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.