Enteral and Parenteral

Nutrition
Applied Nutrition Unit-IV

Imran Waheed
Demonstrator
(INS-KMU)
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 Objectives
By the end of this unit the students will be able
to:
• Define key terms
• Identify the characteristics, nutritional
composition and concentration of formula
feedings.
• Discuss complications associated with Enteral
feeding.

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 Definition of Key Terms
• Enteral nutrition: Enteral feeding is a method of
giving liquid nutrition directly into the stomach or
jejunum through a tube. (N/G or N/J).
• Parenteral nutrition: formula feed that is given
intravenously.
• Infant formula: It is a manufactured food designed
and marketed for feeding to babies and infants under
12 months of age, usually prepared for bottle-feeding
or cup-feeding from powder or liquid. OR
• An artificial substitute for breast milk intended for
feeding infants. It can come in powdered form to be
mixed with water or in instant liquid form.
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 Indications for Tube Feeding
• The following conditions require tube feeding:
• Inability to swallow
• Neurologic and neuromuscular disorders,
• Anatomical and post-surgical malformations of
the mouth and esophagus
• Cancer
• Digestive disorders.
• Failure to grow or malnutrition

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 Types of Enteral Feeding Tubes
• According to the American College of
Gastroenterology, there are six main types of feeding
tubes. These tubes may have further subtypes
depending on exactly where they end in the stomach
or intestines.
• The main types of enteral feeding tubes include:
• Nasogastric tube (NGT) starts in the nose and ends in
the stomach.
• Orogastric tube (OGT) starts in the mouth and ends in
the stomach.

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 Conti…
• Nasoenteric tube starts in the nose and ends in
the intestines (subtypes include nasojejunal and
nasoduodenal tubes).
• Oroenteric tube starts in the mouth and ends in
the intestines.
• Gastrostomy tube is placed through the skin of
the abdomen straight to the stomach (subtypes
include PEG, PRG, and button tubes).
• Jejunostomy tube is placed through the skin of
the abdomen straight into the intestines
(subtypes include PEJ and PRJ tubes).
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 Classification of Enteral Formula

Standard ( polymeric )

Elemental & Semi-Elemental

Disease - Specific

Blenderized

Modular

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 Standard (polymeric )
• Formula containing intact nutrition ( protein, fat,
and CHO) which require normal or near normal
digestive and absorptive capacity and are
complete with respect to vitamin, minerals, and
trace elements at specified volume .
• Contain 1-1.2 kcal/ ml and are used as over the
counter oral supplement and tube feeding
formula. protein content 30 – 40 gm/L

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 Example of Standard Formula

nutren1.0
ENSURE OSMOLITE

Isosource HN IMPACT

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 Calorie Dense

• Standard formula are often concentrated to

provide 1.5-2 kcal/ml when fluid restriction is
required for patient.

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Example of Calorie Dense Formula

ENSURE Nutren® 2.0 Isosource 1.5

Plus

IMPACT
1.5 TwoCal® HN

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 Elemental & Semi-Elemental
• Contain partially or completely hydrolyzed nutrient
(elemental).
• Formula have been hydrolyzed to contain short chain
carbohydrate or simple sugar and peptides or amino
acid.
• Elemental formulas are easier for the digestive system
to digest and absorb, making them better suited for
adults and children with digestive problems.
• Including malabsorption, short bowel syndrome,
inflammatory bowel disease, and other conditions that
can cause problems with absorbing nutrition.

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 Example of Elemental & Semi-
Elemental

Crucial ALITRAQ Peptamen®

VIVONEX TEN PIVOT 1.5 Cal PERATIVE Vital® 1.0 Cal

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 Disease Specific
• Designed for patients with specific disease
states.
• Available for patients with respiratory disease,
diabetes, renal failure, hepatic failure, and
immune compromise.

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 Example of Disease Specific

DIABETISOURCE® AC NOVASOURCE® Renal

Nutren® Pulmonary NutriHep®

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 Blenderized Feeding
• Used for patient that cannot tolerate semi-
synthetic formulas or who wish to consume
family food.
• Formulize with a mixture of blenderized food
source .
• They are made from real food ingredients such as
chicken, vegetables and fruit, along with added
vitamins, minerals, fiber and other nutrients.
• Maintenance of aseptic technique is essential to
prevent bacterial contamination.
• Example are Compleat®, Compleat® Pediatric,
and Compleat® Pediatric Reduced Calorie
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 Modular Formula
• Modular: provides protein, fat, or
carbohydrate as single nutrients or modular
mixtures to allow adjustment of
macronutrient mix.
• Created from individual macronutrient
preparations called modules are prepared for
patients who require specific nutrient
combination to treat their illness.

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 Example of Modular Products

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Complications of Enteral Nutrition
• Food entering the lungs
• Constipation
• Diarrhea
• Improper absorption of nutrients
• Nausea, vomiting
• Dehydration
• Electrolyte abnormalities
• High blood sugar
• Vitamin and mineral deficiencies

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 Conti…
• Feeding tubes inserted through the nose, such as
nasogastric or nasoenteric tubes, can cause
• Irritation of the nose or throat
• Acute sinus infections
• Ulceration of the larynx or esophagus
• Feeding tubes inserted through the skin of the
abdominal wall, such as gastrostomy or
jejunostomy tubes, can become clogged
(occluded) or displaced, and wound infections
can occur.
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 Complications with Tube Enterostomies
• Skin irritation caused by leakage of digestive
fluids onto the skin around the stoma; Irritation
is the most common complication of ileostomies
• Diarrhea
• The development of abscesses
• Inflammation of the ileum
• Intestinal obstruction

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Risk Factors for Aspiration Include
• Decreased level of consciousness
• Diminished gag reflex
• Neurologic injury
• Cardiac sphincter Incompetency
• GI reflux
• Supine position
• Tube malposition

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 Parenteral Nutrition (Types)
• Delivery of nutrients intravenously, e.g. via the
bloodstream.
– Central Parenteral Nutrition: often called Total
Parenteral Nutrition (TPN); delivered into a central
vein
– Peripheral Parenteral Nutrition (PPN):
delivered into a smaller or peripheral vein

A.S.P.E.N. Nutrition Support Practice Manual, 2nd edition, 2005, p.

97

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 TPN vs. PPN
Total Parenteral Nutrition - TPN
• Given when a patient requires:
• An extended period of intensive
nutritional support for those patients •
who cannot tolerate oral or enteral
nutrition.
• Is administered through a central
venous catheter.
• TPN solutions contain high
concentrations of proteins and
dextrose.
• Various components like electrolytes,
minerals, trace elements, and insulin
are added based on the needs of the
patient.
Partial Parenteral Nutrition - PPN
• Given to patients:
Who can tolerate some oral feedings
(i.e., functioning gut) but cannot
ingest adequate amounts of food to
meet their nutritional needs.
• Administered through a peripheral
intravenous catheter.
• Two types of solutions are commonly
used in a number of combinations for
PPN: lipid emulsions and amino acid-
dextrose solutions.

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Total Parenteral Nutrition (TPN)
Examples of total parenteral nutrition solutions
Nutrients Amount
Amino acids 85 g
Dextrose 250 g
Lipids 100 g
+
Na 150 mEq
K+ 80 mEq
Ca2+ 360 mg
2+
Mg 240 mg
Cl- 143 mEq
P 310 mg
Trace elements 5 mL
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 Complications of TPN
• Infection
• Embolism
• Cholecystitis
• Cholelithiasis
• Steatosis
• Steatohepatitis

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 Infant Formula Feeding
• Formula Feeding: Feeding an infant or toddler
prepared formula instead of or in addition to
breastfeeding.
• Some parents choose formula-feeding either
because of personal preference or because
medical conditions of either the mother or the
infant make breastfeeding ill-advised.

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 Breast Feeding Formula Feeding

Advantages -has antibodies, no bacteria -less painful

-foodstuffs in correct proportions -other people can feed
-no risk of allergic reaction baby
-no additives /preservatives -may contain
-builds mother child bond supplement vitamins ,
-no cast no preparations minerals
-breast feeding triggers reduction
of uterus size

Disadvantages -maybe painful -more likely to develop

-mother needs to be present illness (diarrhea etc.)
-damage beauty -risks of wrong mixture
-expensive

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 Reasons for Choosing Formula-
feeding
 There is an inadequate supply of maternal breast
milk.
 The baby is sucking inefficiently.
 Parents are unable to quantify the amount of breast
milk received by the baby.
 Some parents want to know exactly how much their
baby is receiving at each feeding, and
formula/bottlefeeding allows exact measurement.

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 Conti…
 A significant reason for not breastfeeding is
concern about transferring certain drugs the
mother is taking through the breast milk to the
infant.
 An increasing number of mothers must return to
work shortly after their baby's delivery.
 A benefit of bottle-feeding is that the entire
 family can immediately become intimately
involved in all aspects of the baby’s care,
including feeding.
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 Best Formula for Baby
There is no evidence that one brand of formula is better
than another. However, you should consider:
 Choosing a formula based on cow’s milk, unless there
is a cultural, religious or health reason to use a
different formula.
 If possible, choosing a formula with a lower protein
level, which may reduce your baby’s risk of being
overweight or obese in later life.
 Only using special formulas (HA, AR, lactose-free or soy
formula) if they are recommended by a doctor
 Taking into account price and affordability

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Available Infant Formula Preparations
Infant formulas come in three forms. The best choice
depends on your budget and desire for convenience:
• Powdered Formula: Powdered formula is the least
expensive. Each scoop of powdered formula must be
mixed with water.
• Concentrated Liquid Formula: This type of formula also
must be mixed with water.
• Ready-to-use formula: Ready-to-use formula is the
most convenient type of infant formula. It doesn't
need to be mixed with water. It's also the most
expensive option.
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 Types of Formula Milk
• Commercial infant formulas are regulated by
the Food and Drug Administration (FDA).
Three major types are available:
• Cow Milk Protein-based formulas
• Soy-based formulas
• Protein hydrolyzed formulas

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Cow Milk Protein-based Formulas
• Most infant formula is made with cow's milk
that's been altered to resemble breast milk.
• This gives the formula the right balance of
nutrients and makes the formula easier to
digest.
• Most babies do well on cow's milk formula.
• Some babies, however such as those allergic
to the proteins in cow's milk need other types
of infant formula.

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 Cow’s Milk-based Formula
• Most baby formula milks are based on
modified cow's milk, which is recommended
over other types of formulas for most babies.
• The protein in milk can be broken down into
curds (casein) and whey. Casein is lumpy and
whey is watery.
• The ratio of casein to whey can vary according
to the type of baby formula milk.
• There are two main types:

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 Conti…
• First-stage formula: These milks are based mostly on
whey, with a casein: whey ratio of 40:60, which is
about the same as breast milk.
• They are suitable for your baby from birth up to about
a year, and are thought to be easier for baby to digest
than casein-based milks.
• Second-stage, follow-on or hungry-baby formula:
These milks consist of mostly casein, with a
casein:whey ratio of 80:20.
• Manufacturers claim that the higher casein content
means the milk takes longer to digest, keeping baby
fuller for longer.

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 Soy-based Formulas
• Soy-based formulas can be useful if you want
to exclude animal proteins from your child's
diet.
• Soy-based infant formulas might also be an
option for babies who are intolerant or allergic
to cow's milk formula or to lactose, a
carbohydrate naturally found in cow's milk.
• However, babies who are allergic to cow's milk
might also be allergic to soy milk.

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 Goats' Milk Formula
• Different kinds of goats' milk formula are
available in the shops.
• They are produced to the same nutritional
standards as cow's milk-based formula.
• Goats' milk formula is not less likely to cause
allergies in babies than cows' milk formula.

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 Anti-reflux (staydown) formula
• This type of formula is thickened with the aim
of preventing reflux in babies (when babies
bring up milk during or after a feed).

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 Lactose-free Formula
• This formula is suitable for babies who are
lactose intolerant. This means they can't
absorb lactose, a sugar found in milk and dairy
products.
• Lactose intolerance Symptoms include
diarrhea, abdominal pain, wind and bloating

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 Hydrolyzed-protein Formula
If the baby is diagnosed as being allergic to cows'
milk, the appropriate infant formula is fully
hydrolyzed (broken down) proteins. There are two
versions available
• Partially hydrolyzed formula (Comfort formula)
This type of formula milk is made completely
from whey protein. It is marketed as being easier
to digest, and as suitable for babies suffering
from colic, wind, and stomach pain. They are also
sometimes promoted as being good for babies
with allergies.

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• Fully hydrolyzed formula is specially designed
for babies with an allergy or intolerance to
cow's milk.

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 Good Night Milk
• Some follow-on formula has cereal added to it
and is sold as a special formula for babies to
have at bedtime.
• This type of formula isn't needed, and there's
no evidence that babies settle better or sleep
longer after having it.
• Good night formula should never be
given to babies under six months old.
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 Growing-up Milk (Toddler Milk)
• Growing-up and toddler milks are marketed as
an alternative to whole cows' milk for toddlers
and children aged over one.
• Whole cows' milk is a suitable choice as a
main drink for your child from age one.
• Semi-skimmed cows' milk is a suitable main
drink for children over two who are eating a
balanced diet.

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 References
• Enteral nutrition supplies and equipment.
https://www.medicare.gov/coverage/enteral-nutrition-supplies-
equipment Accessed April 21, 2020.
• Bankhead R, et al. Enteral Nutrition Practice Recommendations. In:
Journal of Parenteral and Enteral Nutrition. United States. The
American Society for Parenteral and Enteral Nutrition; 2009: 122-
167.
• Mesejo A, Acosta JA, Ortega C, et al. Comparison of a high-protein
disease-specific enteral formula with a high-protein enteral formula
in hyperglycemic critically ill patients. Clin Nutr,2003;22:295-305.
• Tehila M, Gibstein L, Gordgi D, Cohen JD, Shapira M, Singer P.
Enteral fish oil, borage oil and antioxidants in patients with acute
lung injury (ALI). Clin Nutr, 2003;22(S1):S20

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• Believe you can and
you’re halfway there.
Theodore Roosevelt

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