Implementing Enteral

Nutrition: Formula
Selection and
Administration

Objectives

To describe the categories of enteral formulas

To explain how to choose the appropriate category of
enteral formula for each patients disease state
To describe the various methods for delivering enteral
nutrition and how to choose the most appropriate
formula for each situation

Enteral Formulas: Categories

Polymeric formulas
Commercial
Blenderized
Oligomeric formulas
Disease-specific formulas
Modular formulas (concentrated protein and
carbohydrate preparations)

Polymeric Formulas
Contain intact macronutrients and require digestion:
Intact proteins
Polysaccharides
Disaccharides
Polyunsaturated fatty acids (PUFA)
Medium-chain triglycerides (MCT)

Polymeric Formulas:
Benefits of Commercial Formulas
Commercial Formulas

Blenderized Formulas

Uniform contents
Sterile

Daily nutrient variability

Non-sterile; high bacterial content
and other pathogens
High viscosity
Does not provide adequate caloric
density

Low viscosity
Lactose free
Defined caloric density

Gallagher-Allred. Nutrition Supp Svc 1983; Tanchoco CC, et al. Respirology 2001;6:43-50
Sullivan MM, et al. J Hosp Infect 2001;49:268-273

Commercial Polymeric Formulas:

Selection
Features
Protein, caloric density, and osmolality vary
With or without added fiber
Most are lactose- and gluten-free
Nutritionally complete in sufficient quantities
Patient must have:
Functional GI tract
Normal digestion
Normal absorption

Oligomeric Formula Categories

Hydrolyzed macronutrients facilitate digestion and absorption
Components
Amino acids
Glutamine
Arginine
Peptides
Monosaccharides
Disaccharides

Glucose polymers
Polyunsaturated fatty acids
Medium-chain triglycerides
Vitamins and minerals

Also called elemental, semi-elemental, hydrolyzed, or

chemically defined formula.
In: Rombeau JL, Rolandelli RH, eds. Clinical Nutrition: Enteral and Tube Feeding. 3rd ed. WB Saunders
Company; 1997

Oligomeric Formulas: Selection

Indications for Use:

Inflammatory bowel disease

Pancreatic insufficiency
Malabsorption
Short bowel syndrome
Radiation enteritis
Early enteral feeding
Intolerance to polymeric formula

Enteral Formula Selection:

Disease-Specific Formulas

Pulmonary disease
Glucose intolerance
Cancer-induced weight loss
Hepatic insufficiency
Critical care
Renal failure
HIV+/AIDS

Cabre E, Gassull MA. Nutrition 1992;8:1-9.

Disease-Specific Formula
Selection:
Pulmonary Disease (Chronic)
Pulmonary disease with CO2 retention

Decreased carbohydrate content

Increased fat content
High caloric density
Intact proteins
Fiber supplement

Brown RO et al. Clin Phar 1984;3:152-161; Askanazi J et al. Anesthesiology 1981;54:373-377

Deitel M et al. J Am Coll Nut 1983;2:25-32

Disease-Specific Formula
Selection:
Glucose Intolerance
Glucose Intolerance
Diabetes mellitus
Type I
Type II
Hyperglycemia associated with:
Pancreatic disease
Drug and chemical-induced
Insulin receptor abnormalities

Cabre E, Gassull MA. Nutrition 1992;8:1-9

Hormonal alterations
Genetic syndromes
Metabolic stress

Disease-Specific Formula
Selection:
Glucose Intolerance
Recommendations
Low carbohydrate content
Monosaccharides (fructose)
Glucose polymers
Increased monounsaturated fat (MUFA)
Added fiber

Franz MJ, et al. Diabetes Care 1994;17:490-518; J Am Diet Assoc 1994;94:504-506

Diabetes Care 1997;20:514-517

Disease-Specific Formula
Selection:
Cancer-Induced Weight Loss
Cancer-Induced Weight Loss
Complex metabolic syndrome - anorexia, fatigue,
early satiety
Significant weight loss & muscle wasting
Etiology is multifactorial
Pro-inflammatory cytokines
Acute phase response
Abnormal metabolism
Proteolysis inducing factor (PIF)
Cannot correct by additional calories alone

Negative
Prognosis
&
QOL

Disease-Specific Formula
Selection:
Cancer-Induced
Weight
Loss
Recommendations

High protein and Zn to build muscle

Low fat to avoid early satiety
Low in sucrose for better patient acceptance
High in fermentable fibers
Eicosapentaenoic acid (EPA)
Antioxidants (vitamins A, C, E and Se)
Folate and iron for anemia

Disease-Specific Formula
Selection:
Hepatic
Disease
Hepatic Insufficiency
Altered protein metabolism and protein loss
Altered carbohydrate metabolism
glucose intolerance
low hepatic glycogen stores

Malabsorption of fat and fat-soluble vitamins

Inability to elongate or desaturate essential fatty acids
Vitamin and mineral deficiencies (e.g., B-complex and Zn)
Impaired urea synthesis with hyperammonemia and hepatic
encephalopathy
Fluid and sodium retention
Reduced appetite/oral intake and taste impairment

Disease-Specific Formula
Selection:
Hepatic Disease

Recommendations
High caloric density with low sodium content
Moderately high calorie:nitrogen ratio
High in branched chain AAs and low in aromatic AAs
Non-digestible soluble fiber
Long-chain fatty acids and supplemental MCT
Supplemented with fat soluble vitamins, Zn, folic acid and B
complex vitamins
Low copper, iron, manganese content

Disease-Specific Formula
Selection:
Critical Care
Types of Injury
Elective surgery
Minor trauma
Burn
Pressure ulcer

Patient Conditions
Sepsis
Inflammatory

Disease-Specific Formula
Selection:
Critical Care
Nutrient Choices

Hydrolyzed or intact proteins

Glutamine
Arginine
Taurine, Carnitine
Eicosapentaenoic acid (EPA), Gamma-linolenic Acid (GLA)
Antioxidants
Poullain et al. JPEN 1989;13:382-386; Lacey JM et al. Nutr Rev 1990;48:297-309
A et al. Surgery 1990;108:331-337

Barbul

Disease-Specific Formula
Selection:
Critical Care (Mechanical
Lung Injury / SIRS / ARDS
Ventilation)
Eicosapentaenoic acid (EPA)
Gamma-linolenic Acid (GLA)
Antioxidants
High caloric density
No arginine supplementation
Gadek J. Chest 1998;114:277S; Gadek J. Crit Care Med 1999;27:1409-1420;
Pacht ER, et al. Crit Care Med 2003;31:491-500

Disease-Specific Formula
Selection:
Critical Care

Arginine (a double-edged sword)

Conditionally essential nutrient that enhances wound
healing
Supports immune system and is associated with
reduced infectious complications

Giving arginine to a septic patient is like putting

gasoline on an already burning fire.
- B. Mizock, Medical Intensive Care Unit, Cook County Hospital, Chicago, IL

Disease-Specific Formula
Selection:
Renal Disease
Acute or Chronic Renal Disease
Increased BUN and creatinine
Increase in serum electrolytes:
Na
K
PO4
Mg

Kopple JD. In: Shils ME et al eds. Modern Nutrition in Health and Disease. 8th ed. Philadelphia: Lea &
Febiger; 1994:1102-1134; Blumenkranz MJ et al. Kidney Int 1982;21:849-851

Disease-Specific Formula
Selection:
Renal Disease
Recommendations
Protein content
Predialysis: 30 g/L
Dialysis:
70 g/L
Low electrolyte content
High caloric density

Monson P, et al. J Renal Nutr 1994;4:58-77

ASPEN Board of Directors. JPEN 2002;26 Suppl 1

Disease-Specific Formula
Selection:
Advanced
AIDS
(with
weight
Advanced AIDS
loss)
Weight loss > 5% below normal
CD4 < 400
Serum albumin < 3.0 g/dL
Opportunistic infection
Diarrhea
Impaired immune function
Raiten DJ. Nutrition and HIV Infection. Department of Health and Human Services, Washington D.C.
Grunfeld C et al. Sem Gastro Dis 1991; Kotler DP et al. Am J Clin Nutr 1985

Disease-Specific Formula
Selection:
Advanced AIDS (with weight
Recommendations
loss)
Increased protein
Low fat for improved tolerance
Added fiber
EPA to down regulate metabolic changes associated

with cachexia
Increased levels of antioxidants (beta-carotene, vitamin
E, C) and B vitamins (B6, B12)

Baum MK, et al. Ann N Y Acad Sci 1992;669:165-174

Raiten DJ. Nutrition and HIV Infection. Dept. of Health and Human Services , Washington D.C.

Enteral Formula: Selection

Metabolic requirements
Patient condition or status
Pre-existing conditions
GI function

Enteral Formula: Selection

The physician should know the formulas nutrient profile

to meet specific patient needs

Understand the clinical evidence supporting specific

formula use

Data obtained exclusively from animal models may or

may not apply to the clinical setting

Enteral Formula: Oral

Administration
Oral Supplementation

Indicated especially for patients with malnutrition or at risk

for weight loss

When given between meals, does not reduce intake of

other foods

Frequently stimulates increased intake of other foods

Thickened oral supplements are useful for patients with
dysphagia

Benefits of Oral Supplements

Improvement in Oral Intake
Proportional Increase

250
200

Without Supplement
With Supplement

150
100
50
0
Daily Energy
(kcal)

Daily Protein (g)

Daily Calcium
(mg)

Delmi M et al. Lancet 1990;335:1013-1016

Enteral Formula: Tube Feeding

Type:
Intermittent
Continuous:
24 hours / day
During part of the day or at night
Infusion Method:
Gravity
Infusion pump
Gottschlich MN, Shronts EP, et al. Defined formula diets. In: Rombeau JL, Rolandelli, eds. Clinical
Nutrition: Enteral and Tube Feeding. W B Saunders; 1997; Giocon JO et al. JPEN 1992;16:525-528

Enteral Formula: Administration

Enteral Feeding
Intermittent

Resembles normal feeding and digestion patterns

250-500 mL of formula
Administered over 30-60 minutes
5-8 times daily

Enteral Formula: Administration

Continuous
Plan 1
Beginning:
Progress:
Plan 2
Beginning:
Progress:

Day 1: 1000 mL over 24 hours

Day 2: 1500 mL over 24 hours
Day 3: final volume according to needs
25 mL/h (first 12 hours)
50 mL/h for next 12 hours
rate according to needs

Enteral Formula: Administration

Infusion Pump
Indications

Gravity Infusion
Indications

Small intestine feeding

Fluid restrictions
Risk of aspiration
Need for precise flow rate
Nocturnal feeding
Infants and small children

Suitable for intermittent

feeding

Ambulatory patients
Gastric feeding

Enteral Formula: Administration

Summary

Intermittent feeding
Continuous feeding

ASPEN Board of Directors. JPEN 2002;26 Suppl 1: 34SA.

Summary

Described the categories of enteral formulas

Explained how to select appropriate formulas
Described the methods of enteral nutrition
administration