Continuous… cyclic… intermittent… bolus… Which enteral nutrition (EN) delivery method is right for your patient? Choosing the right regimen is important to help optimize the patient’s nutrition status and improve their quality of life. For certain groups of patients, nocturnal tube feeding may be the best option. This is a type of cyclic feeding in which EN is administered overnight via a feeding pump.
When to use a nocturnal feeding regimen
There are a few reasons why a nighttime tube feeding schedule may be preferred. First, nocturnal EN may help facilitate the transition to an oral diet. Patients are allowed to eat meals during the day without EN simultaneously infusing. This may help decrease feelings of satiety from the tube feeding regimen and promote oral intake during the day.
Second, a nocturnal regimen allows ambulation during the day. Patients who require therapy services and have frequent interruptions in continuous tube feeding regimens would likely benefit from nocturnal EN. Likewise, patients who receive tube feeding at home can enjoy more freedom when they are not tethered to a feeding pump all day.
Lastly, for patients with a jejunostomy tube, a nocturnal feeding schedule is the only regimen that allows freedom from a pump for a portion of the day, as bolus or intermittent regimens are not viable options for small bowel feeding tubes.
How Much of My Patient’s Nutrition Needs Should I Meet?
When starting a patient on a nighttime regimen, this is often the first question asked. For those just starting to transition from EN to an oral diet, it is best to meet a higher percentage of the patient’s nutritional needs from the tube feed regimen to avoid a caloric deficit. A calorie count is helpful to track oral nutrition intake. As oral intake improves, the percentage of nutritional needs supplied by EN can be weaned.
For patients utilizing EN as the sole source of nutrition, the answer is much simpler—100% of nutritional needs should be met by the nighttime feeding regimen.
What Formula Should I Use?
Choosing the best formula for your patient remains largely dependent on the current clinical status and comorbidities of your patient. While any formula can work, concentrated or calorically dense formulas are often needed to maintain a safe infusion rate during the abbreviated timeframe. So, formulas containing 1.5 to 2 kcal/mL are often utilized to decrease the hourly infusion rate and promote tolerance.
What Should the Schedule Be?
When using a nocturnal EN schedule to transition a patient to an oral diet, mealtimes should be considered. Ideally, the tube feeding infusion should start after the last meal of the day and be shut off before breakfast. Many healthcare facilities use a 6:00 PM to 6:00 AM schedule. However, this can be adjusted to patient preference or tolerance. For example, a patient may prefer a 5:00 AM shut off time to allow more time for digestion before breakfast. Or, for patients who demonstrate intolerance with higher infusion rates, a longer cycle time may be preferred to decrease the hourly infusion rate (e.g., 18 hours vs. 12 hours).
Weaning a nocturnal tube feeding regimen
Once you’ve established a nocturnal schedule for your patient, you can start thinking about weaning the EN rate to fully transition to an oral diet, if appropriate. A calorie count or diet recall from your patient are helpful decision-making tools. As your patient’s meal intake improves, the tube feeding order can be adjusted. Nocturnal tube feeds are usually discontinued when approximately 50% to 75% of nutritional needs are being met via the oral diet alone.
Lyncoln Nardo, MS, RD, LD, CNSC is a clinical dietitian from Virginia. She has over six years of experience caring for surgical patients, where her passion is providing enteral and parenteral nutrition support to critically ill patients. Beyond patient care, she enjoys working with dietetic interns and healthcare providers via classes, conferences, and creating nutrition protocols to facilitate best-care practices.
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