Formulation Of Enteral Diets

Question 1

Definition of enteral feeding (types, strategies)

Answer 1

• can be oral nutritional supplements
• tube feeding which bypasses some of the digestive system
• foods are liquid consistency and administered continuously over 12-24 hours (usually while patient sleeps
• can be given as oral sip feeds, continuous pump feeding, bolus feeding, gravity feeding
• bolus feeding a bit better if wanting to mimic mealtimes, but doesnt seem to increase feelings of fullness
• nasogastric tube: goes theough nose down oesophagus to the stomach
• orogastric tube: goes in orally and down into stomach
• nasoduodenal/nasojejnual tube: goes in through nose to the duodenum/ jejunum
• gastrostomy: tube goes through skin to stomach
• jejunostomy: tube goes from skin straight to jejunum

Question 2

Enteral feeding constituents (fiber, protein, lipids)

Answer 2

• can have high energy feeds if want to use low volume (normally it is 1 kcal/mL)
• otherwise, high energy feeds typically reserved for burns patients
• formulas are also available with or without fiber which improves the gut barrier function, increases stool bulk and may reduce diarrhoea
• protein: can be from milk, hydrolysed caesin or soya. Can be given as whole protein (but requires working gut) or as peptide feeds (if there is severe malabsorption, but can precipitate osmotic diarrhoea)
• fat: can be high MCT (for pancreatitis), or omega 3

Question 3

EN diarrhoea

Answer 3

• occurs in 2-95% of tube fed patients
• most likely causes: ABX (93% of EN patients on at least 1 ABX), sorbitol containing medication, enteropathogenic colonisation by C. difficle, inappropriate use of laxatives, PYY inhibition (would usually promote colonic water absorption), FODMAP contents, lack of fiber

Question 4

Disease-specific EN: renal, low Na, respiratory, fish oils

Answer 4

• renal: need to give high kcal, moderate protein and low electrolytes (Nephro HP)
• low sodium: (>145 mmol/L), may be caused by dehydration. Renal and cardiac patients (Nutrison low sodium, with 1.1 mmol/ 100kcal)
• respiratory: no difference for lower CHO and high FAT
• fish oils: evidence shows may be beneficial for down regulation of pro-inflammatory cytokines (via inhibition of proteolysis inducing factor)
• oral nutritional supplements: with antioxidants, omega 3, fiber for FFM synthesis

Question 5

Immuno-nutrition

Answer 5

• using EN fortified with arginine, glutamine and omega 3
• used in post-surgical patients and pre-surgical patients regardless of risk of malnutrition
• ESPEN surgical guidelines found that use of immuno-EN decreased postoperative complications, and lowered length of hospital stay, less suture failure, less wound healing complications
• however ESPEN concluded that glutamine should be used for burns and trauma patients

Question 6

EN for acute pancreatitis

Answer 6

• highly catabolic state, abdominal pain and nausea
• now use EN to maintain gut integrity and decreased intestinal permeability
• EN should be used as gold-standard, with NG tube first line and NJ tube second line
• peptide based formulas often used

Question 7

Semi elemental/ elemental feeds for crohn’s disease

Answer 7

• CD is a relapsing granulomatous inflammatory disease affecting the GI tract from mouth to anus
• causes abdominal pain, diarrhoea and weight loss
• may have highly variable response to nutritional therapies
• in CD can induce remission by switching to an entirely oral diet (as can remove food debris, increasing nutritional status, changes in bacterial flora, immuno-modulatory effects of altered fatty acid substrates)
• elemental feeds are hypo-allergenic with lowest long chain triglycerides but are most expensive and least palatable
• liquid diet has been shown to induce remission in 79% paediatric patients
• steroid therapy is still favoured, although children, pregnant women and patients with long lifetime use of steroids should be offered nutritional therapy