Invited Review

Nutrition in Clinical Practice

Volume 34 Number 2
Addressing Frequent Issues of Home Enteral Nutrition April 2019 186–195

C 2019 American Society for

Patients Parenteral and Enteral Nutrition

DOI: 10.1002/ncp.10257
wileyonlinelibrary.com

Teresa W. Johnson, DCN, RDN, FAND1 ; Sara Seegmiller RN, GIM2 ;

Lisa Epp, RDN, LD, CNSC2 ; and Manpreet S. Mundi, MD2

Abstract
The home enteral nutrition (HEN) population is a medically diverse group whose number has increased substantially in recent
decades. Although medically stable compared with acute care patients requiring nutrition support, HEN population needs are
unique and require a team approach to manage nutrition. Frequently encountered issues by the HEN team include mechanical issues
of the tube site, gastrointestinal and metabolic problems, and patient preferences regarding tube weaning, formula selection, and
compliance. A thorough search of the published literature on how to manage these issues was conducted using scientific healthcare
databases with the following inclusion criteria: English only, last 10 years, and reviews and clinical trials. Where appropriate,
references from the retrieved articles were hand-searched for relevant articles older than 10 years and cited in this review. The
purpose of this review is to provide the HEN team with strategies to address the top issues of home enteral feeding. (Nutr Clin
Pract. 2019;34:186–195)

Keywords
complications; constipation; diarrhea; enteral nutrition; gastrostomy; home enteral nutrition; infection; nutrition support

Introduction including reimbursement issues.9 For example, costs of

Malnutrition occurs in 30%–50% of hospitalized patients,1,2
and these patients are likely to require ongoing medical
services from nutrition support teams after discharge from
acute care centers.3 Providing adequate nutrients with home
enteral nutrition (HEN) can reduce hospital readmission
rates, which is one of the reasons the number of HEN
patients has increased.4-8 In 2013, it is estimated that there
were 437,882 patients receiving HEN in the United States.5
With those increases, clinicians must learn how to navigate
the complex decentralized reimbursement processes in a
diverse patient population.4,9 HEN patients have signifi-
cant comorbidities and feeding challenges that require a
team-based approach and caregiver competence.10,11 HEN
populations are sometimes older with cognitive and/or
mobility limitations. Frequent diagnoses include dysphagia,
neurological impairments such as stroke, and a variety
of cancers.10 Alternately, many HEN patients are able to
resume normal daily activities such as work, school, and
leisure activity. They may assume more responsibility for
their healthcare decisions and typically utilize the internet
or support group information that healthcare providers
(HCPs) will need to navigate with them.
Before HEN is initiated, HCPs must consider issues
including risk vs benefit, formula selection, equipment avail-
ability, patient preferences, and potential cost of therapy,
a particular formula or feeding pump covered during
hospitalization might not be covered in the home setting.
After HEN is initiated, caregivers and patients will need
sustained oversight and guidance for the duration of
therapy. To ensure a safe transition from hospital to home,
experienced HEN teams should utilize up-to-date policies
and procedures for safe tube feeding. They must assess
the ability of caregivers to comply with these directives
and understand that they will need continued accessibility
to clinicians for support and education. Caregivers will
need education on how to operate equipment, administer
feedings and medications, care for the tube-feeding site, and
demonstrate infection control basics. Before transitioning
to home feeding, patients must be hemodynamically
From the 1 Department of Kinesiology & Health Promotion, Troy
University, Troy, AL, USA 2 Mayo Clinic, Rochester, Minnesota,
USA.
Financial disclosure: None declared.
Conflicts of interest: L. Epp is a consultant for Abbott Nutrition,
Nestlé Nutrition, and Halyard Health. All others report no conflicts.
This article originally appeared online on February 11, 2019.
Corresponding Author:
Professor Teresa W. Johnson, DCN, RDN, FAND, 112 Wright Hall,
Troy University, Troy, AL 36081.
Email: tjohnson@troy.edu
Johnson et al
Table 1. Commonly Encountered Issues of Home Enteral Nutrition.
Mechanical Issues Gastrointestinal
of the Tube Site Issues
Leakage Constipation
Dislodgment Diarrhea
Granulation tissue
Infection
stable with normal laboratory values and no major
changes in medical condition. Outcomes are optimized
when HEN teams, rather than single providers, manage
this diverse patient population.12-14 The purpose of this
review is to address issues frequently encountered by
HEN patients after tube placement in adult and pediatric
populations and provide suggestions for management.
Commonly encountered issues of HEN are summarized in
Table 1 and include mechanical issues at the tube site (eg,
leakage, dislodgment, granulation tissue, and infection),
gastrointestinal (GI) issues (eg, constipation and diarrhea),
metabolic issues (eg, dehydration and weight concerns), and
patient-specific issues of tube weaning, formula preferences,
and compliance.
Mechanical and Infectious Issues
Most tube-feeding issues can be resolved within the home
setting. However, almost 25% of HEN patients will require
hospitalization within 6 months of tube placement,14,15
and 3–5 additional home visits by the HCP are needed
in the first 18 months.16,17 The most frequently reported
issues are mechanical problems related to the tube, includ-
ing dislodgment, leaking, and tube occlusion. Concerns
regarding the enteral tube insertion site may be further
complicated by growth of granulation tissue, yeast, and
infection.18
Tube Dislodgment
Potential problems are inherent with each type of tube.
For example, nasoenteric tubes (NETs) increase the risk
of sinusitis, nasal tissue erosion, reflux, aspiration, and
pneumonia when used for longer than 1 month.18 Although
intermittent NET placement by HEN adults using a self-
insertion technique may be preferred by some patients,19
more frequently competent HCPs place tubes and confirm
placement with radiographic tests in adults to avoid inap-
propriately positioned tubes.20 Adults and children have the
same risks for tube dislodgement; however, blind placement
of NETs by registered nurses occurs more frequently in
hospitalized children than adults.21 There is no standard
method that ensures correct NET placement in pediatric
patients. However, consensus statements identified in the
NOVEL (New Opportunities for Verification of Enteral
Tube Location) project recommend initial and scheduled
187
Metabolic Patient-Specific
Issues Issues
Dehydration Formula selection
Weight Weaning
Compliance
gastric pH testing for verifying the correct placement of
NETs.21 Because of concerns from frequent radiation
exposure, radiographic confirmation should be limited
to those patients for whom there is difficulty placing the
tube, those with facial fractures or neurological injuries,
patients with critical illness, and patients with respiratory
problems or who have no gag reflex. Radiographic testing
is also suggested for those who deteriorate shortly after
the tube is placed. NETs can also migrate into the small
bowel and should be marked at initial placement so that
caregivers can monitor changes in tube length. If migration
is suspected, a radiographic exam is needed to check for
proper placement. However, repeated exposure to radiation,
especially in children, is a concern. Other indicators include
color of tube-feeding aspirate (stomach contents are clear;
small-bowel contents are dark because of the presence of
bile acids) and pH (stomach pH is ࣘ5, but small-bowel pH
is ࣙ6).
Introduced in the 1980s, percutaneous endoscopic gas-
trostomy (PEG) tubes are easily placed in adults and chil-
dren and do not require a laparotomy.18 There are 2 varieties
of tubes: PEG tubes are those tubes placed via endoscopy,
and gastrostomy tubes, or G-tubes, refer to tubes placed
in interventional radiology or surgery, without endoscopy.
“PEG tube” tends to be the term used for all tubes, whether
correct or not. Potential complications during PEG inser-
tion are rare (ࣘ4%),22 but dislodgment after transitioning to
home care has serious consequences (eg, peritonitis) if the
stomach has not adhered to the abdominal wall. Tract mat-
uration usually requires 2–4 weeks, but it might be delayed
with conditions that impair wound healing (eg, diabetes and
immunosuppression).19 If the tube dislodges before the tract
has matured, it will need to be replaced by the HCP. If tube
dislodgment occurs after a mature tract has formed (>1
month post placement), the tube must be replaced within 1–
4 hours to prevent stoma closure. Another potential prob-
lem is tube migration into the pylorus and small intestine,
resulting in luminal obstruction.18 Caregivers will need to
recognize signs/symptoms (abdominal pain, diarrhea, and
nausea) and visualize external tube length for significant
length reduction. Caregivers need to know how to deflate
the balloon, retract the tube, reinflate the balloon, and
reposition the skin disk before placing the new tube. For
dislodged bumper-type tubes, the practice of these authors
is to inform the caregiver to cut the bumper off of the
188
Figure 1. Fungal/yeast infection. Used with permission of the
Mayo Foundation for Medical Education and Research. All
rights reserved.
Figure 2. Granulation tissue. Used with permission of the
Mayo Foundation for Medical Education and Research. All
rights reserved.
tubing and place the tubing back into the stoma to prevent
stoma closure. The tube should not be used until a new
tube is placed by a medical professional. If the tube is
replaced outside a clinical setting, X-ray confirmation is
recommended.
Leaking
All types of gastrostomy tubes may leak at the stoma site.
Caregivers will need to learn how to check the balloon for
proper inflation and ensure proper skin disk placement to
prevent leakage or buried bumper syndrome (BBS). Some
leakage around the stoma site is inevitable with long-term
tube feeding. Excessive leakage is more likely found with
fungal infections (Figure 1) at the stoma site, hypergran-
ulation tissue (Figure 2), side torsion on the tube, BBS,
or absence of a skin disk.18,22 Caregivers need to inspect
the site frequently and discriminate normal from abnormal
findings. General guidelines to reduce leakage include the
Nutrition in Clinical Practice 34(2)
use of a proton pump inhibitor, a tube securement device,
or silver nitrate to reduce granulation tissue.18 Some pain is
associated with use of the silver nitrate sticks, and patients
may need an analgesic. There are other treatment options
that can be discussed with the patient’s HCP or HEN team.
Salt-water solutions applied over 7–10 days can also reduce
granulation tissue,23 but it deactivates silver nitrate sticks
and should not be used concomitantly.
Occlusion
Tube occlusion incidence ranges between 25% and 35% and
is more likely with thicker hypercaloric formulas, use of fiber
supplements, frequent checking of gastric residual volume
(GRV), and improper medication administration through
the tube.18,24 To avoid clogging, tubes should be flushed
with 50–60 mL of warm water before and after feedings
and medication administration. Medications should also be
completely dissolved in water before putting them in the
tube and should be given separately from tube feeding and
other medications. Pulling gastric contents into the tube
coagulates protein that may be present in the tube, causing
occlusion. Consequently, routine checks of the GRV are
unnecessary and should be avoided. Home methods of
clearing a clogged tube include warm water flushes, use
of pancreatic enzymes, and bicarbonate or carbonated
beverages as a last resort.18,20,22,24
Infection
Site infections can be a frequent complication of tube-
feeding sites, but most are minor and potentially avoided by
proper surgical techniques and a single prophylactic dose
of antibiotics at the time of placement.18 Excessive mois-
ture around the stoma site promotes bacterial and fungal
growth. Yeast infection is characterized by pruritus, redness,
and satellite lesions at the stoma site and is treated with
a topical antifungal agent (Figure 1). Diagnosing bacterial
infection at the stoma site is more difficult because bacteria
are always present on the skin surface, often leading to
overtreatment (Figure 3). An infection assessment tool us-
ing objective criteria (induration, erythema, and discharge)
has been developed to identify and more appropriately
triage bacterial infection of stoma sites, reducing unneces-
sary antibiotic treatment.25 Leaking at the stoma site and
increased friction may cause the formation of granulation
tissue (Figure 2). If not properly treated, granulation tissue
can lead to serious infection, so keeping the stoma site
dry and avoiding friction to the site must be emphasized
to caregivers. Another contributing factor to wounds is
increased tension on the tube, which may cause BBS and
necrosis.18,22 To reduce risk, the tube should be rotated.
PEG and percutaneous endoscopic jejunostomy tubes can
be rotated (Figures 4 and 5); gastrostomy-jejunostomy and
jejunostomy tubes cannot be rotated (Figures 6 and 7).
Johnson et al 189

Figure 3. Bacterial infection. Used with permission of the

Mayo Foundation for Medical Education and Research. All
rights reserved.

Additional factors that predispose HEN patients to stoma

site infections include malnutrition, significant weight gain,
diabetes, obesity, and steroid use.18,22,26
Surgically placed jejunostomy tubes have the highest
incidence of complications, including migration, clogging,
and malfunction.18 Direct placement carries a higher risk
of surgical complications than PEG tubes with a jejunal
extension, but both are prone to long-term complications,
including fistulas, excessive leakage, infections, and BBS.27
Figure 4. Percutaneous endoscopic gastrostomy (PEG) tube
GI Issues placement. Used with permission of the Mayo Foundation for
Medical Education and Research. All rights reserved.
Constipation
bowel ischemia in patients with dysmotility problems.29
HEN teams address a number of GI issues of tube feeding,
HCPs should also screen for medications that reduce GI
including constipation, diarrhea, nausea, cramps/bloating,
motility, including antacids, antidepressants, selected blood
and aspiration. To prevent constipation, HCPs should
pressure medications, cold medicines, anticholinergics, and
determine fluid needs when tube feeding is initiated and
calcium or iron supplements. A prophylactic stool softener
follow published guidelines when making those calculations
or laxative may be needed if medications cannot be altered.
(Table 2).28 In addition to fluid needs, registered dieti-
Finally, increasing a patient’s physical activity when possible
tians/nutritionists (RDNs) need to calculate water flushes
improves GI motility.30
and percent-free water in the tube-feeding formula to ensure
that patients receive adequate hydration. Infant formulas
often provide sufficient free water such that additional
Diarrhea
water is not usually needed. However, pediatric and adult Diarrhea may be categorized by duration (acute: up
formulas vary in free-water content from 63% to 85%, to 2 weeks; persistent: 2–4 weeks; chronic: longer than
making additional water flushes necessary. Using formula 1 month) or by etiology.30,31 The mechanism of diarrhea
with additional fiber or adding fiber products to enteral is correlated to the classification.30,31 A number of vari-
feeding has little clinical utility in treating constipation ables may cause diarrhea in patients receiving HEN, in-
for most patients and increases the risk of clogging the cluding predisposing diagnoses (malabsorption syndromes,
tube, reduces the absorption of medications, and may cause diabetes, pancreatic insufficiency, and fecal impaction),
190
Figure 5. Percutaneous endoscopic jejunostomy (PEJ) tube
placement. Used with permission of the Mayo Foundation for
Medical Education and Research. All rights reserved.
infection (parasites or bacteria), and selected medica-
tions (sugar alcohols, H2 blocking agents, lactulose,
mineral-containing mixtures, antibiotics, chemotherapy,
and radiation).30,31 When possible, tube feeding should
continue while the etiology is being investigated—ensuring
that adequate fluid, electrolytes, and macronutrients are
provided. The HCP must help the patient distinguish
between diarrhea vs a normal stool change induced by
feeding-tube formula (eg, stool volume and frequency).
Large, watery, greasy stools are likely due to problems in
the small bowel. Frequent passage of mushy brown stools
mixed with blood or mucous likely originates from the
large intestine—especially if abdominal pain is resolved
upon defecation. Persistence of diarrhea at night (unless on
nighttime feeding) suggests the presence of an infectious
agent.31 The patient’s medications and medical history
should be thoroughly reviewed. Stool cultures are needed
when pathogens are suspected.
In the absence of any medical or treatment issues caus-
ing diarrhea, HCPs should consider the delivery of the
enteral product. Cold formula or rapid feeding may induce
Nutrition in Clinical Practice 34(2)
Figure 6. Site of transgastric jejunostomy tube. Used with
permission of the Mayo Foundation for Medical Education
and Research. All rights reserved.
diarrhea. Patients may respond favorably to continuous
feeding or a low-fat or peptide-based formula. Formula with
fructooligosaccharides (FOS) may provide the proper type
of fiber to optimize stool transit time. FOS may be added
to standard formulas (eg, banana flakes, psyllium, and guar
gum) if Clostridium difficile is ruled out.30-32 For patients
with antibiotic-induced diarrhea, prebiotics (FOS) may help
with recolonization of GI bifidobacteria.32 However, this
would not be a viable option for patients unable to tolerate
fermentable oligosaccharides, disaccharides, monosaccha-
rides, and polyols. Some patients may require pancreatic
enzyme replacement therapy.30
Nausea/Vomiting/Aspiration
In an acute-care setting, continuous or intermittent infu-
sions are usually given via pump. However, many HEN
patients are discharged from healthcare facilities on bolus or
gravity feedings without sufficient time to assess tolerance.
Patients who cannot tolerate administration rates of at
least 100 mL/h; those on jejunal feeding; or those at risk
for dumping, aspiration, diarrhea, gastroesophageal reflux
disease, vomiting, or poor glycemic control are not good
candidates for bolus feedings. Feeding these at-risk patients
bolus administration can exacerbate nausea and vomiting
Johnson et al
Figure 7. Balloon jejunal tube. Do not rotate, as it has a tail.
Used with permission of the Mayo Foundation for Medical
Education and Research. All rights reserved.
Table 2. Hydration Needs of Adults and Children.
Population Category Calculation
Adults Age 18–55: 35 mL/kg
Age 55–75: 30 mL/kg
Age >75: 25 mL/kg
Pediatrics 1–10 kg: 100 mL/kg
11–20 kg: 1000 mL + 50 mL/kg >10 kg
>20 kg: 1500 mL + 20 mL/kg >20 kg
and increase the risk for aspiration.33 Additional contribu-
tors to nausea and vomiting include contaminated formula,
infections, constipation, or selected therapeutic treatments
(eg, narcotics) unrelated to the feeding.30,33
Aspiration is 1 of the most serious potential complica-
tions of tube feeding, contributing to pneumonia, atelec-
191
tasis, and lung injury. Occurrence may be as high as 5%
in tube-fed patients.34 Detection is nonspecific and ranges
from microaspiration of saliva to regurgitation of a large
volume of stomach contents into the airway.30 A patient
who requires EN likely has 1 or more risk factors for
aspiration, including diminished sensory perception and
neuromuscular impairment, advanced age, impaired gag
reflex and ability to cough, intubation, and prior need for
mechanical ventilation.35 To reduce risk, patients should
be fed with the head of the bed elevated between 30°
and 45°. Additional strategies to combat aspiration include
the use of a promotility agent, continuous rather than
bolus feedings, jejunostomy feeding, and consideration for
discontinuing analgesia or narcotics, if appropriate. Patients
should also receive oral care to reduce bacterial load of oral
secretions.30
Metabolic Issues (Hydration and Weight
Management)
Hydration
Overhydration and underhydration can be a metabolic
complication of tube feeding. Contributing factors to de-
hydration include excessive fluid loss through stool, urine,
ostomy/fistula, and nasogastric suction. Many children with
special healthcare needs require more fluid because of their
inability to control oral secretions, poor GI motility, and
volume intolerance.36 Concentrated formulas coupled with
inadequate fluid provision also cause dehydration. Signs and
symptoms of dehydration include dry skin, increased heart
rate, decreased blood pressure, and constipation.31 Alter-
nately, excessive fluid provision; rapid refeeding; and renal,
cardiac, or liver disorders may cause overhydration. Fluid
needs should be carefully calculated (Table 2) and provided
through tube feeding or additional intravenous fluid when
indicated—generally 1 mL/kcal. Attention should be given
to fluid intake and output, weight changes, presence of
edema, and biochemical indicators, including electrolytes,
serum urea nitrogen, and creatinine. Patients may need fluid
restriction or a diuretic to correct volume overload or fluid
restriction to correct serum electrolyte dilution.30
Weight Concerns
Clinicians are familiar with the need to monitor weight
in children who are rapidly growing. However, setting
weight goals for the adult population is equally as im-
portant. About 70% of adults in the United States are
overweight, and 35% are obese,37 but half do not realize
their condition.38 Obesity can lead to a number of metabolic
complications, including diabetes, cancer, hypertension, os-
teoarthritis, and gallbladder disease. As clinicians, we do
not want to worsen these complications with HEN. It is
important to discuss a safe, slow weight loss plan with
192
patients. Usually, a 10% weight loss in 6 months is safe,
with the goal to then maintain for 6 months or maintain
a slow weight loss of 0.5 kg/wk. In the obese population,
hypocaloric, high-protein feeding may be beneficial.
The nutrition needs of adult patients change over time,
just as they do in children. The clinician should be aware
that during active treatment (chemotherapy or radiation
therapy), nutrition needs may be increased. Likewise, in
the healing phase (surgery and treatment side effects),
needs may also be higher than expected. It is important to
have frequent follow-up so that HEN can be adjusted as
needed to meet nutrition and weight goals. As previously
mentioned, many adults who are overweight or obese do not
know this. It is important to have a careful, compassionate
conversation about weight goals with patients and their
families so that they are aware of the rationale for your
recommendations.
Specific Patient-Related Issues (Tube Weaning,
Formula Preferences, and Compliance)
Tube-Feeding Weaning
A frequent desire of tube-fed patients is to return to oral
food intake. Many adult patients with head and neck
cancer or stroke survivors are able to wean from feeding
tubes with assistance from therapists and an HEN team.39
Unfortunately, many tube-fed children are survivors of dif-
ficult neonatal experiences and have missed developmental
feeding milestones, which makes weaning a challenge.40,41
The first consideration for children or adults who want to
trial oral feeding is safety. Once therapists have determined
that the tube-fed patient may safely swallow food or liquids,
the tube feeding should be changed from continuous to an
intermittent schedule that approximates a more physiologic
feeding experience. A patient who is unable to tolerate a
liquid bolus is not a candidate for complete tube-feeding
weaning. The patient should be alert and in an upright
position, and bolus tube feeding should be provided after
oral intake. When the patient is able to consume sufficient
calories by mouth during meals, the bolus tube feeding may
be discontinued, or the patient may be switched to supple-
mental night feedings. Food intake records are needed to
track calorie intake and to match patient needs assessed
by weekly weights. The patient should be monitored during
oral feeding for any signs or symptoms of aspiration or tex-
ture intolerance.42 Many children demonstrate tube-feeding
dependency, which is characterized by active refusal to eat or
drink and lack of motivation, ability, or feeding skills after
an extended tube-feeding duration.40 Affected individuals
may have poor motivation to eat and a diminished percep-
tion of hunger. Many children who are medically able to eat
refuse food because of negative experiences associated with
eating or medical treatments and may be diagnosed with
Nutrition in Clinical Practice 34(2)
avoidant/restrictive food intake disorder.40 Long-term tube-
feeding dependency increases the risk of feeding disorders,
narrowed food selection, gagging, dumping, aspiration, and
associated problems with the tube site.40,41
Steps to prevent tube-feeding dependency should be-
gin with the initiation of nutrition support.43 To reduce
negative associations with feeding, underlying food aller-
gies/intolerances should be addressed with formula selection
and tube-feeding route. For example, gagging and retching
is less likely with continuous pump feeding compared with
syringe feeding. Tube-fed children should be included with
family meals to create positive associations with eating.
Providing nocturnal feedings with boluses at meal times
can supply adequate nutrition while supporting the normal
hunger-satiation system. Using a gastrostomy tube instead
of a nasogastric tube for long-term feeding affords a better
opportunity for therapists to foster oral feeding skills and
food intake.43 Ensuring proper upright positioning and pro-
vision of age-appropriate food also reduces the likelihood of
a negative feeding experience.
Tube weaning in children may take months or years
and requires a great deal of commitment from care-
givers. Feeding is a complex process with multiple inputs
from cardiac, respiratory, sensorimotor, and digestive sys-
tems to be assessed. Child/parent feeding dyads should
also be navigated. Consequently, a team approach utiliz-
ing the skills of dietitians, speech language pathologists,
occupational therapists, psychologists, and physicians is
needed.40,41,43
Tube-feeding weaning occurs in 2 phases. In phase 1,
HCPs determine if the patient can safely tolerate oral feed-
ing. Patients are assessed for their ability to safely swallow
food, medical stability, demonstrated interest, endurance,
tolerance for sensory experiences, caregiver commitment,
and volume tolerance.42 Patients who are tube-fed into the
stomach should first be switched to bolus or intermittent
feeding to approximate a more physiologic feeding and
to assess volume tolerance. Swallow evaluation studies are
used to determine the need for food texture modifications
(eg, thickened liquids, pureed or chopped food). In phase 2,
hunger induction methods are used to displace tube feeding
with oral feeding. Strict documentation of food consumed,
enteral formula provided, weight, and bowel and bladder
elimination is required.42 In a slow weaning regimen, enteral
formula is stopped for a few hours before a trial of oral
feeding. Calories taken by mouth are deducted from the
subsequent tube-feeding bolus, with the ultimate goal of
oral intake displacing nutrition from formula. In the rapid
weaning approach, enteral formula is cut by percentages
to reduce satiety; as food intake increases, the formula is
cut by greater percentages. For example, a tube feeding
is discontinued when the patient is able to consume 75%
of energy needs by mouth for 3 consecutive days.42,44 In
children, gastrostomy tube removal may be delayed up to
Johnson et al
3 months to ensure that 100% oral intake supports weight
and growth trajectories.
Formula Preference
Interest and use of blended tube feeding (BTF) have
reemerged, primarily because of consumer demand for
more natural food products, treating tube-feeding intol-
erance, and financial challenges of obtaining commercial
formula (CF).33 Limited research shows the benefit of
BTF,45-49 and the pharmaceutical industry has responded
to this demand by introducing more whole-food blend
products.33 Families report overall improved outcomes and
high satisfaction with BTF.50 Studies of RDNs in the United
States and the United Kingdom found that approximately
60% use and recommend BTF for selected patients.51,52
HCPs are more interested in BTF because of increasing
evidence that diet diversity positively impacts the gut micro-
biome and overall health.33
Although sterile CF with known nutrient composi-
tion may be preferred in acute care settings of immune-
compromised patients, the HEN population is medically
stable and may benefit from full or partial BTF when
oversight is provided by the HEN team. However, not all
patients are candidates for BTF. Patients must be medically
stable, use a >14-French tube, be at least 6 months old, and
be slowly transitioned to blended food.53,54 BTF typically
requires a higher volume to meet nutrient needs, so patients
must be able to tolerate bolus feeding. HCPs should screen
patients with metabolic disorders, medical diagnoses, and
multiple food allergies that would prevent a successful BTF
transition. Caregiver considerations should not be excluded.
BTF preparation is labor intensive and requires additional
equipment, food storage areas, and knowledge of safe food
handling practices. HEN teams will need to assist caregivers
of tube-fed patients with navigation of school, travel, and
potential hospital stays with their BTF. Through initial and
ongoing feeding oversight, HEN teams with BTF training
can help caregivers avoid the potential pitfalls of whole-food
feeding, including clogged tubes, inadequate nutrient pro-
vision, and microbial contamination.13,53 Frequent patient
assessment and analysis/revisions of BTF recipes by the
RDN is of particular importance in pediatric populations
in which growth and higher susceptibility to malnutrition
impact care. Resources are available to assist RDNs with
patient screening, transitioning, and oversight.55-57
Noncompliance
Noncompliance may be a potential HEN complication that
can be overlooked. It is estimated that 10% of HEN patients
do not give at least 80% of daily feedings.58 Likewise, a
study by Lee et al reports that up to 68% of patients
with PEG tubes are noncompliant with prescribed HEN
programs.59 Rather than being judgmental, it is important
193
for clinicians to assess barriers to compliance (eg, time,
money, motivation, education, support, and sleep). It is
important to discuss patient and caregiver preferences as
well as appointments and work and school schedules before
developing a plan without patient input. A signed service
agreement can be helpful so that everyone agrees and
understands the plan. Home medical equipment companies
can be a great resource in communicating with the patient
and the HEN team about compliance issues. In addition
to reporting supply-ordering habits to the HEN team, they
can also reinforce recommendations, as patients do call for
supplies.
Having adequate support can increase compliance.
Clinicians are encouraged to have standard follow-ups
with patients. This can be done by phone or face-to-face.
Referring patients to the Oley Foundation (Albany, NY,
USA) or Feeding Tube Awareness Foundation (New Hyde
Park, NY, USA) can also help support them at home.
Summary
This paper does not address all of the potential feeding
issues of the HEN population. However, it does cover pa-
tients who are most frequently encountered by these authors
and are frequently presented in the published literature43
(Table 1). The concomitant efforts to reduce malnutrition
and decrease length of stay in acute care continue to
drive the increase in HEN use. Competent HEN teams
are required to provide initial and sustained oversight to
this diverse and complex patient population. Anticipat-
ing, preventing, and managing common issues of tube-fed
patients significantly impacts GI, metabolic, and immune
system functions. HEN management must also strive to be
patient-centered by considering formula preferences, patient
and caregiver goals for tube weaning, and optimizing com-
pliance. Caregivers must demonstrate safe food handling
competencies, and formula and equipment reimbursement
issues will need to be carefully navigated by the team.
Statement of Authorship
T. W. Johnson, S. Seegmiller, L. Epp, and M. S. Mundi
equally contributed to the conception and design of the
work; T. W. Johnson, S. Seegmiller, L. Epp, and M. S. Mundi
contributed to the acquisition and analysis of the data;
T. W. Johnson, S. Seegmiller, L. Epp, and M. S. Mundi
contributed to the interpretation of the data. All authors
drafted the manuscript, critically revised the manuscript
and agree to be fully accountable for ensuring the integrity
and accuracy of the work, and read and approved the final
manuscript.
Supplementary Information
Additional supporting information may be found online in the
Supporting Information section at the end of the article.
194 Nutrition in Clinical Practice 34(2)

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