Gastric Residual Volume Assessment in Critically Ill Children

Importance: Routine assessment of gastric residual volume (GRV) to guide enteral feeding in critically ill children is widespread but not based on evidence. Perceived high gastric volumes often lead to withholding feeds, impairing nutritional delivery. Objective: To evaluate the effect of not routinely assessing GRV compared with assessments at least every 6 hours in children undergoing mechanical ventilation on the duration of mechanical ventilation and survival and achievement of nutritional targets. Design, Setting, and Participants: A pragmatic, multicenter, randomized, noninferiority trial in 23 pediatric intensive care units (PICUs) in the UK and 1 in Switzerland. A total of 4700 children aged 0 to 16 years who were receiving invasive ventilation and starting enteral feeds were recruited between June 29, 2023, and December 7, 2025, with 30-day follow-up completed on January 6, 2026. Interventions: Children were randomized (1:1) to receive usual care (GRV assessment every 6 hours) or no routine GRV assessment to guide enteral feeding. In the no routine GRV assessment group, feed tolerance was assessed using only clinical signs. All other enteral feeding practices followed local protocols. Main Outcomes and Measures: The clinical co-primary outcome (noninferiority) was a composite of survival and days free from mechanical ventilation at 30 days. The nutritional co-primary outcome (superiority) was the percentage of children meeting energy requirements by 72 hours. Results: Of the 4700 children randomized (2352 to the no routine GRV assessment group and 2348 to the usual care group), 4460 were included in the intention-to-treat analysis (median [IQR] age, 8 [1-44] months; 1925 [42.6%] females). No routine GRV assessment was noninferior to regular 6-hourly assessments for survival and days free from mechanical ventilation at 30 days (median [IQR], 25 [21-27] days in both groups; adjusted odds ratio [OR], 0.95 [95% CI, 0.86-1.05]). Results of the per-protocol analysis were consistent with the intention-to-treat analysis (adjusted OR, 1.01 [95% CI, 0.90-1.13]). The mean percentage of energy requirements achieved by 72 hours was 80.3% in the no routine GRV assessment group and 76.8% in the usual care group (adjusted mean difference, 3.2 [95% CI, 1.3-5.2] percentage points; P < .001). Conclusions and Relevance: Among critically ill children being enterally fed, not assessing GRV routinely was noninferior to regular assessments every 6 hours and significantly increased nutritional achievement at 72 hours. Trial Registration: isrctn.org Identifier: ISRCTN79668198.

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Publication Details

Journal
JAMA
Published
2026-06-12
DOI
https://doi.org/10.1001/jama.2026.10639
Primary Topic
Clinical Nutrition and Gastroenterology
Type
article
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article

Gastric Residual Volume Assessment in Critically Ill Children

Lynne Latten, Rebecca Harmer, Melanie James, Zia Sadique et al.
JAMA
Clinical Nutrition and Gastroenterology
article

Gastric Residual Volume Assessment in Critically Ill Children

Lynne Latten, Rebecca Harmer, Melanie James, Zia Sadique, Justin Wang, David A Harrison, C D Knott, Carly Au, Julia M. Broomhall, Millie Parke, S Hulme, Julie Camsooksai, Rob Claydon, L P Dodge, Daggett, Paloma Ferrando-Vivas, L Mutch, Marzena Orzol, Benjamin Crulli, Lara Bunni, Louise Humphreys, Bak Jf, Emma Laing, L Lazzari, K M Gadhvi, Margarita Guillén Ortega, Paul R. Mouncey, Tahmina Khatun, L Tous, Irene Chang, P Wellman, Emily Beech, Avishay Sarfatti, Carly Tooke, C. Silvestre, Lamprini Lampro, Nadine Heenan, Farjhana Bokth, E D DAY, Nazima Pathan, Fiona Bowman, Susanne Cathcart, Kate Plant, Joanne Pena, Sara Thomas, Rachael Dewey, Hannah Sedgwick, Laura Miketa, Jahara Khatun, Lyvonne N. Tume, Lewis Veale, Luregn J. Schlapbach, Paris-Lucia Harrison, Julie Menzies, Richard Neal, Esther Daubney, Katherine L. Brown, Ramesh Kumar, Pompa Kukreja, Sarah Fox, Frederic V. Valla, Anna Little, Aleks Williams, Shannon McCarty, Angela Aramburo, Helena Sampaio, Rebecca Marshall, Julie Richardson, Laura O'Malley, Chinwa Okeke, Luise V. Marino, Deborah White, Ruth Hornby, Morgan White, Manal Alasnag, Laura Ainsworth, Sarah Berkenstein, Louise Parker, Holly Belfield, Mark J. Peters, Adil Dingankar, Kerry Woolfall, Nigel J. Hall, Thanh Nguyen, Laura McConaghy, Laura Alcantara-Gemar, GASTRIC-PICU Investigators of the Paediatric Critical Care Society Study Group (PCCS-SG), Rekha Patel, Claire Jennings, Hannah Armah, Helen Fisher, Emma Simpson, Elizabeth Henderson, Andrea Owusu-Ansah, Anzad Madathil Amanullah, Libby Greenberg, Martin Cowie, Amisha Mistry, Roberta Carlisle, Helen Winmill
article en

Abstract

Importance: Routine assessment of gastric residual volume (GRV) to guide enteral feeding in critically ill children is widespread but not based on evidence. Perceived high gastric volumes often lead to withholding feeds, impairing nutritional delivery. Objective: To evaluate the effect of not routinely assessing GRV compared with assessments at least every 6 hours in children undergoing mechanical ventilation on the duration of mechanical ventilation and survival and achievement of nutritional targets. Design, Setting, and Participants: A pragmatic, multicenter, randomized, noninferiority trial in 23 pediatric intensive care units (PICUs) in the UK and 1 in Switzerland. A total of 4700 children aged 0 to 16 years who were receiving invasive ventilation and starting enteral feeds were recruited between June 29, 2023, and December 7, 2025, with 30-day follow-up completed on January 6, 2026. Interventions: Children were randomized (1:1) to receive usual care (GRV assessment every 6 hours) or no routine GRV assessment to guide enteral feeding. In the no routine GRV assessment group, feed tolerance was assessed using only clinical signs. All other enteral feeding practices followed local protocols. Main Outcomes and Measures: The clinical co-primary outcome (noninferiority) was a composite of survival and days free from mechanical ventilation at 30 days. The nutritional co-primary outcome (superiority) was the percentage of children meeting energy requirements by 72 hours. Results: Of the 4700 children randomized (2352 to the no routine GRV assessment group and 2348 to the usual care group), 4460 were included in the intention-to-treat analysis (median [IQR] age, 8 [1-44] months; 1925 [42.6%] females). No routine GRV assessment was noninferior to regular 6-hourly assessments for survival and days free from mechanical ventilation at 30 days (median [IQR], 25 [21-27] days in both groups; adjusted odds ratio [OR], 0.95 [95% CI, 0.86-1.05]). Results of the per-protocol analysis were consistent with the intention-to-treat analysis (adjusted OR, 1.01 [95% CI, 0.90-1.13]). The mean percentage of energy requirements achieved by 72 hours was 80.3% in the no routine GRV assessment group and 76.8% in the usual care group (adjusted mean difference, 3.2 [95% CI, 1.3-5.2] percentage points; P < .001). Conclusions and Relevance: Among critically ill children being enterally fed, not assessing GRV routinely was noninferior to regular assessments every 6 hours and significantly increased nutritional achievement at 72 hours. Trial Registration: isrctn.org Identifier: ISRCTN79668198.

JAMA
University of Liverpool (GB), The University of Queensland (AU), Edge Hill University (GB), University of the West of England (GB), BCS — The Chartered Institute for IT (GB), Great Ormond Street Hospital (GB), Great Ormond Street Hospital for Children NHS Foundation Trust (GB), University Hospitals Bristol NHS Foundation Trust (GB), House of Representatives (NL), London School of Hygiene & Tropical Medicine (GB), Alder Hey Children's NHS Foundation Trust (GB), Hospices Civils de Lyon (FR), Faculty of Public Health (GB), University Children's Hospital Zurich (CH), Intensive Care National Audit & Research Centre (GB), University of Southampton (GB), University College London (GB), Liverpool John Moores University (GB)
Zero hunger
Openalex Percentile: Top 7%
Clinical Nutrition and Gastroenterology
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