid inflammatory responses to dietary components and microbiota antigens in the gut mucosa is achieved by a mechanism termed oral tolerance. This phenomenon is crucial to maintain the physiological immune activity in the gut and to prevent inflammatory disorders such as food allergy and inflammatory bowel diseases. Moreover, orally administered antigens induce regulatory cells that control systemic inflammatory responses as well. Given its specific, systemic and long-lasting effects, oral tolerance represents a promising approach for immunotherapies that aim to modulate inflammatory and autoimmune diseases. However, there are different protocols of feeding for induction of oral tolerance, and they have an impact in tolerance efficiency and length. Herein, we present and discuss different experimental feeding protocols and how they influence the outcome of oral administration of antigens.

Continuous milk feeding versus intermittent bolus feeding in preterm infants

We aimed to assess the current knowledge on continuous versus intermittent bolus feeding in preterm infants. We found that existing evidence does not support the firm recommendation of one strategy among the many alternatives. However, although many areas remain to be investigated, it is probable that continuous feeding might be advantageous compared to intermittent feeding in favoring the faster establishment of full enteral feeding, and decreasing the risk of hypoxic-ischemic gut damage in preterm neonates in critical condition, especially SGA infants, by limiting their gastrointestinal oxygen requirement.