Lec 12- Enteral Nutrition

Question 1

Aims of nutritional therapy

Answer 1

• Maintain adequate hydration
• Prevent malnutrition
• Support growth and repair
• Maintain gut function
• Support immune system

Question 2

Enteral Feeding

Answer 2

• Method of supplying nutrients to the GI tract
  
  • Orally or via a tube
  • Requires functioning GI tract
  • Safer, easier and cheaper than PN
  • Adaptable
  • Short or long term
  • Monitoring required

Question 3

Routes of administering feeds

Answer 3

• Orally- Liquid/solid, thickened liquid (
• Nasogastric feeding
• Gastrostomy feeding
  
  • Longer-term, surgically tube is placed into the stomach and food placed directly in
• Feeding into the jejunum
  
  • bypass stomach

Question 4

Nasogastric feeding

Answer 4

• Most common route for enteral feeding
• Suitable in stomach
• Continuous
  
  • Better tolerate due to larger volumes past slower BUT not physiological
  • Risk of reflux, body always producing acid due to long periods
  • If we give constant alkaline food (MILK), then a reduction in pH can potentially increase the risk of infection
  • Constant blood sugar = constant and tightly controlled insulin release
• Bolus
  
  • Can mimick meals= physiologically normal
  • Parents can be involved in meal times

Question 5

Gastrostomy feeding

Answer 5

• Same as nasogastric (pros and cons/ continuous or bolus)
• Used for long term feeding- years
• Cosmetically more acceptable- Can’t see it
• Fewer tube changes- can last a few years
• A most popular method for placing- percutaneous endoscopic gastrostomy (PEG)
• Button fitted after 3-6 months (more discreet)
• Leakage is the main complication. Can cause inflammation and skin irritation
• Granulomatosis= scar tissue forming on the outside

Question 6

Jejunal feeding

Answer 6

• Bypass the stomach= not stomach content= no aspiration
• Indications
  
  • Risk of aspirations- Parkinsons, stroke, neurological diseases
  • Gastric dysmotility- stomach doesn’t empty
  • Severe vomiting => faltering growth in children
  • Congenital GI anomalies- stomach cancer= obstruction
• Feed always gis given via continuous infusion
• Placement difficult
• Complications- malabsorption- pancreatic enzymes released into the duodenum (first part of the jejunum) we could bypass this, therefore, food may not be digested properly, bacterial overgrowth and tube blockage- tubes are smaller more likely to block

Question 7

Enteral Feeds

Answer 7

• Pre-term formula’s
  
  • For infants <2000g
  • Or more than five weeks early
• Expressed breast milk +/- fortifier
  
  • Presence of immunoglobulin’s and anti-microbial factors
  • Often breast milk lacks extra calories, vits and minerals, so we add them externally
  • Only babies <3kg with fortifier, too much vit A = toxicity
• Standard infant formula- regular milk
  
  • Whole protein, based on cows milk protein and lactose
  • Mimic the calorie and nutritional value of breast milk
• High-calorie infant feeds (40% extra)
  
  • Used for faltering growth / Increased nutritional requirements
    *

Question 8

Enteral feeds

Answer 8

• Soya formula
  
  • Used for cows milk protein allergy if over six months
  • Phyto-oestrogen can potentially affect sexual hormone development
• Hydrolysed feeds
  
  • For severe CMPI and suspected soy intolerance
  • Long-chain proteins are broken
  • Anaphylactic babies can have the amino acid form (even more hydrolysed)
• MCT feeds
  
  • Used for fat malabsorption
  • Medien chain fat goes straight into blood= quicker process
  • Good for cardiac conditions and CF
• Modular feed
  
  • Used if commercial formula unable to meet specific requirements
  • Babies with short bowels

Question 9

Feed additives

Answer 9

• Used to increase calories in feeds
• Carbohydrate source
  
  • Maxijul powder
• Fat source- Calogen/liquigen
• Carbohydrate/fat- Duocal
• Gradually build this up- otherwise diarrhoea

Question 10

In addition to feeds

Answer 10

• Carobel/Gaviscon- Thickens feeds, used to treat reflux
  
  • Carobel better as it thickens entire feed, Gaviscon just thickens the top layer
• NaCl/KCl supplements- Used in modular feeds
• Vitamin/mineral supplements- Modular feeds, restrictive diets
• MCT products- oil- Chylothorax
• Flavourings

Question 11

Feed intolerance

Answer 11

*

Question 12

Nutritional Supplements

Answer 12

• Milkshakes, juices, smoothies, yoghurts
• Used to promote weight gain
• Usually prescribed for oral use but can be given as a bolus feed
• Vary in calories (1-1.5 kcal/mL)
• Vast wastage in the community- some GP’s hesitant to prescribe

Question 13

Prescription issues in the community

Answer 13

• Wrong feed prescribed
  
  • Fibre instead of non-fibre
  • Infant formula- 1st and 2nd stage
• Incorrect packaging
  
  • 200mL bottles instead of 500mL bags
• Nutritional supplements in flavours undesirable to patient
• Manufacturer reporting out of stock or discontinued
• Product, not ACBS listed
• Delivery with homeward/Abbott home enteral feeding supplier
• If in doubt call dietitian

Question 14

Drug interactions

Answer 14

• If the absorption of a drug is affected by food or antacids it will be affected by enteral feeds
• Clinically significant interactions
• Phenytoin- Enteral feeds, decrease drug absorption by 75%
• Cirprofloxacin- Absorption decreased by 30%
• Tetracyclines- Absorption reduced by 70-80% in the presence of milk or dairy products

Question 15

Tube blockage

Answer 15

• Enteral formulations (high viscosity or intact proteins)
• Feeding tube characteristics (Silicone tubes clog more frequently than polyurethane tubes and bore of the tube)
• Insufficient flushing
• Incorrect medication administration