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THE OFFICIAL JOURNAL OF THE BRITISH DIETETIC ASSOCIATION
Editor: Simon Langley-Evans
Journal of
Human Nutrition
and
Dietetics
VOLUME 31 • ISSUE 2 • APRIL 2018
CLINICAL NUTRITION
DIETETIC PRACTICE
DIETARY PATTERNS
CARBOHYDRATES
BODY COMPOSITION AND ENERGY EXPENDITURE
jjhn_v31_i2_Issueinfo.indd 1hn_v31_i2_Issueinfo.indd 1 112-Mar-18 11:52:58 AM2-Mar-18 11:52:58 AM
Journal of
Human Nutrition and Dietetics
The Offi cial Journal of the British Dietetic Association
Editor-in-Chief Editorial Board
Professor Simon Langley-Evans A. Anderson, Centre for Public Health Nutrition Research, University of Dundee, UK
Deputy Head of School of Biosciences T. Baranowski, Bayor College of Medicine, USA
University of Nottingham, J. Bauer, School of Human Movement Studies, University of Queensland, Australia
UK. T. Burrows, University of Newcastle, Australia
E-mail: simon.langley-evans@nottingham.ac.uk J. Coad, Massey University, New Zealand
Associate Editors C. Collins, University of Newcastle, Australia
S Burden, University of Manchester, UK P. Collins, Faculty of Health, Queensland University of Technology, Australia
C Green, Nutricia, The Netherlands K. Davison, Simon Fraser University, Canada
J. Harvey, University of Vermont, USA
M. Hickson, Faculty of Medicine, Imperial College London, UK
J. Hodgson, University of Western Australia, Australia
M. Kiely, CountyCollege Cork, Ireland
F. Kolahdooz, University of Alberta, Canada
I. Lemieux, Quebec Heart Institute, Laval University, Canada
S. Lennie, School of Pharmacy and Life Sciences, Robert Gordon University, UK
A. Madden, School of Health and Emergency Professions, University of Hertfordshire, UK
M. McInley, Queens University Belfast, UK
D. Mellor, University of Canberra, Australia
C. Nowson, Deakin University, Australia
T. Ong, Sao Paolo University, Brazil
A. OSullivan, Institute of Food and Health, University College Dublin, Ireland
M. Pakseresht, University of Alberta, Canada
Y. Probst, University of Wollongong, Australia
A. Roefs, Faculty of Psychology, Maastricht University, The Netherlands
J. Swift, School of Biosciences, University of Nottingham, UK
M. Taylor, School of Biomedical Sciences, University of Nottingham, UK
K. Whelan, Kings College London, UK
L. Williams, Department of Oncology, University of Sheffi eld, UK
L. Wood, University of Newcastle, Australia
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jjhn_v31_i2_Issueinfo.indd 2hn_v31_i2_Issueinfo.indd 2 112-Mar-18 11:52:59 AM2-Mar-18 11:52:59 AM
Journal of Human Nutrition and Dietetics
CLINICAL NUTRITION
Asystematic review of feeding practices among
postoperative patients: is practice in-line with
evidenced-based guidelines?
1,2 2,3 2,3,4 1,2
M. Rattray, S. Roberts, A. Marshall &B. Desbrow
1
School of Allied Health Sciences, Griffith University, Southport, QLD, Australia
2
Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
3
National Centre of Research Excellence in Nursing (NCREN), Griffith University, Southport, QLD, Australia
4
School of Nursing and Midwifery, Griffith University, Southport, QLD, Australia
Keywords Abstract
early oral feeding, perioperative care,
postoperative care, early recovery after surgery. Background: Early oral feeding after surgery is best practice among adult,
noncritically ill patients. Evidenced-based guidelines (EBG) recommend
Correspondence commencing liquid and solid feeding within 24 h of surgery to improve
Megan Rattray, School of Allied Health Sciences, patient (e.g. reduced morbidity) and hospital (e.g. reduced length of stay)
Griffith University, Southport, QLD, Australia. outcomes. Whether these EBG are adhered to in usual clinical practice
Tel.: +61 567 80 154 remains unknown. The present study aimed to identify the time to com-
E-mail: megan.rattray@griffithuni.edu.au
mencement of first oral feed (liquid or solid) and first solid feed among
Howtocite this article postoperative, noncritically ill, adult patients.
Rattray M., Roberts S., Marshall A. & Desbrow B. Methods: MEDLINE, CINAHL, SCOPUS and Web of Science databases
(2018) A systematic review of feeding practices were searched from inception to June 2016 for observational studies report-
among postoperative patients: is practice in-line ing liquid and/or solid feeding practices among postoperative patients. Stud-
with evidenced-based guidelines? J Hum Nutr ies reporting a mean/median time to first feed or first solid feed within 24 h
Diet. 31, 151–167 of surgery or where ≥75% of patients were feeding by postoperative day one
https://doi.org/10.1111/jhn.12486 were considered in-line with EBG.
Results: Of 5826 articles retrieved, 29 studies were included. Only 40% and
22% of studies reported time to first feed and time to first solid feed in-line
with EBG, respectively. Clear and free liquids were the first diet types com-
menced in 86% of studies. When solids were commenced, 44% of studies
reported using various therapeutic diet types (e.g. light) prior to the com-
mencement of a regular diet. Patients who underwent gastrointestinal proce-
dures appeared more likely to experience delayed postoperative feeding.
Conclusions: Our findings demonstrate a gap between postoperative feeding
evidence and its practical application. This information provides a strong
rationale for interventions targeting improved nutritional care following
surgery.
Introduction and/or anastomotic leakage thought to occur if fed prema-
turely (1–3). However, there is little evidence to suggest that
The traditional postoperative feeding approach dictates these adverse outcomes are likely to occur, particularly fol-
fasting patients until the return of bowel function (e.g. pas- lowing nongastrointestinal surgeries (4–6). Traditional post-
(1)
sage of flatus and/or stool or bowel sounds) . This operative feeding results in substantial periods of avoidable
approach was designed to avoid paralytic ileus (leading to inadequate nutritional intake among patients who may
vomiting, aspiration pneumonia and wound dehiscence) already be at nutritional risk, and who require optimal
ª2017The British Dietetic Association Ltd. 151
Postoperative feeding in habitual practice M. Rattray et al.
nutrition for recovery and prevention of complications (4). present study will clarify whether delayed postoperative
Malnutrition is a prevalent problem among surgical fluid and/or solid feeding practices persist and to what
patients as a result of factors preceding (e.g. diseased state, extent among various postoperative groups. This informa-
preoperative dietary practices) and following surgery (e.g. tion will inform whether (and where) interventions are
postoperative symptoms and dietary practices) (7,8). required to bridge the gap between knowledge and prac-
By contrast to traditional beliefs, recent evidence indi- tice to improve patient and health care-related outcomes.
cates early oral or enteral feeding (i.e. within 24 h after As such, the specific aims of this review, in the context of
surgery) is safe and beneficial to adult, noncritically ill, habitual clinical practice, are to identify:
(1,5,6,9–18)
postoperative patients . Early oral feeding has
been associated with a faster recovery of intestinal func- The time to and type of first feed (liquid or solid)
tion (i.e. resolution of ileus) (5,6,9,10,19,20), reduced mor- commenced among noncritically ill, adult, postoperative
bidity (e.g. less infectious complications and improved patients;
wound healing and immunity) (5,11–13,15,21,22) and improved The time to and type of first solid feed commenced
quality of life (e.g. patient satisfaction and ambulation) among noncritically ill, adult, postoperative patients; and
(12,16–19) among various surgical populations such as upper Whether specific postoperative patient groups are at
and lower gastrointestinal, obstetric and gynaecological greater risk of delayed feeding than others.
patients. In addition, a rapid transition back to solid food
is important for reducing the risk of malnutrition and its Materials and methods
(23) (24,25)
associated consequences such as infections ,falls ,
(26) (27)
pressure injuries and morbidity and mortality . The methodology of this review was devised in accor-
Improved patient-related outcomes translate into dance with the Meta-Analyses and Systematic Reviews of
shorter lengths of hospitalisation and reduced healthcare Observational Studies Guidelines (MOOSE) (40) and regis-
(5,9,11,13–16,28)
costs . As such, there are many potential bene- tered at the International Prospective Register for System-
fits to the rapid reintroduction of nutrition following sur- atic Reviews (identification code: CRD 42016052832).
gery.
Over the past decade, early oral feeding practice recom- Search methods
mendations have been incorporated into evidenced-based
postoperative care guidelines for gynaecological (2), hep- Potentially eligible studies were identified by searching the
(29) (30) (31)
atic , pancreaticoduodenal , gastric , colorectal online databases MEDLINE (1965–2016), Cumulative
(32–34)
and rectal and pelvic patients . In general, these Index of Nursing and Allied Health Literature (CINAHL,
guidelines recommend liquid feeding to recommence 1985–2016), SCOPUS (1977–2016) and Web of Science
within 24 h, or ideally within 4 h following surgery in (1956–2016), using a Boolean search strategy developed
low-risk patient populations (e.g. lower gastrointestinal). in collaboration with a librarian. The search strategy
Solid feeding is then suggested to commence within 24 h involved using the AND operator to link keywords used
of surgery (2,29–34). for the population (e.g. postoperativ* OR surg* OR hos-
Despite clear guidelines, it is well known that the adop- pital), exposure (e.g. nil by mouth OR clear fluids OR
tion of research findings into clinical practice is often a slow oral feeding) and outcome (e.g. time OR practice OR fre-
and onerous process, with evidenced-based research taking quency) of interest. Truncation was used where applicable
(35)
up to two decades to establish as habitual practice . Fur- to capture variation in word terminology (e.g. postopera-
thermore, studies show that 30–40% of patients do not tiv*: postoperative, postoperatively) and enclosed quota-
receive healthcare in accordance with evidence-based tion marks were used to search for exact phrases. The
(36)
knowledge . Considering traditional practices are diffi- search was not limited to language, nor restricted by any
(37,38)
cult to change , investigations into whether this is the other means, with the exception of limits set on research
case for early commencement of feeding among noncriti- fields in Web of Science (restricted to: surgery, cardiovas-
cally ill, adult, postoperative patients are warranted. cular system cardiology, gastroenterology hepatology, res-
The present study aimed to examine feeding practices piratory system, general internal medicine, oncology,
in postoperative patients by performing a systematic otorhinolaryngology, urology nephrology, anaesthesiology,
review of the available evidence. Considering transient geriatrics gerontology, emergency medicine, nutrition
improvements are often seen with intervention pro- dietetics, nursing, obstetrics gynaecology, rehabilitation
(39)
grammes in clinical practice , this evidence is reviewed and physiology). To maximise retrieval of eligible evi-
in the context of habitual practice only (i.e. absence of dence, forward and backward citation tracking was per-
recent intervention programmes). Findings from the formed on all included studies.
152 ª2017The British Dietetic Association Ltd.
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