Clinical question
Should tube feeding versus oral diet be used for people at nutritional risk who are at risk of pressure injuries?
Context
Population:
Intervention:
Comparison:
Main Outcomes:
Setting:
Conflicts on Interest:
People at nutritional risk and at risk of pressure injuries
Tube feeding
Oral diet
Any clinical setting
Pressure Injury occurrence
No Guideline Governance Group members of Core Review Group members had a conflict of interest
Evidence to Decision Framework
(Click on the individual judgements for more information)
Summary of Judgements
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Yes
Trivial for intervention (favors comparator)
Large
Very low
No important uncertainty or variability
Probably favors the comparison
Varies
No included studies
No included studies
Don’t know
Varies
Varies
1. Problem:
Is the problem (pressure injuries) a priority?
JUDGEMENT
No
Probably No
Probably Yes
Yes
Varies
Don’t Know
RESEARCH EVIDENCE
The problem of preventing pressure injuries is a significant priority to healthcare in most clinical settings.
In 2021, the Guideline Governance Group undertook a stakeholder survey on priority issues to address in the guideline. Receiving clinical guidance on nutritional interventions to prevent pressure injuries was rated as the highest priority by clinicians (median ranking 5/5) and rated as a high priority by researchers, industry representatives and people with or at risk of pressure injuries and their informal carers (median ranking for all these stakeholder groups 4/5). In an earlier survey conducted by the previous Guideline Governance Group in 2018 (Haesler, Pittman et al. 2022), 71.8% (275/383) of individuals with or at risk of PIs and 65.3% (555/850) of informal carers rated receiving information on diet and hydration as important or very important.
2. Desirable Effects:
How substantial are the desirable anticipated effects?
JUDGEMENT
Trivial
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
| Outcome | Tube feeding | Oral diet | Difference | Relative effect |
|---|---|---|---|---|
| PI occurrence | 463/1281 (36.1%) | 471/2297 (20.5%) | 103 more per 1,000 (from 4 more to 246 more) |
RR 1.50 (1.02-2.20) |
Outcome 1: PI Occurrence
The meta-analysis included one RCT (Hartgrink, Wille et al. 1998) and three non-randomised comparative studies (Peck, Cohen et al. 1990, Arinzon, Peisakh et al. 2008, Teno, Gozalo et al. 2012) that explored using any form of tube feeding compared to maintaining an oral diet to prevent PIs. The meta-analysis showed that using tube feeding is associated with an increase in the occurrence of PIs (relative risk [RR] 1.50, 95% confidence interval [CI] 1.02 to 2.20). It is very uncertain whether tube feeding has an impact on the risk of a new PI occurring in people at nutritional risk and at risk of a PI.
A systematic review (Lee, Hsu et al. 2021) noted that tube feeding is associated with some common PI risk factors, including urine and fecal incontinence and immobility related to increased use of restraints to prevent interference with feeding tubes. These risks might be one reason the meta-analysis results showed that tube feeding was not associated with a reduction in PIs.
3. Undesirable Effects:
How substantial are the undesirable anticipated effects?
JUDGEMENT
Trivial
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
| Outcome | Tube feeding |
Oral diet | Difference | Relative effect |
|---|---|---|---|---|
| Mortality | - | - | Favors oral diet | OR 1.79 (1.04-3.07) |
| Pneumonia | - | - | Favors oral diet | OR 2.25 (0.81-6.24) |
Mortality
A meta-analysis (Lee, Hsu et al. 2021) that included eight studies conducted in older people with advanced dementia showed that tube feeding was associated with an increase in risk of death (odds ratio [OR] 1.79, 95% CI 1.04 to 3.07), but the certainty of evidence is low. Death rates were higher in a group receiving tube feeding compared to oral diet (14.5% versus 0%) in a RCT (Hartgrink, Wille et al. 1998) that was conducted in people undergoing surgery for a hip fracture, although the researchers considered these results were not related to the intervention.
Pneumonia
A meta-analysis( Lee, Hsu et al. 2021) that included four studies conducted in older people with advanced dementia showed that tube feeding was associated with an increase in risk of experiencing pneumonia (OR 2.25, 95% CI 0.81 to 6.24), but the certainty of evidence is very low.
4. Overall certainty of evidence: What is the overall certainty of the evidence of effects?
JUDGEMENT
Very low
Low
Moderate
High
No included studies
RESEARCH EVIDENCE
| Outcome | Relative Importance | Certainty of Evidence |
|---|---|---|
| PI occurrence | CRITICAL | VERY LOW |
Outcome 1: PI occurrence
In a Delphi survey (Lechner, Coleman et al. 2022) that developed a core outcomes et for PI prevention trials, the outcome of PI occurrence was rated as being of critical importance (score of 7-9).
Certainty of the evidence was very low. The evidence was downgraded for risk of bias based on critical appraisal (Davies, Barrado-Martín et al. 2021, Lee, Hsu et al. 2021, Langer, Wan et al. 2024) that indicated there was a high risk of bias across multiple domains. Certainty was also downgraded once for inconsistency and once for imprecision.
5. Values:
Is there important uncertainty about or variability in how much people value the main outcomes?
JUDGEMENT
Important uncertainty or variability
Possibly important uncertainty or variability
Probably no important uncertainty or variability
No important uncertainty or variability
RESEARCH EVIDENCE
In a Delphi survey (Lechner, Coleman et al. 2022) that developed a core outcomes et for PI prevention trials, the outcome of PI occurrence was rated as being of critical important (score of 7-9) by all types of stakeholders (health professionals, people with or at risk of a PI and their informal carers, industry representatives and researchers). Greater than 90% of the 158 participants rated this outcome measure as critically important (Lechner, Coleman et al. 2022).
6. Balance of Effects:
Does the balance between desirable and undesirable effects favour the intervention or the comparison?
JUDGEMENT
Favors the comparison
Probably favors the comparison
Does not favor either the intervention or the comparison
Probably favors the intervention
Favors the intervention
Varies
Don’t know
RESEARCH EVIDENCE
Both desirable and undesirable effects favor oral diet being used for people with nutritional risk and PI risk.
In the Guideline Governance Group’s opinion, the increase in adverse events associated with tube-feeding compared to oral diet, including an increase in PI occurrence, indicates that the balance of effects probably favors using an oral diet.
7. Resources Required:
How large are resource requirements (costs) of the intervention?
JUDGEMENT
Large costs
Moderate costs
Negligible costs and savings
Moderate savings
Large savings
Varies
Don’t know
RESEARCH EVIDENCE
In the Panel Group’s expert opinion nutritional supplements are usually funded within the costs of health care in acute care, intensive care and palliative care settings. Resources are required to implement the intervention, including equipment and nursing time.
In the Guideline Governance Group’s expert opinion, the resources required to implement tube feeding vary depending on the clinical and geographic context.
8. Certainty of evidence of required resources:
What is the certainty of evidence of resource requirements (costs) of the intervention?
JUDGEMENT
Very low
Low
Moderate
High
No included studies
RESEARCH EVIDENCE
No included studies
9. Cost Effectiveness: Does the cost-effectiveness of the intervention favour the intervention or the comparison?
JUDGEMENT
Favors the comparison
Probably favors the comparison
Does not favor either the intervention or the comparison
Probably favors the intervention
Varies
No included studies
RESEARCH EVIDENCE
There was no evidence on cost effectiveness.
10. Inequity:
What would be the impact of recommending the intervention on health inequity?
JUDGEMENT
Reduced
Probably reduced
Probably no impact
Probably increased
Increased
Varies
Don’t know
RESEARCH EVIDENCE
There was no evidence on inequity.
11. Acceptability:
Is the intervention acceptable to key stakeholders?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
In the Panel Group’s expert opinion, it is possible that there is low acceptance from some stakeholders regarding avoiding the use of tube feeding, particularly when the individual has inadequate oral intake. There may also be low acceptance from health professionals in geographic regions in which tube feeding is considered an imperative for preventing PIs in people with nutritional risk and high risk of PIs.
In the Guideline Governance Group’s expert opinion, there is likely to be variation in acceptability for avoiding the use of tube feeding. Some stakeholders are likely to accept that tube feeding is not beneficial for preventing PIs. However, other stakeholders are likely to consider provision of tube feeding is an ethical requirement in the absence of adequate oral intake.
12. Feasibility:
Is the intervention (limiting sitting time) feasible to implement?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
There was no evidence on feasibility.
In the Guideline Governance Group’s expert opinion, the feasibility of implementing tube feeding or otherwise vary according to the clinical and geographic context.
References
American Nurses Association Center for Ethics and Human Rights (2017). Position Statement : Nutrition and Hydration at the End of Life. https://www.nursingworld.org/~4af0ed/globalassets/docs/ana/ethics/ps_nutrition-and-hydration-at-the-end-of-life_2017june7.pdf, American Nurses Association.
Arinzon, Z., A. Peisakh and Y. N. Berner (2008). "Evaluation of the benefits of enteral nutrition in long-term care elderly patients." J Am Med Dir Assoc 9(9): 657-662.
Chou, H.-H., M.-T. Tsou and L.-C. Hwang (2020). "Nasogastric tube feeding versus assisted hand feeding in-home healthcare older adults with severe dementia in Taiwan: a prognosis comparison." BMC Geriatrics 20(1): 60.
Cintra, M. T. G., N. A. de Rezende, E. N. de Moraes, L. C. M. Cunha and H. O. da Gama Torres (2014). "A comparison of survival, pneumonia, and hospitalization in patients with advanced dementia and dysphagia receiving either oral or enteral nutrition." The Journal of nutrition, health and aging 18(10): 894-899.
Davies, N., Y. Barrado-Martín, V. Vickersta, G. Rait, A. Fukui, B. Candy, C. H. Smith, J. Manthorpe, K. J. Moore and E. L. Sampson (2021). "Enteral tube feeding for people with severe dementia." Cochrane Database of Systematic Reviews 8: Art. No.: CD013503.
Haesler, E., J. Pittman, J. Cuddigan, S. Law, Y. Y. Chang, K. Balzer, D. Berlowitz, K. Carville, J. Kottner, M. Litchford, Z. Moore, P. Mitchell and D. Sigaudo-Roussel (2022). "An exploration of the perspectives of individuals and their caregivers on pressure ulcer/injury prevention and management to inform the development of a clinical guideline." J Tissue Viability 31(1): 1-10.
Hartgrink, H. H., J. Wille, P. Konig, J. Hermans and P. J. Breslau (1998). "Pressure sores and tube feeding in patients with a fracture of the hip: A randomized clinical trial." Clin Nutr 17 (6): 287–292.
Jaul, E., P. Singer and R. Calderon-Margalit (2006). "Tube feeding in the demented elderly with severe disabilities." Isr Med Assoc J 8(12): 870-874.
Langemo, D., E. Haesler, W. Naylor, A. Tippett and T. Young (2015). "Evidence-based guidelines for pressure ulcer management at the end of life." International Journal of Palliative Nursing 21(5): 225-232.
Langer, G., C. S. Wan, A. Fink, L. Schwingshackl and D. Schoberer (2024). "Nutritional interventions for preventing and treating pressure ulcers." Cochrane Database of Systematic Reviews 2: CD003216.
Lechner, A., S. Coleman, K. Balzer, J. J. Kirkham, D. Muir, J. Nixon and J. Kottner (2022). "Core outcomes for pressure ulcer prevention trials: results of an international consensus study." Br J Dermatol 187(5): 743-752.
Lee, Y. F., T. W. Hsu, C. S. Liang, T. C. Yeh, T. Y. Chen, N. C. Chen and C. S. Chu (2021). "The Efficacy and Safety of Tube Feeding in Advanced Dementia Patients: A Systemic Review and Meta-Analysis Study." Journal of the American Medical Directors Association 22(2): 357-363.
Lester, S., M. Kleijn, L. Cornacchia, L. Hewson, M. A. Taylor and I. Fisk (2022). "Factors Affecting Adherence, Intake, and Perceived Palatability of Oral Nutritional Supplements: A Literature Review." The Journal of nutrition, health and aging 26(7): 663-674.
McClave, S. A., B. E. Taylor, R. G. Martindale, M. M. Warren, D. R. Johnson, C. Braunschweig, M. S. McCarthy, E. Davanos, T. W. Rice, G. A. Cresci, J. M. Gervasio, G. S. Sacks, P. R. Roberts and C. Compher (2016). "Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)." JPEN J Parenter Enteral Nutr 40(2): 159-211.
Mitchell, S. L., D. K. Kiely and L. A. Lipsitz (1997). "The Risk Factors and Impact on Survival of Feeding Tube Placement in Nursing Home Residents With Severe Cognitive Impairment." Archives of Internal Medicine 157(3): 327-332.
Murphy, L. M. and T. O. Lipman (2003). "Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia." Arch Intern Med 163(11): 1351-1353.
Nair, S., H. Hertan and C. S. Pitchumoni (2000). "Hypoalbuminemia is a poor predictor of survival after percutaneous endoscopic gastrostomy in elderly patients with dementia." The American Journal of Gastroenterology 95(1): 133-136.
Peck, A., C. E. Cohen and M. N. Mulvihill (1990). "Long-Term Enteral Feeding of Aged Demented Nursing Home Patients." Journal of the American Geriatrics Society 38(11): 1195-1198.
Teno, J., P. Gozalo, S. Mitchell, S. Kuo, A. Fulton and V. Mor (2012). "Feeding tubes and the prevention or healing of pressure ulcers. Natural history of feeding-tube use in nursing home residents with advanced dementia." Arch Intern Med 172(9): 697-701.
Ticinesi, A., A. Nouvenne, F. Lauretani, B. Prati, N. Cerundolo, M. Maggio and T. Meschi (2016). "Survival in older adults with dementia and eating problems: To PEG or not to PEG?" Clinical Nutrition 35(6): 1512-1516.
