Review for 10.1186/s12876-025-03837-8 (2025)

Title: Risk Factors for Enteral Feeding Intolerance in Critically Ill Patients: An Updated
Systematic Review and Meta-Analysis
Version: 0 Date: 27 Feb 2025
Reviewer:  Pei Chien Tah
Reviewer's report:
Reviewer comments to the authors
An interesting systematic review related to the risk factors for enteral feeding intolerance in
critically ill patients is scientifically strong, but refining the clarity, structure, and practical
implications will make it even better. There are some comments and feedback for this
manuscript:
Strengths:
Relevant Topic – The study addresses a crucial issue in ICU nutrition, which is highly relevant
for clinical practice.
Comprehensive Literature Review – The manuscript includes a broad literature search with
multiple databases and a systematic approach.
Clear Methodology – The use of PRISMA guidelines and PROSPERO registration adds
credibility.
Robust Data Analysis – Sensitivity analyses and different models strengthen the study's
reliability.
Areas for Improvement:
Title:
The title can be refined for better clarity and flow. Suggested revision: "Risk Factors for
Enteral Feeding Intolerance in Critically Ill Patients: An Updated Systematic Review and Meta-
Analysis"
(This improves readability and corrects "An Updated meta-analysis Systematic review," which
has redundancy.)
Abstract:
Objective Statement: The phrase “influencing factors” can be replaced with “risk factors” for
consistency.
Results Section: Listing all influencing factors in one long sentence reduces readability.
Breaking it down into key categories (e.g., patient characteristics, feeding methods, medications)
would improve clarity.
Methods:
Search Strategy:
- The term “et al.” is incorrectly used in "PubMed, Embase, Scopus, Medline, Web of Science,
CNKI, VIP network, et al." Remove "et al." as it suggests missing sources.
- Clearly state if grey literature (conference abstracts, dissertations) was included or excluded.
Data Extraction & Quality Assessment:
- Specify how discrepancies were resolved between reviewers (e.g., consensus or third-party
adjudication).
- The assessment tools (NOS, AHRQ) are appropriate, but were any modifications made to adapt
them for this study?
Results:
Heterogeneity Analysis:
Heterogeneity values (I²) are well-reported, but some are quite high (e.g., 92% for potassium
preparation, mechanical ventilation, etc). Consider discussing possible sources of high
heterogeneity (I² more than 90%).
Forest Plots & Figures:
You mention "Fig. X" throughout the results, but figures are missing in this text. Ensure figures
are correctly numbered and referenced. Why only show 4 forest plots? How about other forest
plots to report the relationship between BMI and EFI, sepsis and EFI, nutritional formula and
EFI, digestive system diseases and EFI, etc?
Clarity of Statistical Reporting:
"Statistical heterogeneity was found between studies (P = 0.10, I² = 56%)" – consider a clearer
transition when moving between studies to avoid abrupt shifts in focus.
Discussion:
Clinical Implications:
- Your discussion is strong, but more practical recommendations for clinicians could be added,
e.g., how to manage EFI based on identified risk factors.
- The impact of feeding protocols (e.g., continuous vs. bolus feeding) is mentioned briefly but
could be expanded.
Comparison with Previous Studies:
- The discussion references various studies but lacks a critical comparison of how findings align
or contrast with previous meta-analyses.
Limitations Section:
- You mention a regional bias (many studies from China), but consider mentioning language
bias (if non-English studies were excluded).
- The statement "this study was a cross-sectional study" seems incorrect since this is a meta-
analysis. Rephrase to clarify.
Conclusion:
- The final paragraph is too broad. Instead of stating, "Medical workers can comprehensively
understand and reduce the incidence of EFI," provide specific takeaways:
- Which risk factors are modifiable vs. non-modifiable?
- What next steps should be taken in research or clinical practice?
References:
Check formatting consistency (e.g., some journal names are abbreviated, while others are not).
Ensure all citations are in the correct style required by the journal.