Nutritional Support for Patients Sustaining Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Prospective Studies

<div><p>Background</p><p>In traumatic brain injury (TBI), the appropriate timing and route of feeding, and the efficacy of immune-enhancing formulae have not been well established. We performed this meta-analysis aiming to compare the effects of different nutritional support modalities on clinical outcomes of TBI patients.</p> <p>Methods</p><p>We systematically searched Pubmed, Embase, and the Cochrane Library until October, 2012. All randomized controlled trials (RCTs) and non-randomized prospective studies (NPSs) that compared the effects of different routes, timings, or formulae of feeding on outcomes in TBI patients were selected. The primary outcomes included mortality and poor outcome. The secondary outcomes included the length of hospital stay, the length of ventilation days, and the rate of infectious or feeding-related complications.</p> <p>Findings</p><p>13 RCTs and 3 NPSs were included. The pooled data demonstrated that, compared with delayed feeding, early feeding was associated with a significant reduction in the rate of mortality (relative risk [RR] = 0.35; 95% CI, 0.24–0.50), poor outcome (RR = 0.70; 95% CI, 0.54–0.91), and infectious complications (RR = 0.77; 95% CI, 0.59–0.99). Compared with enteral nutrition, parenteral nutrition showed a slight trend of reduction in the rate of mortality (RR = 0.61; 95% CI, 0.34–1.09), poor outcome (RR = 0.73; 95% CI, 0.51–1.04), and infectious complications (RR = 0.89; 95% CI, 0.66–1.22), whereas without statistical significances. The immune-enhancing formula was associated with a significant reduction in infection rate compared with the standard formula (RR = 0.54; 95% CI, 0.35–0.82). Small-bowel feeding was found to be with a decreasing rate of pneumonia compared with nasogastric feeding (RR = 0.41; 95% CI, 0.22–0.76).</p> <p>Conclusion</p><p>After TBI, early initiation of nutrition is recommended. It appears that parenteral nutrition is superior to enteral nutrition in improving outcomes. Our results lend support to the use of small-bowel feeding and immune-enhancing formulae in reducing infectious complications.</p> </div

Comparison of the effect of enteral feeding and parenteral feeding on outcomes in patients with TBI.

<p>(A) Forest plot illustrates the different effect on mortality. (B) Forest plot shows the different effect on poor outcome. PO, poor outcome.</p

Subgroup analyses for studies evaluating the effects of early nutrition and delayed nutrition on mortality.

<p>Abbreviations: EN, enteral nutrition; N, number of studies; NPS, non-randomized prospective study; PN, parenteral nutrition; RCT, randomized controlled trial; RR, relative risk.</p

Funnel plots for the detection of publication bias.

<p>(A) Funnel plot of studies evaluating the effects of feeding timings on mortality, which is approximately symmetric. (B) Funnel plot of studies evaluating the effects of feeding routes on mortality, which appears to be symmetric.</p

Comparison of the effect of enteral feeding and parenteral feeding on infectious complications in patients with TBI.

<p>Comparison of the effect of enteral feeding and parenteral feeding on infectious complications in patients with TBI.</p

Subgroup analyses for studies evaluating the effects of parenteral nutrition and enteral nutrition on mortality.

<p>Abbreviations: EN, enteral nutrition; N, number of studies; PN, parenteral nutrition; RR, relative risk.</p

The flow diagram shows the selection of studies for the meta-analysis.

<p>The flow diagram shows the selection of studies for the meta-analysis.</p

Comparison of the effect of early feeding and delayed feeding on infectious complications in patients with TBI.

<p>Comparison of the effect of early feeding and delayed feeding on infectious complications in patients with TBI.</p

Flow diagram of the literature search and study selection processes.

<p>Flow diagram of the literature search and study selection processes.</p

Effect of modafinil on study discontinuation due to adverse events.

<p>Effect of modafinil on study discontinuation due to adverse events.</p