Timing of Enteral Feeding in Cerebral Malaria in Resource-Limited Settings: A Randomised Trial

Richard J. Maude; Gofranul Hoque; Mahtab Uddin Hasan; Abu Sayeed; Shahena Akter; Rasheda Samad; Badrul Alam; Emran Bin Yunus; Ridwanur Rahman; Waliur Rahman; Romal Chowdhury; Tapan Seal; Prakaykaew Charunwatthana; Christina C. Chang; Nicholas J. White; M. Abdul Faiz; Nicholas P. J. Day; Arjen M. Dondorp; Amir Hossain

doi:10.1371/journal.pone.0027273

Timing of Enteral Feeding in Cerebral Malaria in Resource-Limited Settings: A Randomised Trial

Richard J. Maude, Gofranul Hoque, Mahtab Uddin Hasan, Abu Sayeed, Shahena Akter, Rasheda Samad, Badrul Alam, Emran Bin Yunus, Ridwanur Rahman, Waliur Rahman, Romal Chowdhury, Tapan Seal, Prakaykaew Charunwatthana , Christina C. Chang, Nicholas J. White, M. Abdul Faiz, Nicholas P. J. Day, Arjen M. Dondorp, Amir Hossain

Research output: Contribution to journal › Article › Research › peer-review

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Abstract

Background
Early 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 Findings
A 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.

Conclusions
In 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 Registration
Controlled-Trials.com ISRCTN57488577

Original language	English
Article number	e27273
Journal	PLoS ONE
Volume	6
Issue number	11
DOIs	https://doi.org/10.1371/journal.pone.0027273
Publication status	Published - 16 Nov 2011
Externally published	Yes

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Maude, R. J., Hoque, G., Hasan, M. U., Sayeed, A., Akter, S., Samad, R., Alam, B., Yunus, E. B., Rahman, R., Rahman, W., Chowdhury, R., Seal, T., Charunwatthana , P., Chang, C. C., White, N. J., Faiz, M. A., Day, N. P. J., Dondorp, A. M., & Hossain, A. (2011). Timing of Enteral Feeding in Cerebral Malaria in Resource-Limited Settings: A Randomised Trial. PLoS ONE, 6(11), Article e27273. https://doi.org/10.1371/journal.pone.0027273

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title = "Timing of Enteral Feeding in Cerebral Malaria in Resource-Limited Settings: A Randomised Trial",

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",

author = "Maude, {Richard J.} and Gofranul Hoque and Hasan, {Mahtab Uddin} and Abu Sayeed and Shahena Akter and Rasheda Samad and Badrul Alam and Yunus, {Emran Bin} and Ridwanur Rahman and Waliur Rahman and Romal Chowdhury and Tapan Seal and Prakaykaew Charunwatthana and Chang, {Christina C.} and White, {Nicholas J.} and Faiz, {M. Abdul} and Day, {Nicholas P. J.} and Dondorp, {Arjen M.} and Amir Hossain",

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Maude, RJ, Hoque, G, Hasan, MU, Sayeed, A, Akter, S, Samad, R, Alam, B, Yunus, EB, Rahman, R, Rahman, W, Chowdhury, R, Seal, T, Charunwatthana , P, Chang, CC, White, NJ, Faiz, MA, Day, NPJ, Dondorp, AM & Hossain, A 2011, 'Timing of Enteral Feeding in Cerebral Malaria in Resource-Limited Settings: A Randomised Trial', PLoS ONE, vol. 6, no. 11, e27273. https://doi.org/10.1371/journal.pone.0027273

TY - JOUR

T1 - Timing of Enteral Feeding in Cerebral Malaria in Resource-Limited Settings

T2 - A Randomised Trial

AU - Maude, Richard J.

AU - Hoque, Gofranul

AU - Hasan, Mahtab Uddin

AU - Sayeed, Abu

AU - Akter, Shahena

AU - Samad, Rasheda

AU - Alam, Badrul

AU - Yunus, Emran Bin

AU - Rahman, Ridwanur

AU - Rahman, Waliur

AU - Chowdhury, Romal

AU - Seal, Tapan

AU - Charunwatthana , Prakaykaew

AU - Chang, Christina C.

AU - White, Nicholas J.

AU - Faiz, M. Abdul

AU - Day, Nicholas P. J.

AU - Dondorp, Arjen M.

AU - Hossain, Amir

PY - 2011/11/16

Y1 - 2011/11/16

N2 - 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

AB - 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

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DO - 10.1371/journal.pone.0027273

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VL - 6

JO - PLoS ONE

JF - PLoS ONE

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Timing of Enteral Feeding in Cerebral Malaria in Resource-Limited Settings: A Randomised Trial

Abstract

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