Decision Making Surrounding Mode of Initial Enteral Feeding in Critically Ill Pediatric Patients

Background: Wide practice variation and weak guidelines exist when considering enteral feeding options and the decision to proceed with gastric or postpyloric enteral feeding in critically ill infants and children. The purpose of this pilot study is to explore provider decision making in early feeding of critically ill pediatric patients, review the indications for choice of enteral feeding access, and qualitatively explore the role of institutional culture in medical decision making. Methods: In-person structured interviews of multi-level providers were conducted over a two-week period in PICU, NICU, and pediatric cardiac intensive care unit at our facility. A survey was developed to evaluate practitioner demographics as well as decision-making for feeding access in mock scenarios. Descriptive analysis was used for demographics and quantitative responses. Interview transcripts were analyzed using qualitative content analysis to identify common themes and variance in decision making. Results: Providers selected gastric feeding for most of the mock scenarios, a median of 7.4 times for 10 scenarios [IQR 6-9]. At least 1/3 of respondents selected postpyloric feeding for patients with neurologic impairment, hypotonia, aspiration pneumonia, and severe burns. 85% (n = 22) felt institutional culture plays a role in their decision making. 52% (n = 14) felt that postpyloric tubes result in more complications. Conclusion: Initial feeding tube decisions vary among providers, and many feel institutional culture and personal experience play a role in these decisions. Stronger feeding guidelines may help to decrease variability in enteral access choice.