Enteral Nutrition

Kattia M. Corrales, RD, Lori J. Bechard, M Ed, RD, CNSD, Kelly A. Kane, MS, RD, and Deanne K. Kelleher, RD

Nourishment provided through the alimentary tract, either naturally by oral feeding or artificially through use of a feeding lube, is known as enteral nutrition. The alimentary tract should be the lirst choice for nutritional support. It offers several advantages over intravenous provision of nutrients, otherwise known as parenteral nutrition (Table 16-1).

Tube feeding is indicated when a child or infant is unable to meet nutritional needs orally (Table 16-2). Tube feeding can provide either total or supplemental nutrition. It can be used for short-term rehabilitation or long-term nutritional management. In the child with anorexia, a differential diagnosis can help identify the cause of anorexia and the anticipated duration of tube feeding (Table 16-3). This chapter offers guidelines for choosing the delivery

Table 16-1. Advantages of Enteral Versus Parenteral Nutrition

• Reduced risk of infection and metabolic abnormalities

• Maintains and can help restore the integrity ol gastrointestinal mucosa

• May facilitate restoration of digestive enzymes

• Less expensive than parenteral nutrition

• Mimics standard human nutrition route and equipment for tube feeding, selecting formulas, initiating and advancing feedings, monitoring and evaluating response to therapy, initiating transitional feeding, and home tube feeding.

Table 16-2. Indications for Tube Feeding

Decreased ability to ingest nutrients by mouth Neurologic disorders Coma

Severe mental retardation Cerebral palsy affecting oral motor skills Anatomic abnormalities Facial trauma

Congenital anomalies, ie, TEF Tumor or other mass Prematurity (< 34 weeks) Inability to meet full nutrient needs orally Increased metabolic needs Burns Sepsis Trauma

Congenital heart disease Bronchopulmonary dysplasia Anorexia (see Table 16-3) Psychosocial disorders Anorexia nervosa Nonorganic growth failure

Altered absorption or metabolism requiring modification of diet Chronic diarrhea Short bowel syndrome Inflammatory bowel disease Glycogen storage disease (types I and III) Chronic intestinal pseudo-obstruction Pancreatitis

Amino or organic acidopathies TEF = tracheoesophageal fistula.

Adapted from Davis A. Indications and techniques for enteral feeds. In: Baker SB, Baker RD, Davis A. editors Pediatric enteral nutrition. New York: Chapman and Hall: 1994. p. 68.

Routes and Equipment

Small bore silicone or polyurethane tubes are placed nasally for anticipated usage of 3 months or less:1 larger bore tubes for extended use are placed endoscopically or surgically. Nasogastric tubes are easily placed and often the first consideration for enteral nutrition therapy. Bolus feeding into the stomach can mimic typical meal patterns; nocturnal feedings supplement oral intake. Transpyloric feeding directly into the small bowel allows for use of the gastrointestinal tract despite poor tolerance to gastric feedings

Table 16-3. Differential Diagnosis of Anorexia

Acquired immunodeficiency syndrome (AIDS)

Acute or chronic infection

Cancer

Chronic disease eg. cystic fibrosis, liver disease, sickle cell disease Cyanotic heart disease Drugs

Aminophylline Amphetamines Antihistamines Antimetabolites Chemotherapy Digitalis Narcotics Endocrine disease Esophagitis/gastroesophageal reflux Iron deficiency Lead poisoning Pregnancy

Psychosocial deprivation (neglect/abuse) Psychosocial factors

Chronic mental/environmental stress Depression Zinc deficiency

(Table 16—4).2 Whereas the stomach can expand to accommodate a large bolus, the small intestine cannot. Therefore, continuous feedings are indicated when small bowel feeding is used. Methods of gastric feeding and small bowel feeding are described in Table 16-5 and Table 16-6.

Enteral feeding pumps are employed for slow drip feedings. Pumps are often attached to a pole in the hospital setting and can be programmed to the appropriate rate and volume. Portable pumps are also available for ease of mobility and travel.

Formula Selection

To appropriately select a formula, a complete nutritional evaluation must be conducted. The patient's energy and protein requirements, fluid and electrolyte status, digestive capacity, and organ system function must be assessed, and any food allergies or niacronutrient sensitivity noted. Age is also an important consideration in formula selection as certain formulas are specifically designed to meet the needs of children at specific ages (eg, < 34 weeks, up to I year. I to 10 years, and > 10 years). These formulas may differ in their nutrient composition as well as in their vitamin and mineral content (Tables 16-7. 16-8, 16-9. 16-10. and 16-1 l).

Table 16-4. Types of Enteral Feeding

Indications

Contraindications

Gastric Dysphagia feeding Anorexia

Severe gastroesophageal reflux Poor gastric motility

Supplement to oral intake

Small bowel Delayed gastric feeding emptying

Nonfunctioning Gl tract Inability to access intestine

Increased risk of aspiration

Table 16-5. Gastric Feeding

Ac/vantages

Disadvantages

Orogastric

Nasogastric

Percutaneous endoscopic gastrostomy (PEG)

Surgical gastrostomy

Avoids nasal passage obstruction

Appropriate for infants < 34 weeks gestational age

Easy intubation

Fewer occlusions with larger bore tube Appearance can be hidden under clothing Open surgery not required

Endoscopy not required for placement

Procedure directly accesses stomach

Not appropriate for patients with gag reflex

Nasal or esophageal irritation Easily dislodged

Invasive technique for placement Site at risk for infection Appropriate anatomy required Risks of anesthesia/surgery

Open surgical wound at risk tor infection

Chapter 16 Enteral Nutrition 191

Table 16-6. Small Bowel Feeding

Advantages

Disadvantages

Nasoduodenal/nasojejunal

Gastrostomy-jejunostomy

Jejunostomy

Temporary access for small bowel feeding pH-guided placement available

Transpyloric tube may be passed through existing gastrostomy Intestinal access for feeding and gastric access for decompression and medications Direct access to small bowel

Easily dislocated; may require radiographic evidence of appropriate placement

Requires healing of gastrostomy tract prior to jejunostomy tube placement Meticulous care of both ports necessary

Easily occluded

Adapted from Warman KY. Enteral nutrition: support of the pediatric patient. In: Hendricks KM. Walker WA, editor. Manual of pediatric nutrition. 2nd ed. Toronto: B.C. Decker, Inc.; 1990.

Table 16-7. Infant Formula Selection

Indications Formula Description Age Examples

Premature

Normal Gl tract

Primary or secondary lactose intolerance

Rapidly growing preterm infants High in protein MCT containing Added glucose polymers Ca:P ratio of 2:1 Additional Ca, P, vit A, vit D, folate, Zn

Cow's milk protein Lactose containing Long chain fats

Milk protein isolate or

Soy protein isolate Long chain fats

< 34 weeks gestational age and/or < 2 kg

Former premies now > 2 kg or > 40 weeks corrected age* Full term infants

4-6 months eating cereal and other solids* Full term infants

4-6 months eating cereal and other solids*

Breastmllk + Enfamil Human Milk Fortifier

Breastmilk + Similac Natural Care Enfamil Premature 20 & 24 Similac Special Care

Similac Neosure Enfacare

Breastmllk

Enfamil

Similac

Carnation Good Start Carnation Follow-Up Formula

Enfamil Lactofree Similac Lactose Free Prosobee Isomil

Carnation Follow-Up Soy

Intact protein Whey protein hydrolysate Full term infants sensitivity Long chain fats

Lactose free

Severe protein Free amino acids Full term infants allergy Long chain fats

Lactose free

Malabsorption Whey protein hydrolysate Full term infants

Intractable Medium chain triglycerides diarrhea and long chain fats

Steatorrhea Lactose free

Impaired fat Intact protein Full term infants absorption 86% of fat from MCT

Chylous effusion 3.5% calories from linoleic acid Lymphatic disorder

Decreased renal Intact protein Full term infants function Long chain fat

Low iron

Lower in Ca, P, maintaining 2:1 ratio Lower in K

Nutramigen

Neocate

Pregestimil Alimentum

Portagen

Similac PM 60/40

MCT = medium chain triglycerides. "Use may be controversial.

Table 16-8. Non-Infant Formula Selection: Need for Supplemental Nutrition or Meal Replacement

Indication Formula Description Aget Examples (listed alphabetically)'

Intact gut

Blenderized Homogenized food Contains fiber Polymeric Most isotonic Intact CHO, protein, fat 1-1.2 cal/cc May contain lactose

1-10 years

> 10 years 1-10 years

>10 years

Lactose intolerance

Polymeric Most isotonic Intact CHO, protein, fat 1-1.2 cal/cc Lactose free

Diarrhea, Polymeric constipation Most isotonic or expected long-term use

Intact CHO, protein, fat 1-1.2 cal/cc Lactose free Fiber containing

Compleat Pediatric Compleat Modified

Kindercal, Nutren Jr., PediaSure, Resource Just for Kids

Boost, Carnation Instant Breakfast, Ensure, Healthshake, Isocal, IsoSource, Meritene, NuBasics, Nutren 1.0, Osmolite, Resource Standard, Scandi-Shake

1-10 years Kindercal, Nutren Jr., PediaSure, Resource Just for Kids

>10 years Boost, Ensure, Isocal, IsoSource, NuBasics, Nutren 1.0,

Osmolite, Resource Standard, Scandi-Shake Lactose Free

1-10 years Kindercal, Nutren Jr. with Fiber, PediaSure with Fiber

>10 years Boost with Fiber, Ensure with Fiber, FiberSource, Jevity, NuBasics with Fiber, Nutren 1.0 with Fiber, ProBalance, Ultracal

Chapter 16 Enteral Nutrition 195

Increased protein needs

Polymeric >10 years Most isotonic Intact CHO, protein, fat 0.95-1.2 cal/cc Lactose free Contains approximately 30% more protein than standard versions

Boost High Protein, Ensure High Protein, Entrition HN, Isocal HN, IsoSource HN, IsoSource VHN, Isotein HN, NuBasics VHP, Osmolite HN, Osmolite HN Plus, Promote, Replete

Food Allergies

Food Allergies

Peanuts can leave you breathless. Cat dander can lead to itchy eyes, a stuffy nose, coughing and sneezing. And most of us have suffered through those seasonal allergies with horrible pollen counts. Learn more...

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