Issues in Nutrition of Children
Szajewska H, Shamir R (eds): Evidence-Based Research in Pediatric Nutrition.
World Rev Nutr Diet. Basel, Karger, 2013, vol 108, pp 86–90 (DOI: 10.1159/000351490)
Enteral Nutrition
Sanja Kolaček
Children’s Hospital Zagreb, Zagreb, Croatia
Abstract
Enteral nutrition (EN) is defined as the delivery of nutrients beyond the oesophagus via feeding tubes,
and the oral intake of dietary foods for special medical purposes. It should be provided in patients
with at least a partially functioning gut, whose energy and nutrient needs cannot be met by a regular
food intake. Further indications are when the liquid diet is used as a treatment of the disease, and
when a feeding time in the disabled child is excessively prolonged. Advantages of enteral intake over
parenteral nutrition are well recognized, however there are clinical settings such as intensive care
units where nutritional needs can often be met only by their combination despite the functioning
gut. For the majority of paediatric patients on EN, age-adapted standard polymeric formula enriched
with fibres is an appropriate choice. There is also a wide array of different disease-adapted enteral
formulations that may be beneficial in certain clinical conditions, however for most of them, results
of controlled studies are either missing or do not support the claims. For the delivery of EN, both the
stomach and intermittent feeding mode are more physiological; continuous mode is reserved for
patients with severely diseased gut, postpyloric feeding is indicated in patients with the high risk of
tracheal aspiration, and feeding over gastrostomy is preferable if the anticipated duration of EN is
exceeding 4–6 weeks. Although EN is a well-established and effective feeding method, it may be
poorly tolerated and associated with numerous complications. To minimize the risks, development
of procedural protocols with regular quality controls and audits, and monitoring by a dedicated
nutrition support team are recommended. Copyright © 2013 S. Karger AG, Basel
Definition and Indications
Enteral nutrition (EN) encompasses delivery of liquid formula beyond the oesophagus
via a feeding tube/stoma, and also an oral provision of dietary foods for special
medical purposes as defined in the European legal regulation of the Commission
Directive [1, 2].
It is generally indicated in a patient with a functioning gut, whose energy and nutri-
ent requirements cannot be met by a regular food intake. It is also indicated whenever
diet is used as a treatment of the disease (Crohn’s disease, food intolerances) and when
a feeding time is excessively prolonged (>4–6 h/day), as it is in a disabled child [3].
Specific clinical indications are listed elsewhere [3]. Negative effects of malnutrition
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on the prognosis of various diseases, including surgical patients, have been shown in
many studies [4, 5], and it is therefore recommended to use nutrition support timely –
before malnutrition develops [6, 7]. This does not necessarily mean EN, because di-
etetic advice and oral nutritional supplements have proven to be cost-effective meth-
ods of nutritional support [8]. Advantages of enteral over parenteral intake are well
recognized. However, there are clinical settings, such as intensive care units, where the
reliance on EN alone may result in an unsatisfactory nutritional intake despite a func-
tional gastrointestinal tract, and in these patients their combination is recommended
[3]. An international multicentre cohort study that enrolled 500 critically ill children
(mean age 4.5 years) from 31 intensive care units showed a high prevalence of severe
malnutrition (17%). 67% of all patients received EN, which was initiated within the
first 48 h in the majority of them (60%). However, nutritional delivery was generally
inadequate as enterally fed children received only 38% of the prescribed energy and
43% of the prescribed protein intake. Importantly, an increase in enterally delivered
energy from 33.3 to 66.6% was associated with significantly lower 60-day mortality
(odds ratio 0.27 (0.11–0.67), p = 0.002), while parenteral nutrition, on the contrary,
was associated with higher mortality rate (odds ratio 2.61 (1.3–5.3), p = 0.008) [9].
Enteral Nutrition Formulations
Standard paediatric enteral formula which is recommended as an adequate and cost-
effective form of EN for the majority of patients [3] implies an energy density of 1 kcal/
ml, iso-osmolality (300–350 mosm/kg), whole proteins as nitrogen source, and
content adapted to the requirements of children under the age of 10 years. In addition,
it is generally lactose- and gluten-free. Since recently, standard formulations also
contain non-digestible carbohydrates (fibres) and are advertised as beneficial in
reducing gastrointestinal side effects such as diarrhoea and constipation. This claim
has been substantiated with the results of meta-analysis of controlled studies in adults
and in children that compared fibre-supplemented versus fibre-free formulations
provided as the sole source of nutrition, showing a significant benefit on bowel
functioning, both in patients and in healthy subjects, irrespective if the predominate
symptom was diarrhoea or constipation [10].
In contrast to standard EN formulas, there are disease-specific formulations which
were firstly developed for infants and children with intolerances such allergy or inborn
errors of metabolism, who required elimination of one or more food components.
Their benefits are easily recognized and their use positioned with guidelines and rec-
ommendations, such as guidelines for treatment of food allergy [11]. The next step in
EN formulation was different modifications aiming to be beneficial for specific disor-
ders. Examples are formulas with a high fat content that may be of value for patients
with insulin resistance and in hypercapnic patients with pulmonary disease due to
lower CO2 production, or formulas with reduced protein content for patients with re-
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Enteral Nutrition in Pediatrics 87
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Szajewska H, Shamir R (eds): Evidence-Based Research in Pediatric Nutrition.
World Rev Nutr Diet. Basel, Karger, 2013, vol 108, pp 86–90 (DOI: 10.1159/000351490)
nal disease, or a specific amino acid profile that may benefit patients with hepatic en-
cephalopathy. Despite the fact that those modifications are in line with the pathophys-
iology of the diseases, clinical benefits in paediatric patients remain questionable [3].
The most recent research topics in the design of enteral formula include addition of
anti-inflammatory cytokines or nutrients which, if provided in high doses, could exert
an immunoregulating effect, and are therefore named pharmaconutrients [12]. Trans-
forming growth factor-β-enriched formula for exclusive EN therapy of active Crohn’s
disease [13], glutamine-enriched formula for improving gut barrier function and de-
creasing mucositis in paediatric oncology patients [14] and preterm infants [15], and
the addition of arginine as an epithelial barrier-promoting factor for prevention of
necrotising enterocolitis in preterm babies [16] are the examples of disease treatment-
dedicated pharmaconutrients. However, there are very few controlled studies in pae-
diatric patients, and for that reason claims of benefit should be evaluated critically.
Delivery of Enteral Nutrition
Site
The stomach is the preferred site for formula delivery because the acid barrier is
preserved, hyperosmolar feeds are better tolerated, gastric content is slowly released
into the duodenum and nasogastric tubes (stomas) are more easily positioned and
maintained. Postpyloric access is reserved for clinical conditions in which tracheal
aspiration, gastroparesis and gastric outlet obstruction preclude gastric feeding [3].
However, results of studies comparing gastric versus postpyloric sites are conflicting,
often not showing a clinical benefit in either adults or children. Moreover, in preterm
infants an increased incidence of gastrointestinal disturbances (RR 1.45, 95% CI
1.05–2.09) and of mortality (RR 2.46, 95% CI 1.35–4.46) was found in a postpylorically
fed group [17]. A more recent study has shown that in critically ill adults with
numerous risk factors for tracheal aspiration, feeding into the mid- and distal, but
not into proximal duodenum reduced the risk of aspiration and associated pneumonia
[18]. Despite the lower risk, in 20 paediatric patients it has been reported that reflux
occurs also during transpyloric feedings and that the rate is doubled during feeding
time compared to non-feeding periods [19]. This is consistent with studies in adults
showing an increased number of transient lower oesophageal sphincter relaxations
and acid reflux episodes after installation of formula into jejunum [20].
Route
The major criterion influencing the choice of route (stoma vs. tube) is the anticipated
duration of EN. Feeding via gastrostomy/jejunostomy is preferred in patients requir-
ing EN for at least 4–6 weeks and nasoenteric feeding is a better option if oral feeds
are to be resumed earlier [3, 21]. Recently published guidelines [3, 21–23] provide
information that may assist in providing care to patients requiring nasogastric tubes
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88 Kolaček
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Szajewska H, Shamir R (eds): Evidence-Based Research in Pediatric Nutrition.
World Rev Nutr Diet. Basel, Karger, 2013, vol 108, pp 86–90 (DOI: 10.1159/000351490)
or gastrostomies for delivery of EN. In contrast to what was previously recommended,
recent studies in neonates determined that pH ≤5 is a reliable and safe cut-off for con-
firmation of nasogastric tube placement [24], and the distance nose-ear-mid-umbili-
cus is more precise than nose-ear-xiphoid for predicting the insertion length for gas-
tric tube placement [25]. Finally, it seems that feeding (electrolyte solution) can be
initiated already 3 h after percutaneous endoscopic gastrostomy placement in chil-
dren without an increase in complications [26].
Mode
Continuous formula infusion is often recommended in malnourished children with
severe chronic diarrhoea and intestinal failure because reduced absorptive surface and
transport proteins may be more efficiently used, and the osmotic load is better
tolerated [27]. However, intermittent feeding is more physiological, provides a cyclical
hormone surge and regular gallbladder emptying [28] and if delivered orally supports
development of age-appropriate feeding habits and oromotor skills [29].
Monitoring and Complications
Patients receiving EN should be monitored regularly for growth, fluid, energy and
nutrient intake, blood and biochemical changes, and therapeutic efficacy. EN may be
poorly tolerated and associated with significant risks and complications, which are
listed elsewhere together with the methods for their prevention and treatment [3, 23].
Failure to withdraw from EN, when it is clinically justified, is one of the most
challenging complications. A recent study has shown that the introduction of normal
oral bolus feeding is particularly demanding if started after the age of 5 years, not only
because the critical time window for development of age-appropriate feeding skills is
missed, but also parents are too anxious to agree to commonly seen short-term weight
loss due to feed reductions [30]. However, despite the broad range of potential
complications, EN is the well-established, safe and effective method, particularly if
procedural protocols are followed, regular quality control applied, and if a dedicated
nutrition support team is involved [4, 31].
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Prof. Sanja Kolaček, MD, PhD
University Department of Paediatrics
Children’s Hospital Zagreb
Klaiceva 16, HR–10000 Zagreb (Croatia)
Siriraj Medical Library, Mahidol University
E-Mail sanja.kolacek @ gmail.com
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Szajewska H, Shamir R (eds): Evidence-Based Research in Pediatric Nutrition.
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