Skipping routine stomach checks was safe for ventilated children and fed them better

A long-standing intensive-care routine — regularly drawing back the contents of a sick child's stomach through a feeding tube to check the feeds are being tolerated — can be safely abandoned, and dropping it feeds children better, according to the GASTRIC-PICU trial published in JAMA [s1].

The practice being tested is the routine assessment of gastric residual volume: every few hours, staff aspirate the stomach through the feeding tube and measure what comes back, on the theory that a large volume means the feed is not moving on and risks being vomited and inhaled into the lungs [s1]. The habit is widespread but is not based on evidence, and a perceived high volume often prompts staff to withhold feeds — which impairs the delivery of nutrition to children who are already critically ill [s1]. GASTRIC-PICU asked whether the checks are worth doing at all.

What the trial did

GASTRIC-PICU was a pragmatic, multicentre, randomised non-inferiority trial run in 23 paediatric intensive care units (PICUs) in the UK and one in Switzerland [s1]. It recruited 4,700 children aged 0 to 16 years who were receiving invasive ventilation and starting enteral (tube) feeds, between 29 June 2023 and 7 December 2025, with 30-day follow-up completed on 6 January 2026 [s1]. Children were randomised 1:1 to usual care — gastric residual volume assessed every 6 hours — or to no routine assessment, in which feed tolerance was judged from clinical signs alone [s1]. All other feeding practices followed local protocols [s1]. The trial was registered as ISRCTN79668198 and sponsored by the Intensive Care National Audit & Research Centre [s2].

The trial had two co-primary outcomes. The clinical one, tested for non-inferiority, was a composite of survival and days free from mechanical ventilation at 30 days [s1]. The nutritional one, tested for superiority, was the percentage of children meeting their energy requirements by 72 hours [s1].

What it found

Of the 4,700 children randomised — 2,352 to no routine assessment and 2,348 to usual care — 4,460 were included in the main analysis; their median age was 8 months and 42.6% were female [s1].

Dropping the checks was non-inferior on the clinical outcome. The median number of days alive and free from ventilation at 30 days was 25 (interquartile range, 21 to 27) in both groups, with an adjusted odds ratio of 0.95 (95% confidence interval, 0.86 to 1.05) [s1]. A per-protocol analysis, which looks only at children treated as assigned, agreed closely (adjusted odds ratio, 1.01; 95% confidence interval, 0.90 to 1.13) [s1].

On nutrition, removing the checks did better. The mean percentage of energy requirements met by 72 hours was 80.3% in the no-routine-assessment group against 76.8% with usual care, an adjusted mean difference of 3.2 percentage points (95% confidence interval, 1.3 to 5.2; P<.001) [s1].

How to read it

This is a de-implementation trial — a study designed not to add a treatment but to test whether an entrenched practice can be safely removed. Its clean result is that the routine check bought nothing for safety and cost children some of their nutrition, because feeds were being paused on the strength of a measurement that did not predict harm [s1]. Removing it left the hard outcomes unchanged and let more children reach their feeding targets sooner [s1].

The trial's scale and design lend it weight: nearly 4,700 children across two dozen units, with the clinical outcome held to a non-inferiority test and the nutritional outcome to a superiority test, so the "better feeding" claim was not a fishing expedition but a prespecified question [s1]. It was sponsored by an academic clinical-audit body rather than a company with a product to sell [s2].

The findings apply to critically ill children on invasive ventilation who are being tube-fed, not to every child in intensive care, and a trial of removing a practice cannot blind staff to what they are — or are not — doing [s1]. Local feeding protocols still governed everything else, so the result is about the residual-volume check specifically, not about how aggressively to feed [s1].

Why it matters

Intensive care is full of rituals that persist because they feel prudent, and each one costs time, attention and — here — nutrition. GASTRIC-PICU shows that this particular ritual can go, freeing nursing time and improving feeding without any measurable cost to safety [s1]. It is a reminder that stopping a low-value practice can be as valuable as starting a new one.

For a related lesson in how routine interventions fare when they are finally put to a controlled test, see our coverage of sham-controlled surgery for shoulder and knee pain.

This article describes trial results and is not medical advice. Decisions about feeding critically ill children are for their treating clinicians.

Sources

• Gastric Residual Volume Assessment in Critically Ill Children: The GASTRIC-PICU Randomized Clinical Trial — JAMA, 2026 (primary trial report)
• No routine gastric residual monitoring to guide enteral feeding in paediatric intensive care units, ISRCTN79668198 — ISRCTN registry (trial registration; sponsor ICNARC)