Background
When a person is unwell and is unable to eat (or to eat enough), the lack of nutrition can be a serious obstacle to recovery. In these circumstances, feeding through a feeding tube that enters through the nose and passes through the stomach to the small intestine beyond (a post-pyloric naso-enteral feeding tube), is an option.
Review question
Once the feeding tube has entered the digestive system, placing the feeding tube into the small intestine rather than the stomach is difficult. Metoclopramide (which is also an anti-sickness medication), increases the rate at which the stomach empties, and has tested as a therapy to determine whether it assists with placement of post-pyloric naso-enteral feeding tubes.
Use of metoclopramide is controversial, as it may cause harms (adverse reactions), which may be serious and may include an irreversible neurological condition that can be caused by prolonged use, or high doses of metoclopramide.
Study characteristics
We originally searched for clinical trials in 2002; and again in 2008 and 2014. We identified four studies that investigated the use of metoclopramide in placement of post-pyloric naso-enteral feeding tubes. The trials included a total of 204 adult participants; 108 participants were treated with metoclopramide, and 96 were given a placebo or no treatment. All four studies were done in hospitals in the USA. The number of participants included in the trials varied from 105 to 10.
The trials were all performed before 1995. They were all small, and examined two different doses of metoclopramide (10 mg and 20 mg), delivered in two different ways (intravenously, and injected into muscle). The way in which they were conducted and reported was poor.
Key results
Analysis of the four trials revealed that metoclopramide did not have a clear beneficial on the placement of post-pyloric naso-enteral feeding tubes. No harms (adverse reactions) were reported, though it was not clear how thoroughly the people running the trials recorded them. No costs of treatment were reported.
Quality of the evidence
The quality of the evidence is very low. The four trials were too small to identify any effect clearly; they also used different doses of metoclopramide, (tested against placebo or no treatment). It is unlikely that further studies will be performed to establish whether metoclopramide is helpful in placement of post-pyloric naso-enteral feeding tubes.
In this review, we found only four studies that fitted our inclusion criteria. These were small, underpowered studies, in which metoclopramide was given at doses of 10 mg and 20 mg. Our analysis showed that metoclopramide did not assist post-pyloric placement of naso-enteral feeding tubes.
Ideally randomised clinical trials should be performed that have a significant sample size, administering metoclopramide against control, however, given the lack of efficacy revealed by this review it is unlikely that further studies will be performed.
Enteral nutrition by feeding tube is a common and efficient method of providing nutritional support to prevent malnutrition in hospitalised patients who have adequate gastrointestinal function but who are unable to eat. Gastric feeding may be associated with higher rates of food aspiration and pneumonia than post-pyloric naso-enteral tubes. Thus, enteral feeding tubes are placed directly into the small intestine rather than the stomach, and the use of metoclopramide, a prokinetic agent, has been recommended to achieve post-pyloric placement, but its efficacy is controversial. Moreover, metoclopramide may include adverse reactions, which with high doses or prolonged use may be serious and irreversible.
To determine the effect of intravenous metoclopramide on post-pyloric placement of the naso-enteral tube in adults.
Trials were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 10) which includes the CUGPD group's specialised register of trials, MEDLINE (1996 to 21 October 2014), EMBASE (1988 to 21 October 2014), LILACS (2005 to 21 October 2014) We did not confine our search to English language publications. Searches in all databases were updated originally in January 2005, then in November 2008 and again in October 2014. No new studies were found in 2008 or in 2014.
We selected randomised controlled trials of adults needing enteral nutrition, who received intravenous or intramuscular metoclopramide to aid placement of transpyloric naso-enteral feeding tubes, compared to placebo or no intervention.
We used standard methodological procedures expected by The Cochrane Collaboration. All analyses were performed according to the intention-to-treat method. We present risk ratios (RR) with 95% confidence intervals (CI).
Four studies, with a total of 204 participants were included and analysed. The trials compared metoclopramide with placebo (two trials) or with no intervention (two trials). Metoclopramide was investigated at doses of 10 mg (two trials) and 20 mg (two trials). There was no statistically significant difference between metoclopramide versus placebo or no intervention administered to promote tube placement (RR 0.82, 95% CI 0.61 to 1.10). Metoclopramide at doses of 10 mg (RR 0.82, 95% CI 0.60 to 1.11) and 20 mg (RR 0.62, 95% CI 0.15 to 2.62) were equally ineffective in facilitating post-pyloric intubation when compared with placebo or no intervention.