The Ins and Outs of Enteral Nutrition - Oley 9-15-18
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1 The Ins and Outs of Enteral Nutrition KELLY GREEN CORKINS, MS, RD-AP, CSP, LDN, FAND CLINICAL DIETITIAN III, LE BONHEUR CHILDREN’S HOSPITAL, MEMPHIS, TN
2
Disclosures
u Abbott Speakers Bureau – honoraria
(Not product related)3
Objectives
u Provide information on the differences in enteral
formula categories (polymeric or standard, peptide
based, elemental, commercially prepared
blenderized).
u Discuss the home made blenderized diet – advantages
and disadvantages.
u Discuss ENFit
u Describe common symptoms of formula intolerance
and other medical related reasons for intolerance.4
FORMULAS
BLENDERIZED TUBE
The Ins FEEDINGS
ADMINISTRATION5
Enteral Formula Regulation
u Considered Medical Foods by the United States Food and Drug
Administration.
u “a food which is formulated to be consumed or administered enterally under
the supervision of a physician and which is intended for the specific dietary
management of a disease or condition for which distinctive nutritional
requirements, based on recognized scientific principles, are established by
medical evaluation.”
u Efficacy studies are not required.
u Pre-marketing review or approval is not required.
u Manufacturing is monitored and regulated.
Escuro NCP 2016;31(6):709-722
Brown NCP 2015;30(1):72-856
Enteral Formulas
(P) = Pediatric Product available
Standard/ Peptide based/
Elemental (P) Specialty
Polymeric (P) Semi-elemental (P)
Manufactured Diabetes/glucose
Blenderized (P) intolerance
Renal (P)
Hepatic
Pulmonary
Immune
modulating7
Pediatric versus Adult Products
Pediatric Products: Adult Products:
u 12% kcals from protein u 16% kcals from protein
u 34-43% kcals from fat u 30% kcals from fat
u 45-57% kcals from u 54-61% kcals from
carbohydrate carbohydrate
u Higher in calcium and vitamin D u Higher in Folic Acid and Zinc8
Composition of enteral formulas
u Protein
u Animal sources have a higher biological value than
plant sources.
u Intact, hydrolyzed, amino acid
u Fat
u Essential Fatty Acids
u LCT versus MCT
Savino P, NCP 2018;33(1):90-98.
Brown B, NCP 2015;30(1):72-85.9
Composition of enteral formulas
u Carbohydrate
u FODMAPs (fermentable fiber, oligosaccharides,
disaccharides, monosaccharides, and polyalcohols)
u Fiber
u Soluble and Insoluble both arrive to the colon
unchanged (not digested and absorbed)
u Insoluble does not dissolve in water and retains water
making stools softer
u Prebiotic fiber is soluble and fermented in the colon and
include FOS and inulin.
Savino P, NCP 2018;33(1):90-98.
Brown B, NCP 2015;30(1):72-85.10
Tube feeding Administration
u Continuous infusion (pump)
u Intermittent/Cyclic feedings (pump)
u Bolus/Gavage (syringe)
u Gravity Drip – many times forgotten
Martin K, NCP 2017;32(6):712-72111
Pump Feedings
u Not as precise as we might assume
u Walker et al in Houston
u Compared actual volume of formula infused (container catching it,
not human subjects) to pump rate and volume infused from the pump.
u The variable was hang height.
u They found: The volume deliver was less than what was calculated
from the rate and from the volume the pump recorded. The higher the
hang height the closer these numbers were, so hang height is a
significant factor.
Walker NCP 2018;33(1):151-15712
Choosing the Best Enteral Regimen
/Reimbursement Escuro AA, NCP, 2016;31(6):709-72213
What is a blenderized tube feeding (BTF)?
u Sometimes referred to as:
u Pureed diet through gastrostomy tube (PDGT)
u Homemade tube feeding (HMTF)
u Real foods/Whole foods
u Home prepared foods are liquefied in a blender and given through
a g-tube
u BTF can replace some of the feedings or all of the feedings
u Can be made using a commercial product as part of the recipe
u Some recipes use baby foods for increased consistency and
eliminating the need for a high quality blender.
Martin NCP 2017;32(6):712-721.
Vermilyea NCP 2016;31(1):59-67.14
Reasons for Increased Interest
Bobo NCP 2016;31(6):730-73515
Why do Patients choose BTF?
u More natural
u Like eating what the family is eating
u Makes them feel normal
u Better tolerance
u Don’t like the ingredients in the commercial products
u Food allergies
Hurt RT et al, NCP, 2015;30(6):824-829.16
Risks
u Microbial contamination
u Unbalanced nutrition/malnutrition – too much or too
little
u Tube clogging and increased wear on tubing
u What do the Enteral Nutrition Practice Campbell, NCP, 2006;
Recommendations say? Hurt RT, NCP 2013;
Bankhead R et al, JPEN, 2013
u Suggest commercial products
u BTF requires additional attention to safe food handling and storage17
Who is appropriate for BTF?
u Medically stable on an enteral regimen at home u Motivated parents/caregivers
u Syringe, Bolus feedings or feedings with hang time u Refrigerator, electricity, blender
less than 2 hours
u Volume tolerance
u >10 French tube size (usually 14 French)
u Access to clean water and food
u Gastric feedings
u > 8 months of age
u Appropriate growth or clearly able to meet needs
u Able to meet fluid needs with flushes
with the diet
u Caregivers have a good working relationship with
healthcare professionals, esp. a dietitian Bobo NCP 2016;31(6):730-735.
Vermilyea NCP 2016;31(1):59-67.
Escuro NCP 2016;31(6):709-722.
Brown NCP 2015;30(1):72-85.18 Contraindications to BTF u Less than 6 months of age u Gastrostomy tube smaller than 10 French u Jejuenostomy tube (or g-j-tube) u Requires continuous feedings u Immunocompromised u Lack of resources/motivation/skills u Significant malabsorption issues
19
Considerations
u Food borne illness (home versus hospital)
u Safe preparation is crucial
u Nutrient variability
u Inconsistency in recipes/food quality
u Requires high level of commitment from the caregiver
u Higher viscosity (increased risk for tube occlusion)
u Increased osmolality
u Could contribute to adverse GI symptoms. (more research needed)
Vermilyea NCP 2016;31(1):59-67.
Brown NCP 2015;30(1):72-85.20
Potential Benefits
There are no randomized controlled studies comparing BTF to formulas.
u Psycho-social needs met
u Caregiver feels in control and food is nurturing
u Can participate in preparation of family meals
u “Eating” the same meal as everyone else
u Decreased reflux symptoms
u Decreased reports of constipation
u Provides phytochemicals and fibers not found in commercial products
u Improved retching and gagging with fundoplication
u May promote oral intake21
BTF
u Required 50% more calories on the BTF to maintain BMI
u BTF micronutrient was superior
u Significant decrease in vomiting and use of acid-suppressive
agents
u Stool consistency and frequency was unchanged but stool softener
increased
u Caregivers were more satisfied and would recommend it
Gallager NCP 2018;42(6):1046-1060.22
ENFit
Developed to prevent misconnections.
(cannot be connected to IV or respiratory equipment.)
Screw, so unlikely to slip and come apart and helps prevent leaks.23
ENFit - Challenges
u It is a small bore connector.
u Medication administration.
u Bacterial contamination – attention to cleaning.
u Blenderized Tube Feeding
u Mundi and colleagues found that formula, size of tube, blender used,
and time of blending had more impact on the force needed to push
the feeding through the tube than the connector used.
Guenter NCP 2016;31(6):769-772.
Lord NCP 2018;33(1):16-38.
Mundi JPEN 2018 – online first24
DIARRHEA
CONSTIPATION
The Outs GASTRIC RESIDUALS
REFLUX25
Diarrhea
u Usually defined based on stool frequency and
consistency, but no standard definition.
u It can cause:
u Electrolyte abnormalities
u Pressure sores
u Malnutrition (increased frequency of holding
feedings)
Majid NCP 2012;27(2):252-260.26
Diarrhea - Evaluation
u Protocols are helpful.
u What type of diarrhea?
u Motility, inflammatory, malabsorption, osmotic, secretory
u Recent changes in regimens?
u Medications (sorbitol, antibiotics, antacids, laxatives, H2 blockers, stool softeners)
u Formula Composition
u Fiber – prebiotic fiber (FOS)
u Bacterial Contamination
Majid NCP 2012;27(2):252-260.
Savino NCP 2018;33(1):90-98.27
Constipation
u More frequent than diarrhea.
u Associated with increased ICU stay, feeding
intolerance, and difficulty weaning from the vent.
u Causes include:
u Medications (H2 Blockers)
u Dehydration
u Decreased motility
Bittencourt NCP 2012;27(4):533-39.28
Constipation - Fiber
u Soluble fibers reduce gastric emptying and are
associated with decreasing cholesterol and triglyceride
levels.
u Insoluble fiber:
u Increase fecal mass
u Promote optimal intestinal functioning/transit
u Prevent/decrease constipation
u Reduce laxative use Bittencourt NCP 2012;27(4):533-39.29
Gastric Residuals
What amount of residuals is significant?
u Time consuming
u Increase risk of clogging the tube
u Increase risk of contaminating the feedings
u Electrolyte imbalances if not replaced
u May result in holding feedings unnecessarily negatively
impacting nutrition status.
Lord NCP 2018;33(1):16-38.30
Gastroesophageal Reflux
u Increased LES relaxations
u Increased intra-abdominal pressure
u Delayed gastric emptying
u Increased gastric acid secretion
u Overeating/overfeeding –
u bolus too large/infused too fast31
Summary
u Enteral formulas are safe and provide adequate nutrition but as professionals
and consumers need to be aware of differences in each understanding that
marketing can be misleading.
u BTF is a viable option for many home enteral nutrition recipients, but it is not
appropriate for everyone and needs close monitoring by a registered dietitian
and team.
u Enfit was developed to improve patient safety, yet we need to evaluate
challenges associated with this change.
u Intolerances can happen and can be related to formula or may be
secondary to many things.32
References
u Hurt RT et al. Blenderized tube feeding use in adult home enteral nutrition patients: A
cross-sectional study. NCP. 2015;30(6):824-829.
u Escuro AA, Hummell AC. Enteral Formulas in Nutrition Support Practice: Is there a better
choice for you patient? NCP. 2016;31(6):709-722.
u Martin K, Gardner G. Home Enteral Nutrition: Updates, Trends and Challenges. NCP.
2017;32(6):712-721.
u Walker R et al. Hang height of enteral nutrition influences the delivery of enteral
nutrition. NCP. 2017;33(1):151-157.
u Vermilyea S, Goh VL. Enteral feedings in children: Sorting out tubes, buttons, and
formulas. NCP. 2016;31(1):59-67.
u Bobo E. Reemergence of blenderized tube feedings: Exploring the evidence. NCP.
2016;31(6):730-735.33
References
u Gallagher K et al. Blenderized enteral nutrition diet study: feasibility, clinical, and
microbiome outcomes of providing, blenderized feeds through a gastric tube in a
medically complex pediatric population. NCP. 2018;42(6):1046-1060.
u Pentiuk SP, et al. Pureed by gastrostomy tube diet improves gagging and retching in
children with fundoplication. JPEN. 2011;35:375-379.
u O’Flaherty T. Use of a pureed by gastrostomy tube (PBGT) diet to promote oral intake:
review and case study. Support Line. 2015;37:21-23.
u Novak P et al. The use of blenderized tube feedings. ICAN. 2009;1(1):21-23.
u O’Flaherty et al. Calculating and preparing a pureed-by-gastrostomy-tube (PBGT) diet
for pediatric patients with retching and gagging postfundoplication. ICAN.
2011;3(6):361-364.34
References
u Lord LM. External access devices: types, function, care, and challenges. NCP
2018;33(1):16-38.
u Savino P. Knowledge of constituent ingredients in enteral nutrition formulas can make a
difference in patient response to enteral feeding. NCP 2018;33(1):90-98.
u Bittencourt AF, Martins JR, Logullo L et al. Constipation is more frewuent than diarrhea
in patients fed exclusively by enteral nutrition: results of an observational study. NCP
2012;27(4):533-539.
u Guenter P, Lyman B. ENFit enteral nutrition connectors: benefits and challenges. NCP
2016;31(6):769-772.
u Majid HA, Emery PW, Whelan K. Definitions, attitudes, and management practices in
relation to diarrhea during enteral nutrition: A survey of patients, nurses and dietitians.
NCP 2012;27(2):252-260.You can also read
