If patients cannot meet theirnutritional needs orally, consider augmenting with additional feeding by tube rather than parenterally

Author: Craig DeWolfe, MD

What to Do - Take Action

Appropriate nutrition is vital to maintaining health and recovering from disease and injury. Research in this field has offered the practitioner many choices in nutritionalformulationanddelivery. Yet, when patients are unable to effectively meet their needs by mouth, enteral nutrition should be considered the next best choice. It is more physiologic, less costly, and associated with fewer complications than parenteral nutrition. Some studies suggest that it is underutilized in up to 60% of cases. Practitioners should familiarize themselves with the risks and benefits of enteral and parenteral nutrition while reconsidering the contraindications to gastrointestinal feeds. The use of a validated algorithm may offer additional assistance when maximizing nutritional delivery.

Patients are regularly placed on intravenous fluids or total parenteral nutrition (TPN) at the expense of oral or enteral feeds. However, research in areasas diverseas dehydrationto respiratoryfailuresuggests thatoral hydrationandenteralfeedsaregenerallythepreferredrouteofprovidingnutrition. Enteral feeds maintain the gastrointestinal lining, limit the translocation of enteric bacteria, provide enhanced utilization of nutrients, are easier to administer at a lower cost, and are associated with fewer infectious, metabolic and hepatobiliary risks than TPN.

Specialformulashavebeendevelopedforpatientsofallagesandaccording to disease process. Some studies suggest that enteral nutrition for critically ill children should start with hypo-or isotonic lactose-free or elemental formulas advancing to a standard formula over 3 to 4 days. Additionally, rates incriticallyillchildrencanbegina1mL/kg/hrwithstepwiseincreasesevery 4 to 6 hours to the goal calories. Alternative formulas or additives can be provided for children with fat malabsorption or azotemia/hyperammonemia. Practitioners should acquaint themselves with these formulations or regularly enlist the help of a nutritionist when offering the best substrate for the patient. The clinician should also consider the optimal route of enteral feeds, as each may carry their own set of risks and benefits. For example, flexible polyurethane or Silastic oral or nasogastric tubing may be the easiest access and promote gastric pH balance while limiting the risks of sinus disease or mucosal irritation from the larger tubing of the past. But they may place a patient with slow gastric empty or other risk factors associated with aspiration at greater risk for pneumonia than a fluoroscopic, endoscopic, or surgical transpyloric placement of the same tube. In patients who require prolonged enteral nutrition, tube enterostomies may minimize the risk of tube displacement and resolve concerns related to the physical appearance of the tube on the face.

Health care providers should ensure the safety of enteral nutrition by limiting the aspiration risk, preventing mechanical problems, and ensuring metabolic balance. First, to prevent aspiration, the practitioner should ensure correct placement of the tube, elevate the upper part of the body 30 degrees while infusing the formula, and check residuals. If problems persist, they should consider starting continuous feeds or placing a transpyloric tube. Other mechanical problems include tube migration into the esophagus or rarely into the trachea, local irritation and infection, or partial intestinal obstruction. Taking care to prevent these complications include proper tube measurement, placement, and stabilization. Thereafter, caretakers should recheck the tube placement regularly, clean the ostomy site daily, and limit leakage. Finally, to ensure metabolic balance, the practitioner should regularly assess the patient's nutritional status and fluid and electrolyte balance.

One should use the parenteral route only when the patient is at risk for malnutrition from not eating, has failed an enteral trial, or has severely diminished intestinal function. The practitioner may need to use parenteral nutrition in very low-birth-weight infants who are building up on enteral feeds, orinotherpatients with ischemicinjurytothebowel,significantbowel resection, fistula, obstruction, malabsorption, or bleeding. When using parenteral nutrition, the possible complications include infection or thrombosis related to the intravenous catheter or metabolic disturbances. After parenteral nutrition has begun, the patient should be regularly monitored for complications and transitioned quickly to oral or enteral feeds.

Timely transition to enteral feeds is better assured by the use of a validated algorithm that regularly assesses the nutritional needs of every patient with the ultimate goal of providing enteral feeds as soon as possible. Such a protocol works by encouraging the initiation of enteral feeds, assessing and troubleshooting gastrointestinal tolerance, and advancing to goal feeds in a safe but efficient manner. One such algorithm in a multicenter randomized clinical trial in an intensive care unit was shown to improve the nutritional support to patients while hospital lengths of stay and mortality rates decreased.

In summary, enteral nutrition should be considered in patients who cannot effectively meet their nutritional needs by mouth. A greater appreciation of the benefits of enteral nutrition, contraindications, and the ways to manage risks will result in better patient outcomes.

Suggested Readings

American Society for Parenteral and Enteral Nutrition. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 1993;17(4 Suppl):1SA–52SA.
Chellis MJ, Sanders SV, Webster H, et al. Early enteral feeding in the pediatric intensive care unit. JPEN J Parenter Enteral Nutr. 1996;20:71–73.
Martin CM, Doig GS, Heyland DK, et al. Multicentre, cluster-randomized clinical trial of algorithms forcritical-care enteral andparenteral therapy (ACCEPT). CMAJ. 2004;170:197– 204.

Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

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