1 The Ins and Ots of Enteral Ntrition KELLY GREEN CORKINS, MS, RD-AP, CSP, LDN, FAND CLINICAL DIETITIAN III, LE BONHEUR CHILDREN S HOSPITAL, MEMPHIS, TN
Disclosres 2 Abbott Speakers Brea honoraria (Not prodct related)
Objectives 3 Provide information on the differences in enteral formla categories (polymeric or standard, peptide based, elemental, commercially prepared blenderized). Discss the home made blenderized diet advantages and disadvantages. Discss ENFit Describe common symptoms of formla intolerance and other medical related reasons for intolerance.
4 The Ins FORMULAS BLENDERIZED TUBE FEEDINGS ADMINISTRATION
Enteral Formla Reglation 5 Considered Medical Foods by the United States Food and Drg Administration. a food which is formlated to be consmed or administered enterally nder the spervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive ntritional reqirements, based on recognized scientific principles, are established by medical evalation. Efficacy stdies are not reqired. Pre-marketing review or approval is not reqired. Manfactring is monitored and reglated. Escro NCP 2016;31(6):709-722 Brown NCP 2015;30(1):72-85
Enteral Formlas 6 (P) = Pediatric Prodct available Standard/ Polymeric (P) Peptide based/ Semi-elemental (P) Elemental (P) Specialty Manfactred Blenderized (P) Diabetes/glcose intolerance Renal (P) Hepatic Plmonary Immne modlating
Pediatric verss Adlt Prodcts 7 Pediatric Prodcts: 12% kcals from protein 34-43% kcals from fat 45-57% kcals from carbohydrate Higher in calcim and vitamin D Adlt Prodcts: 16% kcals from protein 30% kcals from fat 54-61% kcals from carbohydrate Higher in Folic Acid and Zinc
Composition of enteral formlas 8 Protein Fat Animal sorces have a higher biological vale than plant sorces. Intact, hydrolyzed, amino acid Essential Fatty Acids LCT verss MCT Savino P, NCP 2018;33(1):90-98. Brown B, NCP 2015;30(1):72-85.
Composition of enteral formlas 9 Carbohydrate FODMAPs (fermentable fiber, oligosaccharides, disaccharides, monosaccharides, and polyalcohols) Fiber Solble and Insolble both arrive to the colon nchanged (not digested and absorbed) Insolble does not dissolve in water and retains water making stools softer Prebiotic fiber is solble and fermented in the colon and inclde FOS and inlin. Savino P, NCP 2018;33(1):90-98. Brown B, NCP 2015;30(1):72-85.
Tbe feeding Administration 10 Continos infsion (pmp) Intermittent/Cyclic feedings (pmp) Bols/Gavage (syringe) Gravity Drip many times forgotten Martin K, NCP 2017;32(6):712-721
Pmp Feedings 11 Not as precise as we might assme Walker et al in Hoston Compared actal volme of formla infsed (container catching it, not hman sbjects) to pmp rate and volme infsed from the pmp. The variable was hang height. They fond: The volme deliver was less than what was calclated from the rate and from the volme the pmp recorded. The higher the hang height the closer these nmbers were, so hang height is a significant factor. Walker NCP 2018;33(1):151-157
Choosing the Best Enteral Regimen 12 /Reimbrsement Escro AA, NCP, 2016;31(6):709-722
What is a blenderized tbe feeding (BTF)? 13 Sometimes referred to as: Preed diet throgh gastrostomy tbe (PDGT) Homemade tbe feeding (HMTF) Real foods/whole foods Home prepared foods are liqefied in a blender and given throgh a g-tbe BTF can replace some of the feedings or all of the feedings Can be made sing a commercial prodct as part of the recipe Some recipes se baby foods for increased consistency and eliminating the need for a high qality blender. Martin NCP 2017;32(6):712-721. Vermilyea NCP 2016;31(1):59-67.
Reasons for Increased Interest 14 Bobo NCP 2016;31(6):730-735
Why do Patients choose BTF? 15 More natral Like eating what the family is eating Makes them feel normal Better tolerance Don t like the ingredients in the commercial prodcts Food allergies Hrt RT et al, NCP, 2015;30(6):824-829.
Risks 16 Microbial contamination Unbalanced ntrition/malntrition too mch or too little Tbe clogging and increased wear on tbing What do the Enteral Ntrition Practice Recommendations say? Sggest commercial prodcts BTF reqires additional attention to safe food handling and storage Campbell, NCP, 2006; Hrt RT, NCP 2013; Bankhead R et al, JPEN, 2013
Who is appropriate for BTF? 17 Medically stable on an enteral regimen at home Syringe, Bols feedings or feedings with hang time less than 2 hors >10 French tbe size (sally 14 French) Gastric feedings Appropriate growth or clearly able to meet needs with the diet Caregivers have a good working relationship with healthcare professionals, esp. a dietitian Bobo NCP 2016;31(6):730-735. Vermilyea NCP 2016;31(1):59-67. Escro NCP 2016;31(6):709-722. Brown NCP 2015;30(1):72-85. Motivated parents/caregivers Refrigerator, electricity, blender Volme tolerance Access to clean water and food > 8 months of age Able to meet flid needs with flshes
Contraindications to BTF 18 Less than 6 months of age Gastrostomy tbe smaller than 10 French Jejenostomy tbe (or g-j-tbe) Reqires continos feedings Immnocompromised Lack of resorces/motivation/skills Significant malabsorption isses
Considerations 19 Food borne illness (home verss hospital) Safe preparation is crcial Ntrient variability Inconsistency in recipes/food qality Reqires high level of commitment from the caregiver Higher viscosity (increased risk for tbe occlsion) Increased osmolality Cold contribte to adverse GI symptoms. (more research needed) Vermilyea NCP 2016;31(1):59-67. Brown NCP 2015;30(1):72-85.
Potential Benefits 20 There are no randomized controlled stdies comparing BTF to formlas. Psycho-social needs met Caregiver feels in control and food is nrtring Can participate in preparation of family meals Eating the same meal as everyone else Decreased reflx symptoms Decreased reports of constipation Provides phytochemicals and fibers not fond in commercial prodcts Improved retching and gagging with fndoplication May promote oral intake
BTF 21 Reqired 50% more calories on the BTF to maintain BMI BTF microntrient was sperior Significant decrease in vomiting and se of acid-sppressive agents Stool consistency and freqency was nchanged bt stool softener increased Caregivers were more satisfied and wold recommend it Gallager NCP 2018;42(6):1046-1060.
22 ENFit Developed to prevent misconnections. (cannot be connected to IV or respiratory eqipment.) Screw, so nlikely to slip and come apart and helps prevent leaks.
ENFit - Challenges 23 It is a small bore connector. Medication administration. Bacterial contamination attention to cleaning. Blenderized Tbe Feeding Mndi and colleages fond that formla, size of tbe, blender sed, and time of blending had more impact on the force needed to psh the feeding throgh the tbe than the connector sed. Genter NCP 2016;31(6):769-772. Lord NCP 2018;33(1):16-38. Mndi JPEN 2018 online first
24 The Ots DIARRHEA CONSTIPATION GASTRIC RESIDUALS REFLUX
Diarrhea 25 Usally defined based on stool freqency and consistency, bt no standard definition. It can case: Electrolyte abnormalities Pressre sores Malntrition (increased freqency of holding feedings) Majid NCP 2012;27(2):252-260.
Diarrhea - Evalation 26 Protocols are helpfl. What type of diarrhea? Motility, inflammatory, malabsorption, osmotic, secretory Recent changes in regimens? Medications (sorbitol, antibiotics, antacids, laxatives, H2 blockers, stool softeners) Formla Composition Fiber prebiotic fiber (FOS) Bacterial Contamination Majid NCP 2012;27(2):252-260. Savino NCP 2018;33(1):90-98.
Constipation 27 More freqent than diarrhea. Associated with increased ICU stay, feeding intolerance, and difficlty weaning from the vent. Cases inclde: Medications (H2 Blockers) Dehydration Decreased motility Bittencort NCP 2012;27(4):533-39.
Constipation - Fiber 28 Solble fibers redce gastric emptying and are associated with decreasing cholesterol and triglyceride levels. Insolble fiber: Increase fecal mass Promote optimal intestinal fnctioning/transit Prevent/decrease constipation Redce laxative se Bittencort NCP 2012;27(4):533-39.
29 Gastric Residals What amont of residals is significant? Time consming Increase risk of clogging the tbe Increase risk of contaminating the feedings Electrolyte imbalances if not replaced May reslt in holding feedings nnecessarily negatively impacting ntrition stats. Lord NCP 2018;33(1):16-38.
Gastroesophageal Reflx 30 Increased LES relaxations Increased intra-abdominal pressre Delayed gastric emptying Increased gastric acid secretion Overeating/overfeeding bols too large/infsed too fast
Smmary 31 Enteral formlas are safe and provide adeqate ntrition bt as professionals and consmers need to be aware of differences in each nderstanding that marketing can be misleading. BTF is a viable option for many home enteral ntrition recipients, bt it is not appropriate for everyone and needs close monitoring by a registered dietitian and team. Enfit was developed to improve patient safety, yet we need to evalate challenges associated with this change. Intolerances can happen and can be related to formla or may be secondary to many things.
References 32 Hrt RT et al. Blenderized tbe feeding se in adlt home enteral ntrition patients: A cross-sectional stdy. NCP. 2015;30(6):824-829. Escro AA, Hmmell AC. Enteral Formlas in Ntrition Spport Practice: Is there a better choice for yo patient? NCP. 2016;31(6):709-722. Martin K, Gardner G. Home Enteral Ntrition: Updates, Trends and Challenges. NCP. 2017;32(6):712-721. Walker R et al. Hang height of enteral ntrition inflences the delivery of enteral ntrition. NCP. 2017;33(1):151-157. Vermilyea S, Goh VL. Enteral feedings in children: Sorting ot tbes, bttons, and formlas. NCP. 2016;31(1):59-67. Bobo E. Reemergence of blenderized tbe feedings: Exploring the evidence. NCP. 2016;31(6):730-735.
References 33 Gallagher K et al. Blenderized enteral ntrition diet stdy: feasibility, clinical, and microbiome otcomes of providing, blenderized feeds throgh a gastric tbe in a medically complex pediatric poplation. NCP. 2018;42(6):1046-1060. Pentik SP, et al. Preed by gastrostomy tbe diet improves gagging and retching in children with fndoplication. JPEN. 2011;35:375-379. O Flaherty T. Use of a preed by gastrostomy tbe (PBGT) diet to promote oral intake: review and case stdy. Spport Line. 2015;37:21-23. Novak P et al. The se of blenderized tbe feedings. ICAN. 2009;1(1):21-23. O Flaherty et al. Calclating and preparing a preed-by-gastrostomy-tbe (PBGT) diet for pediatric patients with retching and gagging postfndoplication. ICAN. 2011;3(6):361-364.
References 34 Lord LM. External access devices: types, fnction, care, and challenges. NCP 2018;33(1):16-38. Savino P. Knowledge of constitent ingredients in enteral ntrition formlas can make a difference in patient response to enteral feeding. NCP 2018;33(1):90-98. Bittencort AF, Martins JR, Logllo L et al. Constipation is more frewent than diarrhea in patients fed exclsively by enteral ntrition: reslts of an observational stdy. NCP 2012;27(4):533-539. Genter P, Lyman B. ENFit enteral ntrition connectors: benefits and challenges. NCP 2016;31(6):769-772. Majid HA, Emery PW, Whelan K. Definitions, attitdes, and management practices in relation to diarrhea dring enteral ntrition: A srvey of patients, nrses and dietitians. NCP 2012;27(2):252-260.