e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e223–e225

Contents lists available at ScienceDirect

e-SPEN, the European e-Journal of

Clinical Nutrition and Metabolism
journal homepage: http://www.elsevier.com/locate/clnu

Educational Paper

Basics in clinical nutrition: Enteral nutrition

Pat Howard
Bristol Royal Infirmary, Bristol, United Kingdom

a r t i c l e i n f o

Article history:
Received 8 May 2009
Accepted 13 May 2009

Keywords:
Enteral nutrition
Feeding solution
Intestinal function

Learning objectives – absence of intestinal function due to failure, severe inflam-

– To appreciate the different routes by which enteral nutrition
can be delivered
– To understand the indications for and contraindications to
enteral nutrition
– To identify the indications and benefits of enteral tube feeding
– To select an appropriate enteral feeding solution
– To recognize key characteristics associated with the delivery of
enteral tube feeds
– To characterize complications associated with enteral nutrition
mation or, in some instances, post operative stasis
– complete intestinal obstruction
– inability to access the gut e.g. severe burns, multiple trauma
– high loss intestinal fistulaea
– relative contraindication to tube feeding is also increased
likelihood of opportunistic infection e.g. maxillo-facial surgery
or oncology treatments
– ethical considerations e.g. terminal care.
Note: In cases of doubt a time limited trial may be considered.

3. Routes for enteral tube feeding

1. Indications for enteral nutrition
If a patient has a functioning gut but is unable or unwilling to eat
sufficient to meet his/her nutritional needs, various options of
enteral feeding can be considered.
In principle, feeding solutions should be introduced to the
gastrointestinal (GI) tract at the point where it is possible to absorb
them. It is also possible to use modified feeds e.g. peptide based
formulae to overcome gastrointestinal incapacity thereby avoiding
the need for parenteral nutrition.
2. Contraindications to enteral nutrition
Although the enteral route should always be the first option,
there may be occasions when it is contraindicated. These include:
E-mail address: espenjournals@gmail.com (Editorial Office).
The gut can be accessed in a range of places and the choice of
feeding route will depend on the underlying pathology, the antic-
ipated duration of tube feeding and the preference of the patient
(see Fig. 1).
4. Choice of feeding solution
Local practice, preference and availability will help determine
the most appropriate solutions for the majority of patients (see
Fig. 2). With help of this diagram and structured approach to choice
for a correct enteral diet a proper nutritional system can be
selected.
A structured approach will enable the correct choice to be made:
1) Is gastrointestinal function normal?
Yes – Choose a whole protein feed
No – Consider a semi-elemental/elemental product

1751-4991/$ - see front matter Ó 2009 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.eclnm.2009.05.008
e224 P. Howard / e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e223–e225

Supplementation

Oral

Sip feeding

Naso gastric*
Enteral Percutaneous
Nutrition Pharyngostomy endoscopic
Gastric gastrostomy
Oesophagostomy (PEG)

Gastrostomy* Radiologically
inserted
gastrostomy
Tube (RIG)
Nasoduodenal*
Feeding
Duodenal Surgical
gastrostomy
Extended gastrostomy*

Naso jejunal

Jejunal Extended gastrostomy*

Direct access
Surgical jejunostomy

Fine needle
*Preferred routes catheter

Fig. 1. Routes for enteral feeding.

2) Is the fluid volume restricted and/or is a higher energy con- 3) Is the patient constipated?
taining feed needed? Yes – Choose a feed containing insoluble fibre
Yes – Choose a high energy feed and consider whether No – Consider a standard feed or a feed containing soluble
a disease specific formula might be needed fibre
No – Choose a standard feed

Adult

Whole
Protein
With
fibre Mixed
Paediatric
Without
fibre
Semi-elemental (Di-/tri-peptides)
Enteral Adult
Tube Elemental (Amino acids)
Feeding Modified
Solutions Protein Semi-elemental (Di-/tri-peptides)
Paediatric
Elemental (Amino acids)

- Respiratory (Altered CHO: fat ratio)

Disease - Renal (Low protein, low electrolyte, high
Specific energy, low fluid)
- AIDS/HIV (Modified fat/peptides, added
fibre, energy dense)
- Intensive Care (Added glutamine/n3 fatty
acids/arginine)
- Hepatic (Added branched chain amino acids)
- Cardiac insufficiency (Low sodium)
- Milk intolerance (Soy based)

Fig. 2. Types of solutions available for enteral tube feeding.

 P. Howard / e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e223–e225 e225

Note: Feeds containing soluble fibre could be given instead of an individual basis and it should be delivered as high up the GI tract
a standard feed due to the other benefits they confer e.g. glycaemic as possible while ensuring maximum absorption.
control.
Conflict of interest
4) Is there a specific dietary restriction or other nutritional need?
Yes – Consider a disease specific or a paediatric formulation There is no conflict of interest.
No – Choose a standard feed

5. Summary
A selection of commercially produced enteral feeding solutions
is widely available. The most suitable solution should be selected on
Further reading
1. McAtear CA, editor. Current perspectives on enteral nutrition in adults. Maiden-
head, Berkshire, UK SL6 4SH: BAPEN, PO Box 922; 1999.
2. Payne-James J, Grimble G, Silk D, editors. Artificial nutritional support in clinical
practice. Edward Arnold; 1995.