Enteral & Parenteral

Feeding
Oleh:
Imelda T. Pardede
Bagian Gizi Medik FK UNRI

If the gut
works,it use it
Or loose

I. Enteral feeding

Enteral Feeding

Method of provision of nutrients into the GIT

through a tube
Nutritional support for patients whose oral
intake does not meet requirement >5 days
Have adequate intestinal functional capacity

1. Feeding tubes
Categories:
1. Through nasal cavity: NGT, NET
2. Through abdominal wall: gastrostomies,
jejunostomies

Feeding tubes
Type of access:
State of upper GIT
Anticipated length of feeding
Expertise of the professional

a. NGT

Usually for short term (<4 weeks)

enteral feeding in hospitals
Contraindication includes:
- obstruction of upper GIT
- severe reflux
- cranial or facial trauma
- gastric dysmotility

b. NET

Usually for longer term (>4

weeks) enteral feeding
Used if risk of aspiration exists
or when gastric motility is
impaired
Advancement of tube from
gaster into the small bowel
may require administration of
prokinetic drugs
Placement of tube into
duodenum or jejunum may be
facilitated by endoscopic or
radiographic techniques.

2. Feeding formulas

Medical foods (US FDA 1989):

distinguished from other foods for special
dietary purposes of foods which make health
claims by the requirement that they be used
under medical supervision
Criteria:
- food for oral or tube feeding
- labeled for dietary management of a
medical disorder, disease or condition

Feeding formulas

Polymeric formulas
Monomeric formulas
Blenderized foods
Formulas for specific metabolic needs
Modular formulas
Hydration solutions

Feeding formula: polymeric

Contains macronutrients in the form of intact

protein, TAG & CHO polymers
Contains micronutrients: vitamins, minerals,
trace elements & (fiber)
Lactose & gluten free
Caloric density: 1 2 kcal/mL
Osmolality: 300 650 mOsm/kg
Most commonly used formula
EntrasolTM, Nutren1.0TM, Nutren FiberTM,
EnsureTM

Feeding formula: monomeric

Contains macronutrients in form of:

- protein as peptide/amino acids
- fat as LCT & or MCT
- CHO as partially hydrolized maltodextrin or
oligosaccharides
Require less digestion: for patients with impaired
digestion/absorption pancreatic insuff., SBS
Contains micronutrients: vitamins, minerals &
trace elements

Lactose & fiber free

Caloric density: 1 1.5 kcal/mL
Higher osmolality: 270 650 mOsm/kg
Osmolality >300 mOsm/kg water shift
diarrhea
Exmp: PeptamenTM

Feeding formula: natural food

Blenderized natural food

Prepared from: milk, beef, fruits,
vegetables & fiber
Nutrient content & nutritional
completeness unsure
Risk of solution contamination: increased

Feeding formula: specific metabolic

needs

Nutritional product in which specific

nutrient added/removed to meet
special metabolic requirement
Categories:
- formula for patients with inherited
metabolic disorder
- formula for patients with specific
medical condition

High BCAA formula

High EAA formula
High fat/low CHO formula
Immune-modulating formula
Formulas for Diabetes

Assignment

Feeding formula: modular

Provide each of macronutrients or

micronutrients singly
Used to prepare specialized formula or to
modify regular formula
Contains: CHO polymers, TG of LCT or MCT
and protein modular products

Feeding formula: hydration solutions

Provides fluid & electrolyte to prevent

dehydration in diarrhea
Contains sodium & glucose
Osmolarity varies between 224 311 mmol/L
Exp: oralit

3. Nutrient absorption & utilization

Carbohydrates
Protein & amino acids
Fats
Vitamins & trace elements
Fiber

4. Indication & contraindication

General: inadequate amount of food ingested with

adequate GI function
Specific:
- severe dysphagia e.c. obstruction or dysfunction of oropharynx or
esophagus
- coma, delirious state
- persistent anorexia
- nausea or vomiting due to gastric disorder
- fistula of distal intestine or colon
- severe malabsorption
- recurrent aspiration: jejunostomy
- certain diseases or disorders
- increased nutritional requirement
- growth induction in children with specific diseases: Crohn disease

Contraindication:
- complete intestinal obstruction
- paralytic ileus
- severe pseudointestinal obstruction
- severe diarrhea
- extreme malabsorption

5. Methods of infusion

Bolus
- gravity feeding
- syringe
Continuous drip by
Infusion pump

Complication

Arising from tube insertion

- trauma & bleeding from nose & upper GIT
- perforation
- misplacement into respiratory tract
- aspiration pneumonia
- vomiting
Arising from the feeding
- clogging, kinking, bursting
- obstruction of feeding tubes

Complication

Clinical problems associated with tube feeding

- diarrhea
- aspiration
- contamination of feeding solutions
- underfeeding
- overfeeding
- refeeding syndrome
- constipation

II. Parenteral feeding

Parenteral Feeding
A provision of nutrient solution into systemic
circulation, bypassing alimentary tract & the
1st circulatory pass through the liver.
Objective: maintaining or improving nutritional
& metabolic status of patients who in critical
period of time cannot be adequately
nourished by oral and enteral feeding

System of delivery: venous access

Central parenteral nutrition (CPN)

Peripheral parenteral nutrition
(PPN)

System of delivery: method of administration

Continuous
Intermittent

Admixture method:
1) Y-site
2) TNA

Parenteral formulas

Complex solution provides nutrients adequate to support

vital metabolic activities, promote weight gain, wound
healing, anabolism & growth
Fluid: 30 40 mL/kg/day
Carbohydrate dextrose: 40 50% total cal.
initial dose: 125250 g/day
Protein synthetic crystalline AA: 1020 % of total
cal. 0.82 g/day
Fat EFA linoleic acid from soybean and or safflower
Emulsifier: egg yolk phosphatides & glycerol 15
30% total cal.
Packaging: 10%, 20% and 30%

Parenteral formulas

Electrolytes: Na, K, Ca, Mg, Cl, P, and acetate

No bicarbonate
Vitamins: A, D, E, B1, B2, B3, B5, B6, B12, C,
biotin, folic acid and K
Trace minerals: Zn, Cu, Cr, Mn
No iron
Biliary disease: Cu, Mn
Renal dysfunction: Se, Cr, Mo

Indications: patient selection

Conditions that impair absorption of nutrients: SBS,

intestinal atresia, enterocutaneous fistula, infectious
colitis, effects of radiation or chemotherapy, small bowel
obstruction
Need for bowel rest: severe inflammatory bowel
disease, ischemic bowel, severe pancreatitis, chylous
fistula, preoperative status, VLBW
Severe motility disorders state: prolonged ileus, pseudoobstruction, scleroderma, visceral organ myopathy
Inability to achieve or maintain enteral access: unstable
clinical condition, hyperemesis gravidarum, eating
disorders

Indication: timing for nutritional intervention

Patient not expected to resume oral or

enteral intake for at least 10 to 14 days
Baseline nutritional status: malnourished vs
well-nourished
Illness severity: critical vs stable

Complication

Hyperglycemia
Fluid & electrolyte disturbances
Hepatobiliary complications
Metabolic bone disease

References

Contemporary Nutritional Support Practice 2 nd ed.

Saunders, 2003
Krauses Food, Nutrition & Diet Therapy 11th ed.
Saunders, 2004
Practical Aspects of Nutritional Support.
Saunders, 2004
Modern Nutrition in Health & Disease 10th ed.
Lippincott Williams & Wilkins, 2006
Handbook of Clinical Nutrition 4th ed. Elsevier,
2006