Skip to main content
Article thumbnail
Location of Repository

Does enternal nutrition affect clinical outcome? A systematic review of the randomized trials

By Ronald L. Koretz, Alison Avenell, Timothy O. Lipman, Carol L. Braunschweig and Anne C. Milne


Background: Both parenteral nutrition (PN) and enteral nutrition (EN) are widely advocated as adjunctive care in patients with various diseases. A systematic review of 82 randomized controlled trials (RCTs) of PN published in 2001 found little, if any, effect on mortality, morbidity, or duration of hospital stay; in some situations, PN increased infectious complication rates. Objective: To assess the effect of EN or volitional nutrition support (VNS) in individual disease states from available randomized controlled trials (RCTs). Design: We conducted a systematic review. RCTs comparing EN or VNS to untreated controls, or comparing EN to PN, were identified and separated according to the underlying disease state. Meta-analysis was performed when at least 3 RCTs provided data. The evidence from the RCTs was summarized into one of five grades. A or B indicated the presence of strong or weak (low quality RCTs) evidence supporting the use of the intervention. C indicated a lack of adequate evidence to make any decision about efficacy. D indicated that limited data could not support the intervention. E indicated either that strong data found no effect, or that either strong or weak data suggested that the intervention caused harm. Patients and settings: RCTs could include either hospitalized or non-hospitalized patients. The EN or VNS had to be provided as part of a treatment plan for an underlying disease process. Interventions: The RCT had to compare recipients of either EN or VNS to controls not receiving any type of artificial nutrition or had to compare recipients of EN with recipients of PN. Outcome measures: Mortality, morbidity (disease-specific), duration of hospitalization, cost, or interventional complications. Summary of grading: A – No indication was identified. B – EN or VNS in the perioperative patient or in patients with chronic liver disease; EN in critically ill patients or low birth weight infants (trophic feeding); VNS in malnourished geriatric patients. (The low quality trials found a significant difference in survival favoring the VNS recipients in the malnourished geriatric patient trials; two high quality trials found non-significant differences that favored VNS as well.) C – EN or VNS in liver transplantation, cystic fibrosis, renal failure, pediatric conditions other than low birth weight infants, well-nourished geriatric patients, non-stroke neurologic conditions, AIDS; EN in acute pancreatitis, chronic obstructive pulmonary disease, non-malnourished geriatric patients; VNS in inflammatory bowel disease, arthritis, cardiac disease, pregnancy, allergic patients, preoperative bowel preparation D – EN or VNS in patients receiving non-surgical cancer treatment or in patients with hip fractures; EN in patients with inflammatory bowel disease; VNS in patients with chronic obstructive pulmonary disease E – EN in the first week in dysphagic, or VNS at any time in non-dysphagic, stroke patients who are not malnourished; dysphagia persisting for weeks will presumably ultimately require EN. Conclusions: There is strong evidence for not using EN in the first week in dysphagic, and not using VNS at all in non-dysphagic, stroke patients who are not malnourished. There is reasonable evidence for using VNS in malnourished geriatric patients. The recommendations to consider EN/VNS in perioperative/liver/critically ill/low birth weight patients are limited by the low quality of the RCTs. No evidence could be identified to justify the use of EN/VNS in other disease states

Topics: Enteral, Nutrition, Malnutrition, Randomised Controlled Trials
Publisher: Blackwell Publishing
Year: 2007
OAI identifier:

Suggested articles


  1. (1997). A comparison of parenteral hyperalimentation and early enteral feeding regarding systemic immunity after major hepatic resection – the results of a randomized prospective study. HepatoGastroenterology
  2. (2004). A prospective randomised controlled trial of nutritional supplementation in malnourished elderly in the community: clinical and health economic outcomes. Clin Nutr
  3. (2000). A prospective randomized study of preoperative nutritional supplementation in patients awaiting elective orthotopic liver transplantation. Transplantation
  4. (2000). A randomised controlled trial evaluating the use of enteral nutritional supplements postoperatively in malnourished surgical patients. Gut
  5. (2003). A randomised trial of the effect of nutritional supplementation on the nutritional status of undernourished elderly patients after discharge from hospital. MSc Thesis,
  6. (2003). A randomised, double-blind assessment of the effect of nutritional supplementation on the prevention of pressure ulcers in hip-fracture patients.
  7. (1998). A randomized controlled single-blind trial of nutritional supplementation after acute stroke. JPEN
  8. (1998). A randomized controlled study of total parenteral nutrition and enteral nutrition by elemental and polymeric diet as primary therapy in active phase of Crohn’s disease.
  9. (2003). A randomized controlled trial of early oral feeding in laryngectomized patients. Laryngoscope
  10. (1992). Accelerated improvement of alcoholic liver disease with enteral nutrition. Gastroenterology
  11. (2001). AGA technical review on parenteral nutrition. Gastroenterol
  12. (2006). and economics are the only end-points for trials. Proc Nutr Soc
  13. (1998). Artificial nutrition after major abdominal surgery: impact of route of administration and composition of the diet. Crit Care Med
  14. (1994). Benefits of dietary supplementation in elderly patients with fractured neck of femur (MSc dissertation).
  15. (2002). Benefits of nutritional supplementation in free-living, frail, undernourished elderly people: a prospective randomized community trial.
  16. (2003). Branched-chain amino acids for hepatic encephalopathy. The Cochrane Database of Systematic Reviews
  17. (1980). Clinical observations on the effects of elemental diet supplementation during irradiation. Clin Radiol
  18. (1982). Comparison between pre-operative enteral (naso-gastric tube) and parenteral feeding in patients with cancer of the oesophagus undergoing surgery. (Abstract) JPEN
  19. (1994). Comparison of enteral feeding and total parenteral nutrition after liver transplantation. Lancet
  20. (2002). Comparison of standard and immune-enhancing oral formulas in asymptomatic HIV-infected persons: A multicenter randomized controlled clinical trial. JPEN
  21. (1997). Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis. JPEN
  22. (1998). Comparison of total parenteral nutrition and an oral, semielemental diet on body composition, physical function, and nutrition-related costs in patients with malabsorption due to acquired immunodeficiency syndrome. JPEN
  23. (1990). Consistent wound care and nutritional support in treatment. Decubitus
  24. (1988). Controlled trial of bowel rest and nutritional support in the management of Crohn’s disease. Gut
  25. (1985). Controlled trial of nutritional supplementation, with and without branched chain amino acid enrichment, in treatment of acute alcoholic hepatitis. J Hepatology
  26. (1993). Controlled trial on nutrition supplementation in outpatients with symptomatic alcoholic cirrhosis. JPEN
  27. (1984). Die unmittlebare postoperative enterale Sondenernahrung nach Dickdarmresektion. (German with English abstract) Chirurg
  28. (2005). Dietary counseling improves patient outcomes: a prospective, randomized, controlled trial in colorectal cancer patients undergoing radiotherapy.
  29. (1988). Dietary supplementation and respiratory muscle performance in patients with COPD. Chest
  30. (1990). Dietary supplementation in elderly patients with fractured neck of the femur. Lancet
  31. (1996). Dietary supplementation with Sustagen in elderly patients with fractured neck of femur (PhD Thesis).
  32. (1994). Early enteral feeding associated with an attenuation of the acute phase cytokine response and improved outcome following multiple trauma.
  33. (2005). Early enteral feeding by nasoenteric tubes in patients with perforation peritonitis. World J Surg
  34. (1992). Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Ann Surg
  35. (2003). Early enteral immunonutrition in patients with severe sepsis. Results of an interim analysis of a randomized multicenter clinical trial. Intensive Care Med
  36. (2002). Early enteral nutrition attenuates toxicity of radiochemotherapy in ENT-malignancies. (Abstract) Clin Nutr
  37. (1995). Early enteral nutrition support in patients undergoing liver transplantation. JPEN
  38. (2002). Early enteral supply of fiber and Lactobacilli versus conventional nutrition: a controlled trial in patients with major abdominal surgery. Nutrition
  39. (1997). Early feeding or enteral nutrition in patients with cirrhosis after bleeding from esophageal varices? A randomized controlled study. Dig Dis Sci
  40. (1998). Early postoperative enteral feeding in patients with nontraumatic intestinal perforation and peritonitis.
  41. (1985). Early postoperative enteral nutrition by jejunal catheter in major digestive surgery. Comparison with exclusive parenteral nutrition. (French with English abstract) Chirurgie
  42. (2001). Early postoperative enteral nutrition improves gut oxygenation and reduces costs compared with total parenteral nutrition. Crit Care Med
  43. (1997). Early postoperative feeding after elective colorectal surgery. Arch Surg
  44. (1990). Effect of dietary supplementation on nutritional status and clinical outcome in 501 geriatric patients - a randomised study. Clin Nutr
  45. (1997). Effects of a postoperative oral supplementary protein enriched liquid diet on body composition, protein status and quality of life in gastric carcinoma patients. (German). Aktuelle Ernahrungsmedizin
  46. (1997). Effects of different feeding regimes on septic complications and immune parameters in polytraumatised patients. (German with English abstract) Anasthesiol Intensivmed Notfallmed Schmerzther
  47. (1995). Effects of enteral and parenteral nutrition on gut mucosal permeability in the critically ill. Am J Respir Crit Care Med
  48. Effects of oral nutritional supplements to adults with chronic obstructive pulmonary disease. Clin Resp Physiol 1987; 23(Suppl 12):
  49. (2002). Effects of route and timing of nutrition support in critically ill patients. (Abstract) Gastroenterology
  50. (1987). Enteral and parenteral branched chain amino acid-supplemented nutritional support in patients with encephalopathy due to alcoholic liver disease. JPEN
  51. (2002). Enteral nutrition in surgical patients. Surg Today
  52. (1997). Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial.
  53. (1997). Enteral or parenteral feeding after total gastrectomy: prospective randomised pilot study.
  54. (1992). Enteral versus parenteral feeding. Effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg
  55. (1996). Enteral versus parenteral nutrition after oesophagogastric surgery: a prospective randomized comparison.
  56. (1994). Enteral versus parenteral nutrition after severe closed head injury.
  57. (1993). Enteral versus parenteral nutrition as adjunct therapy in acute ulcerative colitis.
  58. (2001). Enteral versus parenteral nutrition: a pragmatic study. Nutrition
  59. (1996). Enteral versus parenteral nutrition: effects on gastrointestinal function and metabolism. Nutrition
  60. (1986). Enteral versus parenteral nutritional support following laparotomy for trauma: a randomized prospective trial.
  61. (1986). Enteral versus parenteral therapy for intractable diarrhea of infancy: a prospective, randomized trial.
  62. (1994). Exercise training and nutritional supplementation for physical frailty in very elderly people.
  63. (2005). Failure of conventional strategies to improve nutritional status in malnourished adolescents and adults with cystic fibrosis.
  64. (1985). Fine bore jejunostomy feeding following major abdominal surgery: a controlled randomized clinical trial.
  65. (2005). FOOD Trial Collaboration. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicenter randomised controlled trial. Lancet
  66. (1994). Gut failure – predictor of or contributor to mortality in mechanically ventilated blunt trauma patients?
  67. Gut mucosal nutritional support – enteral nutrition as primary therapy after multiple system trauma. Gut 1994; Supplement 1:S32-S34.
  68. (2002). Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study.
  69. (1997). Immediate postoperative enteral feeding results in impaired respiratory mechanics and decreased mobility. Ann Surg
  70. (2003). Immunonutrition in the intensive care unit. A systematic review and consensus statement. Clin Nutr
  71. (1992). Impact of nutritional supplementation on treatment delay and morbidity in patients with head and neck tumors treated with irradiation. Nutrition
  72. (2004). Improvement of weight and fat-free mass with oral nutritional supplementation in patients with Alzheimer’s disease at risk of malnutrition: a prospective randomized study.
  73. (2002). In: The Cochrane Library,
  74. (2002). Influence of route of feeding on outcome in patients after major abdominal surgery. (Abstract) Clin Nutr
  75. (1995). Intervention study in institutionalized patients with Alzheimer disease. J Nutr Health Aging 2003; 7:304-308 111. Gray-Donald
  76. (1997). Is the bowel rest a key factor in the management of active Crohn’s disease? Rivista Italiana di Nutrizione Parenterale ed Enterale
  77. (2000). Jejunal feeding in acute pancreatitis: prevention of septic complications and multiorgan failure? (Hungarian with English abstract) Magyar Sebeszet
  78. (1981). Long term nutritional support as an adjunct to chemotherapy for breast cancer. JPEN
  79. (2004). Long-term branched chain amino acids in patients undergoing chemoembolization for hepatocellular carcinoma: a randomized trial. Aliment Pharmacol Ther
  80. (1997). Long-term oral administration of branched chain amino acids after curative resection of hepatocellular carcinoma: a prospective randomized trial. The San-in Group of Liver Surgery.
  81. (1983). Long-term tolerance of a special amino acid oral formula in patients with advanced liver disease. Nutr Rep Int
  82. (2004). MacLean-Mueller Prize. Enteral or parenteral nutrition for severe pancreatitis: a randomized controlled trial and health technology assessment.
  83. (1995). Meta-analysis of enteral nutrition as a primary treatment of active Crohn’s disease. Gastroenterology 1995; 108:1056-1067 175. Fernandez-Banares
  84. (2004). Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. BMJ
  85. (1994). Must early postoperative oral intake be limited to laparoscopy? Dis Colon Rectum
  86. (1988). Needle catheter jejunostomy: a controlled, prospective, randomized trial in patients with gynecologic malignancy.
  87. (1998). Nightly enteral nutrition support of elderly hip fracture patients: a phase I trial.
  88. (2004). Nightly enteral nutrition support of elderly hip fracture patients: a pilot study.
  89. (1998). Nutrition intervention for weight gain in cystic fibrosis: a meta-analysis. J Pediatr
  90. (1993). Nutrition support after total laryngectomy. JPEN
  91. (1976). Nutritional enhancement of exercise performance in chronic obstructive pulmonary disease: a randomised controlled trial. Thorax 2003; 58:745-751 141. Tomlinson RJ,
  92. (1994). Nutritional status of elderly patients during recovery from chest infection. Age Ageing
  93. (1978). Nutritional status of long-stay geriatric inpatients: effects of a food supplement (Complan). Age Ageing
  94. (2005). Nutritional supplementation for hip fracture aftercare in older people. The Cochrane Database of Systematic Reviews
  95. (2005). Nutritional supplementation for stable chronic obstructive pulmonary disease. The Cochrane Database of Systematic Reviews
  96. (1987). Nutritional supplementation in ambulatory patients with chronic obstructive pulmonary disease. Am Rev Resp Dis
  97. (1996). Nutritional support and functional status in undernourished geriatric patients during hospitalisation and 6-month follow-up. Aging Clin Exp Res
  98. (1984). Nutritional support as an adjunct therapy of advanced cancer patients.
  99. (1989). Nutritional support in hospitalized patients with alcoholic liver disease.
  100. (2001). Nutritional support in patients with chronic obstructive pulmonary disease during hospitalization for an acute exacerbation; a randomized controlled feasibility trial. Clin Nutr 2004; 23:1184-1192 143. Vlaming
  101. (1996). Nutritional support in severe acute pancreatitis. Controlled clinical trial.
  102. (2000). Oral dietary supplements in pre- and postoperative surgical patients: a prospective and randomized clinical trial. Nutrition
  103. (1987). Parenteral versus needle jejunostomy nutrition after total gastrectomy. Clin Nutr
  104. (1992). Perioperative nutritional support: a randomised clinical trial. Clin Nutr
  105. (1995). Physiologic effects of nutritional support and anabolic steroids in patients with chronic obstructive pulmonary disease. A placebocontrolled randomized trial. Am J Resp Crit Care Med
  106. (2001). Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: a randomised multicentre trial. Lancet
  107. (1986). Postoperative enteral vs parenteral nutrition. Arch Surg
  108. (1998). Pressure sores and tube feeding in patients with a fracture of the hip: a randomized clinical trial. Clin Nutr
  109. (2003). Prevention of malnutrition in older people during and after hospitalisation: results from a randomised controlled clinical trial. Age Ageing
  110. (2000). Protein-energy oral supplementation in malnourished nursing-home residents. A controlled trial. Age Ageing
  111. (1996). Randomised trial of safety and efficacy of immediate postoperative enteral feeding in patients undergoing gastrointestinal resection. BMJ
  112. (2004). Randomized clinical trial of the effects of preoperative and postoperative nutritional supplements on clinical course and cost of care.
  113. (1990). Routine oral nutritional supplementation for stroke patients in hospital (FOOD): multicentre randomised controlled trial. Lancet 2005; 365:755-763 106. Fuenzalida CE, Petty TL,
  114. (1981). Serial serum zinc levels in preterm infants during parenteral and enteral feedings.
  115. (1992). Short term benefits of post-operative oral dietary supplements in surgical patients. Clin Nutr
  116. (1997). Short-term restorative nutrition in malnourished patients: pro’s and con’s of intravenous and enteral alimentation using compositionally matched nutrients. Int Surg
  117. (2006). Smyth RL on behalf of the CALICO Trial Collaborative Group. Oral protein energy supplements for children with cystic fibrosis: CALICO multicenter randomised controlled trial. BMJ
  118. (2002). Study of the effect of a liquid nutrition supplement on the nutritional status of psycho-geriatric nursing home patients.
  119. (1989). Supplemental nasogastric feeding in cystic fibrosis patients during treatment for acute exacerbation of chest disease.
  120. (1986). Surg
  121. (1989). TEN versus TPN following major abdominal trauma – reduced septic morbidity.
  122. (1982). The effect of a dietary supplement (Build-up) on nutritional status in hospitalized elderly patients. Hum Nutr: Appl Nutr
  123. (1987). The effect of nutritional support on outcome from severe head injury.
  124. (1989). The effect of oral nutritional supplements on head and neck cancer.
  125. (1983). The favorable effect of early parenteral feeding on survival in head-injured patients.
  126. (1988). Total enteral nutrition versus total parenteral nutrition after major torso injury: attenuation of hepatic protein reprioritization. Surgery
  127. (1981). Total parenteral nutrition versus gastrostomy in the preoperative preparation of patients with carcinoma of the oesophagus.
  128. (2005). Treatment with supplementary arginine, vitamin C, and zinc in patients with pressure ulcers: a randomised controlled trial. Clin Nutr
  129. (1990). Utility and importance of caloric supplementation with an immune-enhancing diet in gastrectomized patients. (Abstract) Clin Nutr 2003; 22:S86 14. Cabre E,
  130. (1990). Very early nutrition supplementation in burned patients. Am J Clin Nutr

To submit an update or takedown request for this paper, please submit an Update/Correction/Removal Request.