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A Post-Extubation Early Feeding Protocol (PEEF) in a Tertiary Paediatric Intensive Care Unit: A Quality Improvement

Sora Jung1, Sainath Raman2,3, Ian Hughes4,5

  • 1Children's Critical Care Unit, Gold Coast University Hospital, Southport, Australia.

Journal of Paediatrics and Child Health
|December 3, 2025
PubMed

Insights

The Post-Extubation Early Feeding (PEEF) protocol successfully reduced the time to restart enteral nutrition and reach pre-extubation feeding rates in paediatric intensive care unit patients. Further assessment and education are needed to fully achieve protocol goals.

Area of Science:

  • Pediatric critical care medicine
  • Clinical nutrition
  • Quality improvement initiatives

Background:

  • Delayed recommencement of enteral nutrition post-extubation is a common challenge in pediatric intensive care units (PICUs).
  • Early enteral nutrition is crucial for patient recovery and outcomes.

Purpose of the Study:

  • To evaluate the effectiveness of a Post-Extubation Early Feeding (PEEF) protocol on the timing of enteral nutrition resumption after extubation in a tertiary PICU.
  • To assess the impact of the PEEF protocol on the time taken to reach pre-extubation feeding rates.

Main Methods:

  • A quality improvement project implemented the PEEF protocol in a tertiary PICU.
  • Retrospective analysis of data from children (0-18 years) undergoing planned extubation before (Nov 2019-Oct 2020) and after (Nov 2021-Oct 2022) protocol implementation.
  • The PEEF protocol aimed to re-commence enteral nutrition at 50% of the pre-fasting rate within 1 hour and reach the pre-extubation rate within 2 hours post-extubation.

Main Results:

  • A total of 795 patients were analyzed (372 pre-PEEF, 423 post-PEEF).
  • The median time to recommence enteral nutrition decreased significantly from 4.2 hours pre-PEEF to 3.2 hours post-PEEF (p < 0.0001).
  • The median time to reach the pre-fasting feeding rate also reduced from 7.3 hours pre-PEEF to 5 hours post-PEEF (p = 0.0005).

Conclusions:

  • Implementation of the PEEF protocol led to a significant reduction in the time to resume enteral nutrition and reach target feeding rates.
  • While improvements were observed, the outcomes did not consistently meet the ambitious goals set by the PEEF protocol.
  • Ongoing assessment and targeted education are recommended to further optimize enteral feeding practices post-extubation.
Abstract

Keywords:
PICUenteral nutritionfeeding protocolpost extubation early feeding

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