Enteral nutrition overview and formula selection considerations

The following is an excerpt from an original Dietitians On Demand case study.

What is enteral nutrition?

Enteral nutrition, or tube feeding, is a liquid food composed of carbohydrates, fat, protein, micronutrients, and fluid which enters the human body through a tube in the nose, mouth, stomach, or small intestine.¹

In general, feeding tubes entering the body through the nose or mouth are considered for short-term use (no more than four to six weeks) while gastrostomy, jejunostomy, and G-J tubes are used for long-term use.²In the long-term care setting, PEG tubes are one of the most common feeding tube types found, and feeding can typically begin four hours after tube placement.³

There are many different conditions that may lead to a resident to require tube feeding. According to the Enteral Nutrition Practice Guidelines published by the American Society for Parenteral and Enteral Nutrition (ASPEN), “The principal indication for EN [enteral nutrition] is a functional GI [gastrointestinal] tract with sufficient length and absorptive capacity and the inability to take nutrients through the oral route either totally or in part.”⁴

Formula selection

Enteral formulas vary in caloric content from 1.0-2.0 kcal/mL. Formulas are composed of different sources of carbohydrates, protein, fats, and micronutrients.⁴

Carbohydrates

The majority of energy in enteral formulas generally comes from carbohydrates, with standard/polymeric formulas providing 30-60% of energy from carbohydrates. Carbohydrates can come in the form of sucrose, fructose, corn syrup solids, or sugar alcohols. Carbohydrates in enteral formulas provide 4 kcal/gm.

Protein

Standard/Polymeric enteral formulas provide 10-25% of energy from protein sources, including milk protein, whey protein, casein, caseinates, or soy protein. Protein in enteral formulas provides 4 kcal/gm.

Fats

Standard/Polymeric enteral formulas provide 10-45% of energy from fat sources, including canola oil, corn oil, soy lecithin, safflower oil, and/or medium-chained triglycerides. Fats in enteral formulas provide 9 kcal/gm.

Micronutrients

Enteral formulas will meet 100% of the adult Dietary Reference Intakes (DRIs) in a volume designated on the nutrition label, which is generally 1,000-1,500 mL of formula.

Specialty enteral nutrition formulas

There are also specialty enteral formulas to meet specific nutritional needs. Some examples are listed below.

• Semi-elemental formula: partially hydrolyzed; used for individuals with dysfunction in the GI tract preventing standard enteral formulas to be digested or tolerated.
• Elemental formula: fully hydrolyzed; used only for individuals who cannot tolerate semi-elemental formula
• Disease-specific enteral formula: specialty formulas are available for medical conditions including diabetes, chronic obstructive pulmonary disease (COPD), acute respiratory distress syndrome (ARDS), wound healing, chronic kidney disease (on and off dialysis), liver failure, and compromised immune system. These products have varying differences in macronutrient and micronutrient content based on specific disease states (e.g., very high protein for wound healing).

Selecting an enteral nutrition formula

Selection of an enteral nutrition formula should be based on nutrition assessment and needs, physical assessment, GI function considerations, overall medical condition including medical history and metabolic abnormalities, and goals/outcomes for the patient.⁵

When able, a standard enteral formula should be selected. Specialty formulas are often more expensive, may not be covered by insurance, and may not have adequate scientific evidence to support use.

These are just a few of the considerations for tube feeding, others include tube access, navigating insurance coverage and monitoring the tolerance of an enteral nutrition regimen. Grab the full case study to ensure you don’t miss a thing!

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References

Enteral nutrition supplies and equipment. https://www.medicare.gov/coverage/enteral-nutrition-supplies-equipment Accessed August 27, 2019.

Nestle Health. Medicare Part B: General Coverage Guidelines for Enteral Nutrition. 2015. https://www.nestlemedicalhub.com/sites/site.prod.nestlemedicalhub.com/files/2020-07/medicare%20part%20b%20nestle%20healthcare%20nutrition%20products.pdf Accessed August 30, 2019.

Abbott Nutrition. PATHWAY Reimbursement Support Patient Insurance coverage. 2019. http://pathwayreimbursement.com/patient-insurance-coverage#medicaid Accessed September 3, 2019.

Academy of Nutrition and Dietetics. Nutrition Care Manual. Enteral Nutrition: Enteral formula. https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=255693&lv2=255696&lv3=272572&ncm_toc_id=272572&ncm_heading=Nutrition%20Care Accessed August 28, 2019.

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.