Which Enteral Nutrition Formula Should I Suggest for a Patient?
Which Enteral Nutrition Formula to Recommend
There are so many different commercial enteral nutrition formulas on the market, and each are unique to specific patient needs, medical conditions, and requirements. So which one is just right for your patient? In this article, we’ll go over the aspects of enteral nutrition, some criteria to consider for choosing the right formula, and a comparison to the various formulas available.
What is enteral nutrition?
Enteral nutrition, or commonly referred to as “tube feeding”, is a liquid formula providing macronutrients (carbohydrates, proteins, and fats), micronutrients (vitamins and minerals), and water, all components necessary for sustaining life. Enteral nutrition formulas are supplied to a patient by way of a tube either through the nose, ending in the stomach or intestines (used for short-term needs), or a tube surgically placed directly into the stomach or small intestines (used for long-term needs).
The formulas are initiated and continued on a patient who has a working gastrointestinal (GI) tract at some point. The entire GI tract runs from the mouth to the anus. For example, if the patient is unable to swallow food and liquids safely, but has a working stomach, the tube may be placed directly into the stomach, bypassing the mouth and esophagus. On the other hand, if the patient’s stomach does not function properly, the tube may be placed into the small intestine at the duodenum (first section of the small intestine), or the jejunum (second section). In the event all areas of the GI tract are not functioning properly, the decision to initiate total parenteral nutrition, or TPN, may be initiated. This article will not go over TPN, as this is an extensive topic on its own, but in short, TPN is the administration of carbohydrates, amino acids, lipids, vitamins, minerals, and fluids through a large central vein.
Initial assessment – Questions to consider
- How many calories and how much fluid does the patient need to meet their nutritional needs?
- Does the patient have a working GI tract?
- Is the patient consuming any amount of food orally? If so, is there any risk of aspiration?
- Does the patient have any medical conditions which require specialized nutrition, such as diabetes, renal issues, liver issues, or pulmonary issues?
- Does the patient have a higher need for protein due to wasting or pressure wounds?
- Does the patient have any complications with breaking down or absorbing nutrients, such as pancreatitis, short bowel syndrome, or other malabsorption issues?
- Can the patient benefit from any nutrient additives, such as EPA/DHA, prebiotics, or supplemental arginine or glutamine?
- Does the patient have any food allergies or sensitivities, such as dairy, lactose, soy, gluten, fish, shellfish, eggs, or nuts?
- Is the patient taking any medications that may interact with certain ingredients or levels of nutrients?
- Are there any other special concerns to consider, such as a Jewish patient in need of a Kosher formula?
- Is the patient paying out of pocket for the formula, or will he/she be receiving financial assistance or has insurance to cover?
- Can the patient tolerate larger volumes of formula at one time (bolus feed), or does he/she require a slower administration of formula (continuous feed with use of a pump or gravity)?
So many types of enteral nutrition formulas! Which type fits my patient’s needs?
Standard formula – Standard formulas are used with patients who have no specific medical conditions or higher nutrient needs. The formulas commonly come in different calorie strengths for patients with higher calorie needs or when volume needs to be taken into consideration. For example, there are 1.0 cal/ml (1,000 calories per 1,000 ml), 1.2 cal/ml (1,200 calories per 1,000 ml), 1.5 cal/ml (1,500 calories per 1,000 ml), and 2.0 cal/ml (2,000 calories per 1,000 ml). Standard formulas tend to be less expensive than the following types of formulas.
Condition-specific formula – Patients with diabetes, liver disease, pulmonary disease, and renal complications have enteral nutrition formulas designed specifically for their medical conditions.
- Diabetic formulas will contain a carbohydrate blend with complex carbohydrates and fiber to help manage blood sugar levels
- Pulmonary formulas are lower in total carbohydrates to help reduce the amount of carbon dioxide produced by the patient and also higher in calories to meet the elevated energy needs in a lower volume
- There are renal formulas designed for patients on dialysis and those not on dialysis. For dialysis patients, the formulas are calorically-dense for patients on a fluid restriction, protein is higher as some protein is lost during dialysis, and electrolytes (potassium, phosphorus, and magnesium) are reduced. Similar to formulas for dialysis, renal formulas for non-dialysis patients will be calorically-dense and have low electrolytes, however, these formulas will be lower in protein and may contain medium chain triglycerides to decrease possible fat malabsorption
- Hepatic formulas are designed for patients with liver disease and will be calorically-dense, high in branched-chain amino acids, low in total fat and high in medium chain triglycerides for better absorption
Wound management and immune support formulas
- Wound management formulas can provide higher amounts of protein (approximately 25% of total calories vs. 15% from standard formulas) and may contain added nutrients, such as arginine and glutamine, which have been shown to assist with the healing process
- Immune support formulas provide several ingredients which can help increase a patient’s immune function who may be at risk of infection. Such ingredients may include omega-3 fatty acids, arginine, and dietary nucleotides
Elemental formula – Elemental formulas contain hydrolyzed protein in either a peptide form or as free amino acids and are designed for patients with difficulties breaking down nutrients or malabsorption issues. Common conditions which may require this type of formula include pancreatitis, short bowel syndrome, Crohn’s disease, delayed gastric emptying, or other malabsorption problems. The formulas can be low in fat or not. If the amount of total fat is the standard recommendation of approximately 30% of total calories, the source of fat can be higher in medium chain triglycerides to decrease the potential for fat malabsorption. Some elemental formulas may use an enzyme derived from pork, which would not be appropriate for patient’s in need of a Kosher formula.