Practical and Formula Selection

for Enteral Nutrition to prevent

Hospital Malnutrition

Nur Aisiyah Widjaja

Pediatric Nutrition and Metabolic Diseases
Dept of Child Health Airlangga University
Dr. Soetomo General Hospital
Surabaya
 Enteral Nutrition

Nutritional Support

Nutritional consequences
to prevent hospital malnutrition
Prevalence of undernutrition in
hospitalized children 6-50%
increase during hospital stay

incidence complications and

mortality
ESPGHAN comitee on Nutrition , JPGN 2010.
Prieto M. J. Environ. Res. Public Health 2011.
Malnutrition and Disease : a Viscous Cycle

Kolacek S. 2009
 The impact of mild clinical condition
496 children age 1-192 with mild (grade 1) conditions
BMI during hospitalization decreased in 19.56%
Risk factors for hospital-acquired malnutrition
age < 24 months, fever, night time abdominal pain,
hospital stay >5 days

Campanozzi A, et al. Nutrition 2009;93:540-47

Hospital malnutrition with acute and chronic
infection diseases in Pediatric Ward
Dr. Soetomo Hospital
Prospective observational study, July-September 2009
105 children with acute infection (stay 7 days )
Body weight during hospitalization decreased in 43,8%
42 children with chronic infection ( stay 7 days )
Body weight during hospitalization decreased in 65,7%

inappropiate to meet energy requirement from oral

intake during hospitalization

Widjaja N, Hidayati N,Irawan R,Hidayat B, PIT Medan 2009

 What is Enteral Nutrition ?

Delivery of liquid diet by tube

( naso-gastric, gastrostomy, transpyloric)
Provision of specialized oral nutritional suplements
( food for special medical purposes, diseases specific
requerements eg food intolerance, inborn error of
metabolism, inadequate oral intake )

ESPGHAN comitee on Nutrition , JPGN 2010.

Koletzko. Pediatric Nutrition in Practice, Karger 2008
 ESPGHAN Recommendation

Start enteral nutrition within the first 24 to

48 hours after admission, when oral feeding
is not possible and inappropiate to meet the
patients need (energy requirement )

ESPGHAN comitee on Nutrition , JPGN 2010.

Enteral Nutrition Support Decision Tree
Hospital admission
Nutritional assessment No Follow up and
Does the patient need nutritional periodic
support? nutritional
assessment
Yes
Functional gastrointestinal tract
No Parenteral
Nutrition
Yes
Enteral Nutrition
Support

ESPGHAN comitee on Nutrition ,

JPGN 2010.
 Need for Nutrition Support (EN,PN)

Insufficient oral Intake

60-80% of individual requirement for 10 days

Children 1 yo initiate nutrition support within 5
days of anticipated lack of oral intake
Infants 1 yo : within 3 days
Total feeding time > 4-6 h/day in disabled children
(neurologically impaired )

ESPGHAN comitee on Nutrition , JPGN 2010.

 Need for Nutrition Support (EN,PN)
Wasting and stunting

< 2 yo : inadequate growth/weight gain for > 1 month

> 2 yo : weight loss /no weight gain for > 3 months
Weight/age falls over 2 growth channels (growth chart)
Tricep skin fold consistently < 5th percentile for age
Fall in height velocity > 0,3 SD per year
Early/mid puberty : decrease in height velocity
> 2cm/year compare to previous year

ESPGHAN comitee on Nutrition , JPGN 2010.

 Clinical condition when EN is used
Inability to take enough food
Disfunctional eating/swalowing,facial trauma,coma,anorexia
muscle weaknes,fatique

Maldigestion, malabsorption
Enteropathies,pancreatic insufficiency,cystic fibrosis,short bowel
syndrome

Increased nutritional requirements

Burn,trauma,congenital heart disease

Altered substrate need or metabolism

Inborn error metabolism,renal or hepatic diseases

Primary disease management

Chronic diarrhea of infancy,crohns disease
Koletzko B. Pediatric Nutrition in Practice ,2008
 Use the gut whenever possible
and as much as possible

Enteral Nutrition (EN)

Improve gut function and morphology

Limits bacterial translocation and sepsis

Decreases incidence of multiorgan failure
Is 3x less expensive
EN prefer over PN whenever feassible

Koletzko B. Pediatric Nutrition in Practice ,2008

ESPGHAN comitee on Nutrition , JPGN 2010.
 If parenteral nutrition (PN) is needed :
avoid complete enteral starvation (NPO)
when possible

Even minimal EN (trophic feeding) along with

parenteral nutrition promotes intestinal
perfusion, releases enteral hormones, and
improves gut barrier function
Try not to use PN but partial PN (with EN)

Koletzko B. Pediatric Nutrition in Practice ,2008

ESPGHAN comitee on Nutrition , JPGN 2010.
 Contraindication Enteral Nutrition

Absolute
- GIT obstruction mechanical/ Paralytic ileus
- GIT ischemia /necrosis/perforation
- Inability to access the GIT (severe trauma/burns)
- Peritonitis
Relative
- Intestinal dysmotility, toxic megacolon,
gastrointestinal bleeding, high output, enteric fistula,
severe vomiting, intractable diarrhea
Koletzko B. Pediatric Nutrition in Practice ,2008
ESPGHAN comitee on Nutrition , JPGN 2010.
 Enteral Nutrition Algorithm

Longterm Nutritional Support

No ( 4 weeks) Yes (> 4 weeks )

Nasoenteric Tube Tube enterostomy

Aspiration Risk

Yes No Yes No
Transpyloric Nasogastric Jejunostomy Gastrostomy
Tube Tube PEG
by dr NAW 15
ESPGHAN comitee on Nutrition , JPGN 2010
 Site of EN delivery
Stomach preferred if feasible
Physiologic, reservoir with gradual release
Antimicrobial effect
Tubes easily placed
Less diarhea , better osmotic tolerance
Postpyloric Jejunum
GER Pulmonary infection
Tracheal aspiration, gastropharesis, gastric outlet
obstruction or previous gastric surgery that precludes
gastric feeding,early post operative feeding after major
abdominal surgery
Must have continuous delivery (by pump) no bolus
ESPGHAN comitee on Nutrition , JPGN 2010
 Percutaneous endoscopic gastrotomy (PEG) or
jejunostomy (PEJ)

Duration of EN > 4-6 weeks

Methode of placement endoscopycally

surgiccally
radiologically
Endoscopy preferred cheapest and quickest
low rate of complications

Surgery preferred in neurologically impaired

strict indication,side effect

Koletzko B. Pediatric Nutrition in Practice ,2008

ESPGHAN comitee on Nutrition , JPGN 2010.
Percutaneous endoscopic gastrostomy (PEG)
 Which tube material?

PVC (Polyvinylchloride)
- Cheap
- Softener (palate esters) maybe toxic
- Became hard after a few days
- Use only for short duration (3-5 days)
Silicon or polyurethan
- More expensive
- Remain unchange
- Non toxic
- Good for long duration (4-8 weeks)
Samour. Pediatric Nutrition 2012
 Tube feeding

PVC (Polyvinylchloride) Silicon or polyurethan

 Bolus or continuous delivery

Bolus Continuous
intermittent
Physiologic Ability to increase volume of formula
more rapidly
Simple and Improved absorption of major nutrients
cheap in infants with intestinal diseases
Non-restrictive Associated with a reduced incidence of
vomiting in infants with GER

Freedom from Greater caloric intake when volume

infusion tolerance may be a problem
equipment

Samour P. Pediatric Nutrition 2012

Continuous Feeding Pump
Bolus/intermitten feeding set
Continuous nasogastric milk feeding versus
intermittent bolus milk feeding
for premature infants less than 1500 grams

Randomised and quasi-randomised clinical trials

The seven included trials, involving 511 infants, found no

differences in time to achieve full enteral feeds
between feeding methods.

Premji SS, Chessell L. Cochrane Database of Systematic Reviews 2011

 Net absorption for total calories,lipids,proteins in SBS
Tube feeding vs oral (randomized cross over study 15 px)

A. Total Calories
B. Total Lipids
C. Total Proteins
Continuous tube feeding
intake (exclusively or conjunction
with oral feeding) following
net abs the postoperative period
significantly increased net
losses absorption

Joly F.Gastroenterology 2009

 Pureed (blenderized)
Normal food for tube feeding ?

Use of pureed (blenderized)

normal food for tube feding is
not recommended because of
the high risks of nutritional
inadequacy and microbial
contamination

ESPGHAN comitee on Nutrition , JPGN 2010

 Formula selection for EN
Breastmilk
Polymeric Formula :
- Infant Formula
- Preterm Formula
- Post discharge formula
- High calori formula : WHO formula (F 75, F100)
casein base formula, whey-casein formula
Special medical purposes formula
- Elemental formula
- Semi elemental formula
- Inborn Metabolic Disease formula :PKU,MMA,MSUD,etc
Samour P. Pediatric Nutrition 2012
 Types of Formula for EN
Polymeric Semi elemental Elemental
Karbohidrat Complex Glucose polymers Glucose polymers
carbohydrate (maltodextrin) (maltodextrin)
Protein intact peptides of varying Amino acids
proteins chain length(ext
(casein /whey hydrolyzed)
based
Fat Mainly LCT Primary MCT Mainly MCT (95%)
(85%) (60-65%)
Osmolality 300-450 250-300 300-600
Taste Palatable, Expensive,more Very expensive,bad
cheap bitter taste
Concider Intact GI Better absorbed,less Better absorbed
tract needed alergenic ,Non alergenic
Beneficial Standard Malabsorbtion Malabsorbtion
feed ,maldigestion ,maldigestion
 EN formula : composition

Generally gluten free

Lactose free or only low amount
Iso-osmolality (300-350 mosm/kg) preferable, (high
osmolality may induced diarrhea ), particularly for
continuous intrajejunal feeding
Dietary fibre appropriate for most patients, prevent
both diarrhea, and constipation

Koletzko B. Pediatric Nutrition in Practice ,2008

 Lipid in enteral nutrition formula

High fat (>40%) glycaemic load

(insulin resistance post surgical, septicaemia,burn, CO2
production, beneficial in hypercapnea )
Medium chain triglycerides (MCT)
Beneficial in severe fat malassimilation
(severe cholestasis,exocrine pancreatic insufficiency
,interuption of enterohepatic bile circulation ,severe short
bowel syndrome, low absorbtion surface area, lymphatic
system disorder )
Long chain omega-3 polyunsaturated fatty acids
Anti inflammatory and immune modulating effect acretion in
neural tissue
Samour. Pediatric Nutrition 2012
Koletzko B. Pediatric Nutrition in Practice ,2008
 Application of MCT diet for chylothorax was effective

282 neonatal/infant
operation on CHD
Retrospective review
26 chylothoraces
(9,2%)

24 MCT diet (92%) 1 TPN 1 resolve

Min 10 days without tx

17 resolve (71%) 7 prsistent

16 conversions to
regular nutrition
within 7 days (94%)
1 temporary relaps
after nutrition
conversion

Biewer et al. Journal of

Cardiothoracic Surgery 2010, 5:127
 Semi-elemental formula is safe for pediatric patients
with gastro-intestinal disease
Prospective open trial study

47 Infants and children that were hospitalized because of

a variety of symptoms of GI disease
Acceptability and tolerance (volume of formula
intake, GI symptoms, and stool characteristics) were
recorded daily by the parents..
Non Essential AA
Essential AA

Yvan Vandenplas.
Amino Acids (2010) 38:909914
 Home enteral nutrition

Better quality of life, cheaper, safe, effective

Use when longer term EN if anticipated
Require well structure training of care givers

- NG tube placement, stoma and tube management,

maintenance,feed preparation, storage, delivery
- Managing pumps and delivery set
- Monitoring child
- Prevention and treatment of complication
Require experienced centre and nutrition support team
to provide help (24 h/7d) and monitoring

ESPGHAN comitee on Nutrition , JPGN 2010

 Home Enteral Nutrition : enteral support begins early age
< 18 yo : 304 patient, 1995-2004
Indication administering HEN

Oncologic
Type of enteral access
Digestive
Oncologic
Neurologic
Digestive
FTT
Neurologic
Miscelaneous
cases FTT

Mean age at the start of Miscelaneous

cases
treatment was 4.02 4.09
years, median of 2.5 years;
28% of all patients were under
1 year. Mean treatment
duration 306 544 days.
Giner CP et al. Nutr Hosp.2012
 Type of formula selection for HEN

Pediatric polymeric formulas were mostly prescribed in

190 patients (62.5%). Products were adapted to the
age and diagnosis of each patient
Giner CP et al. Nutr Hosp.2012
 Complications of Naso Enteric feeding tubes
Complications
Gastrointestinal
Diarrhea,nausea,vomiting,
bloating, abd distention
Aspiration
Technical
Occlusion,migration, GIT
lession
Infective
Gastroenteritis,septicaemia
Metabolic
Fluid,glucose,electrolyte,
trace elements,vitamins
Behavioural
Oral aversion, altered taste
Prevention and treatment
Formula selection and delivery,osmolality,
viscosity, disease specific. Increase dose
stepwise
Monitoring gastrointestinal residual
Tube,stoma selection and placement
PVC vs PU/silicon, endoscopy vs surgery
Quality control, hygiene,hang time 4-6h
Monitoring growth
(weight,height/length, skinfolds),
hematology, biochemistry
Team approach,involve patient,try
different formula
 Adverse effects of overfeeding

Excessive body fat deposition

Hyperglycaemia, hyperlipidaemia
Hepatic disfunction
Ventilation weaning difficulties

No overfeeding define your goals

 Refeeding syndrome

During initiation of EN or PN in severly malnourished

patients
Sudden reversal of catabolism insulin secretion
interacellular shift of P, Mg, K
rapid fall in serum concentration

Hypophosphataemia, haemolytic anaemia, muscle weakness,

impaired cardiac function, potential for cardiac failure,
fluid overload, arrhytmia and death

ESPGHAN comitee on Nutrition , JPGN 2010

39
 Prevention of refeeding syndrome

Highest risk in severe malnutrition particularly during

1st week of feeding
Limit initial EN to provide ~ 50- 75% of energy needs
Increase over 3-5 days if tolerated
Use frequent small feeds ( 1 kcal /ml) to minimize fluid
load

ESPGHAN comitee on Nutrition , JPGN 2010

 Weaning from enteral nutrition

Regularly reassess patients

Continued need for EN
Stepwise reduction of EN if condition stable and
nutritional status satisfactory, may take days to
many months
Stop EN if oral supply and growth are satisfactory
 Post Ileostomy ec. Total Bowel
Case Enteral Feeding Obstruction + Atresia Ani post
Sigmoidostomy +
Short Bowel Syndrome + UTI+AKI
st.Injury + sepsis +Microcephaly +
Severe malnutrition + Severly
Stunting

1 month later
3 months old

C/male /2 mo/2400 g/51 cm/34cm

Birth weight 2800g

C/male /3 mo/3500 g
Normal Growth and Development

Baby C / 9 months old

BW 8,2 kg , Length 68 cm
Head Circumference 43 cm
 Key messages
Use the gut whenever and as much as possible
Start enteral nutrition within the first 24 to 48
hours after admission, when oral feeding is not
possible to meet energy requerement
Type of formula selection based on the age and
diagnosis of each patient
Do not overfeed (severe malnutrition) refeeding
syndrome
Close monitoring of patients, best quality of care by
team approach ( physician/pediatric nutrition,
dietician, nurse, psychosocial support)
Route of absorption and transport of dietary fat as a
basis of classification as fatty acid according chain
length

1. Fatty acid 10 carbon atoms transported as free

fatty acid bound to albumin via to the portal vein to
the liver,oxidized in the liver and enter the hepatic
vein to the systemic circulation as non fat
2. Fatty acid 14 carbon atoms transported as
chylomicron triglyceride via the lymphatic system to
the systemic circulation as fat