Enteral nutrition: A way to provide food through a tube placed in the nose, the

stomach, or the small intestine. A tube in the nose is called a nasogastric tube or
nasoenteral tube. A tube that goes through the skin into the stomach is called a
gastrostomy or percutaneous endoscopic gastrostomy (PEG). A tube into the
small intestine is called a jejunostomy or percutaneous endoscopic jejunostomy
(PEJ) tube.

Enteral nutrition is often called tube feeding

feeding tube is a medical device used to provide nutrition to patients who cannot
obtain nutrition by swallowing. The state of being fed by a feeding tube is called
enteral feeding or tube feeding. Placement may be temporary for the treatment
of acute conditions or lifelong in the case of chronic disabilities. A variety of
feeding tubes are used in medical practice. They are usually made of
polyurethane or silicone.

Definition

Nutrients, either a special liquid formula or pureed food, are delivered to a patient
through a tube directly into the gastrointestinal tract, usually into the stomach or
small intestine.

Description

A flexible, narrow tube is inserted into some portion of the digestive tract and
liquid formulas or liquefied foods are placed into the tube to meet the patient's
nutritional needs. The feeding may be pumped into the tube or allowed to drip
into the tube continuously or at scheduled feeding times.

A feeding tube can be inserted by a surgical or nonsurgical procedure in several

positions along the gastrointestinal tract. The tube may be inserted into the nose

and passed down the throat and through the esophagus. A nasogastric tube is
inserted through the nose with the end of the tube reaching into the stomach. A
nasoduodenal or nasojejunal tube is inserted through the nose and ends in either
the duodenum or jejunum, both of which are portions of the small intestine. This
type of tube placement is usually used for short-term feeding. Surgical placement
of a feeding tube may be done if there will be a long-term need for feeding that
bypasses the upper digestive tract. An esophagostomy creates an opening in the
esophagus, a gastrostomy creates an opening into the stomach, and a
jejunostomy creates an opening into the jejunum. The feeding tube is then
inserted through the surgically created opening.

Tube feedings can be a mixture of regular foods that are blended with liquid to
make a consistency that will pass through the tube. Nutritionally balanced liquid
products are often more convenient to use and ensure a balance of proteins,
fats, and carbohydrates along with vitamins and minerals. Specialized formulas
are also available to meet almost any nutritional need. For example, patients with
severe burns, protein-energy malnutrition, or slow wound healing may require
formulas that are higher in protein. Patients with renal failure may require low-
protein formulas with lower concentrations of minerals and vitamins

A tube feeding, in which nutrition is delivered through a tube into the GI tract
(called enteral nutrition), is used for individuals who have a functioning
gastrointestinal (GI) tract but cannot ingest enough nutrients orally to meet their
current needs.

Tube feedings can be used as the sole source of nutrition or in combination with
oral intake. In certain situations, tube feeding is indicated.

Enteral nutrition (EN) is the use of the GI tract for feeding. The GI tract should be
used if possible because it tends to atrophy when not used. Gut bacteria can
translocate to the circulatory system through an atrophied GI tract and increase
the risk for infection.

Parenteral nutrition (PN) is the use of a site outside the GI tract, specifically, the
circulatory system, for feeding. The general rule for deciding whether to use
enteral or parenteral feeding is, "If the gut works, use it".

Indications for Tube Feeding Use Specific Indications for Use

• Protein-energy malnutrition with inadequate oral nutrient intake for 5 or

more days
• Less than 50% of required nutrient intake orally for 5-7 days
• Severe dysphagia
• Coma
• Low output enterocutaneous fistulas

Contraindications for Enteral Nutrition

• Intestinal obstruction, ileus, or hypomotility of the intestine

• Severe diarrhea
• High output enterocutaneous fistulas
• Severe acute pancreatitis or shock
• When prognosis does not warrant aggressive nutritional support

Feeding Tubes

Silicon or polyurethane feeding tubes are commonly used because they are soft,
flexible, and small in diameter. They do not harden or corrode with exposure to
gastric juice. Generally, the best choice of tubing is the smallest diameter tube
through which the feeding can flow

Types of Enteral Formulas

There are many different types of enteral formulas that can be used for tube
feedings. The actual formula used depends on the individual patient's needs.
There are three basic types of enteral formulas: intact, hydrolyzed, and modular.

Intact Enteral Formulas

Intact formulas, also called polymeric formulas, contain unaltered molecules of

proteins, carbohydrates, and fats. They are best for people who can digest and
absorb nutrients without difficulty.

Polymeric formulas are available as standard formulations containing protein

isolate with one or more sources of carbohydrate and fat; or as blenderized
whole food formulations. Blenderized formulas, which are used infrequently, are
more likely to clog feeding tubes since they have a high viscosity. There is a
greater risk of food-borne illness with blenderized formulas

Hydrolyzed Formulas

Hydrolyzed formulas, also called monomeric formulas, contain predigested

proteins and simple carbohydrates, plus a small amount of oil or a blend of
medium chain triglycerides (MCTs) and oil.

Monomeric formulas are "predigested" and are a good choice for patients who
lack the ability to digest or have a small absorptive area. Patients with feeding
tubes in the lower GI tract may also benefit from these formulas.

Monomeric formulas contain very little residue and are appropriate for patients
that require bowel rest.

Modular Formulas

A modular formula is an incomplete liquid supplement that contains specific

nutrients, usually a single macronutrient (carbohydrate, protein or fat).

Different modules can be combined to result in a nutritionally complete diet.

Modular diets can be tailored to an individual's needs but are generally complex
to design, and may fail to meet all of the patient's nutritional needs.
 Nutritional Information

Most intact formulas contain about 1 kcalorie per ml. Some formulas are
designed for those who need more kcalories and protein in a smaller volume of
fluid and contain 1.5 to 2 kcals per ml.

Enteral formulas contain high biological value protein such as casein,

lactalbumin, and soy protein isolate.

Most formulas are available as lactose free preparations to accomodate patients

with lactose intolerance.

Special Enteral Formulas

Special formulas are also available to Some common types of
meet the needs of patients with specific specialized formulas
medical problems, such as: include:

• Glucose intolerance • Fiber-containing

• Liver disease • Glutamine
• Lung disease supplemented
• GI dysfunction • Controlled
• Renal disease carbohydrate
• Medium chain
• HIV/AIDS triglycerides
• Protein Modified
• HIV/AIDS

The osmolality of an enteral formula is an important consideration in terms of

tolerance.

Osmolality is the number of molecules and ions per kilogram of a solution.

It may be easier to think of osmolality as the number of particles per kilogram of

water.

Formulas with Fiber Benefits of Formulas with Fiber

Some enteral formulas contain
dietary fiber (in the form of soy
polysaccharide, fruit, vegetable
and oat fiber). Tube-fed patients
with diarrhea, constipation, and
other medical problems may
benefit from a high-fiber diet.
Fiber-containing formulas promote normal
gastrointestinal (especially bowel) function, and are
especially important for patients on long term TF.
The soluble fiber is converted by bacteria to short chain
fatty acids which serve as a source of fuel to the cells
lining the colon, helping maintin a healthy colon lining
 Glossary
activity factor a factor used in the equation to determine energy needs that takes into consideration
activity level (eg. ambulatory vs. nonambulatory).
anabolic state a physiological state of building tissue.
aspiration pneumonia the presence of GI contents, such as formula, in the lungs.
atrophy the breaking down of a tissue or organ.
basal energy expenditure energy expended by the body at complete rest.
bolus feeding a feeding of up to 480 ml of formula within a 30 - 60 minute time frame.
blood urea nitrogen (BUN) the amount of nitrogen associated with urea in the blood. High values are associated
with dehydration and compromised kidney function.
catabolism the breaking down of tissue or molecules
continuous drip feeding the provision of formula in an ongoing manner in small amounts.
dietary fiber undigestible carbohydrate.
drug-nutrient interaction a reaction between a medication and a nutrient that may have adverse outcomes for
drug action or nutritional status.
dumping syndrome a physiologic response related to the rapid emptying of the stomach contents into the
small intestine. Water is drawn into the intestines resulting in nausea, cramping, and
diarrhea. The concommitant drop in blood volume causes a sympathetic nervous system
response.
dysphagia difficulty swallowing.
emulsification the mixing of two substances that are not normally mixable with the use of a substance
that can mix with each.
enteral nutrition nutrient intake via the gastrointestinal tract.
enterocutaneous fistula an opening between the intestines and the skin.
esophagostomy an opening created into the esophagus.
free water available water; unbound water.
gastrostomy an opening created into the stomach.
glutamine an amino acid that serves as a nitrogen shuttle and a fuel to the GI tract.
hematocrit volume of the blood that is composed of red blood cells. A high hematocrit indicates
dehydration.
high biological value protein protein that is efficiently used by the body. Animal proteins (except gelatin) are high
biological value proteins.
hydration status fluid status.
hydrolysis the splitting apart of a molecule with water.
hydrolyzed formula predigested formula.
hypertonic having a higher osmolality than the comparison solution.
hypoalbuminemia low blood albumin concentration.
ileus paralysis of at least part of the GI tract.
indirect calorimetry the estimation of energy expenditure via the measurement of oxygen consumption and
carbon dioxide production.
injury factor factor in the calculation of energy needs that accounts for the patient's state of stress.
isotonic having approximately the same osmolality of the comparison solution.
jejunostomy an opening created into the jejunum.
lactose intolerance an inability to digest lactose because of insuffient lactase enzyme resulting in cramping,
bloating, and/or diarrhea.
medium chain triglycerides (MCT) triglycerides with fatty acids consisting of 8-10 carbons in the carbon chain.
modular formula a formula consisting of a singular macronutrient. A complete diet can be formulated by
mixing modular formulations.
nasoduodenal a feeding tube that enters the nose and ends in the duodenum.
nasogastric a feeding tube that enters the nose and ends in the stomach.
nasojejunal a feeding tube that enters the nose and ends in the jejunum.
normoglycemia normal blood glucose concentration.
NPO Latin: non per os; nothing by mouth.
obligatory fluid output the minimum amount of urine output necessary to excrete waste products.
osmolality particles of solute per kilogram of solvent.
the difference in concentration between two solutions on either side of a semipermeable
osmotic gradient
membrane.
ostomy a surgically created opening.
percutaneous endoscopic the insertion of a feeding tube into the stomach which is pulled out of the body through
gastrostomy (PEG) an incision in the abdominal wall.
polymeric formula an enteral formula composed of intact macronutrients.
portal system the vessels that connect to the liver.
pulmonary function lung function.
RDA Recommended Dietary Allowances; the United States' standard for adequate
consumption of nutrients by healthy individuals.
renal solute load (RSL) the sum total of materials that must be excreted by the kidneys.
regurgitation the backflow of GI contents.

residual volume the volume of enteral formula left in the stomach.

residue undigested materials.

saline salt solution.
sepsis infection.
soluble fiber dietary fiber that can dissolve in water.
tolerance the degree to which symptoms arise from a formula infusion.
transnasal through the nose.
transpyloric through the pyloric sphincter.
tube feeding an enteral feeding utilizing a tube that delivers nutrients directly into the GI tract.