UNIT IV: Enteral and Prenatal Nutrition.

1. Identify the characteristics, nutritional composition and concentration of formula feedings.

2. Complications associated with Enteral feeding.

What is percutaneous endoscopic gastrostomy (PEG)?

Percutaneous endoscopic gastrostomy (PEG) is a surgical procedure for placing a tube for feeding without
having to perform an open operation on the abdomen (laparotomy). It is used in patients who will be
unable to take in food by mouth for a prolonged period of time. A gastrostomy, or surgical opening into
the stomach, is made through the skin using an a flexible, lighted instrument (endoscope) passed orally
into the stomach to assist with the placement of the tube and secure it in place.

What is the purpose of percutaneous endoscopic gastronomy?

The purpose of a percutaneous endoscopic gastronomy is to feed those patients who cannot swallow food.
Irrespective of the age of the patient or their medical condition, the purpose of percutaneous endoscopic
gastronomy is to provide fluids and nutrition directly into the stomach.

Who does percutaneous endoscopic gastronomy?

Percutaneous endoscopic gastronomy is done by a physician. The physician may be a general surgeon,
an otolaryngologist (ENT specialist), radiologist, or a gastroenterologist (gastrointestinal specialist).

Where is percutaneous endoscopic gastronomy done?

PEG is performed in a hospital or outpatient surgical facility. It is not necessary to perform a percutaneous
endoscopic gastronomy in anoperating room.
Enteral and Prenatal Nutrition
ENTERAL NUTRITION
Nutrition plays an important role in the prevention and management of many diseases. None today would
challenge the concept that nutritional support is an integral and essential element in the care of the patient
who is critically ill nutritionally, depleted or both. Patients unable to consume necessary nutrients orally
require alternative form of nutritional support.
Definition
 Term Enteral means "within or by the way of the gastrointestinal (GI) tract."
 Nutritional support via placement through the nose, esophagus, stomach, or intestines (duodenum
or jejunum)
Complications with Chronic illness
 Anorexia,
 Hyper metabolism,
 Malabsorption,
 Atrophy of muscles,
 Liver,
 Kidney,
 Gastrointestinal tract
 Heart,
 Impaired cell mediated immunity,
 Susceptibility to infection,
 Poor wound healing,
 Anemia.

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The use of enteral feeding is increasing because of:
a. The development of simple and low risk procedures for placement of tubes in GI tract
particularly percutaneous endoscopic gastrostomies and jejunostomies.
b. The availability of wide variety of commercial enteral feeding formulas.
c. Enteral nutrition is generally less expensive than parenteral nutrition.

Tube Identification
• Nasogastric
• Nasoduodenal
• Nasojejunal
• Oral placement
• Should be small in diameter and soft
• Surgical Esophagostomy
• Surgical or Percutaneous endoscopic gastrostomy tube
• Surgical or Percutaneous endoscopic jejunostomy tube

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Goals of feeding
A. Selection of an appropriate formula
B. Formula delivery
C. Indications of nutritional status
o Signs of feeding intolerance
Indications
Specific conditions for which nutrition indicated for adults and children shown in table 1
Indications for nasoenteric Tube feeding for adults
Neurological indications:
1. Severe Head injuries
2. Cerebrovascular accidents
3. Coma due to any cause
4. Neoplasms: Advanced primary and secondary intracranial tumors
5. Dysphagia associated with neurological disorders
Hypermetabolism:
1. Postoperative major surgery
2. Sepsis
3. Trauma Burns Organ transplant acquired immune deficiency syndrome
Surgical indications:
1. Facial and jaw surgeries
2. Head & Neck surgeries
3. Oropharyngeal surgeries
4. Pharyngoesophageal surgeries
5. Polytrauma associated with extensive abdominal surgeries
6. Patients with burns for surgeries unable to take oral nutrition
7. Surgery complicated with sepsis
Gastrointestinal (GI) disease
1. Short-bowel syndrome (if absorptive capacity of remaining bowel is sufficient e.g.
approximately a minimum of 100 cm jejunal and 150 cm of ileal length of functioning small bowel
with ileocecal value intact.
2. Inflammatory bowel disease
3. Minimal GI tract fistula output ( less than 500mL/d)
4. Pancreatitis
5. Esophageal obstruction
6. Malabsorption
7. Fistulas
Cancer
1. Oral malignancies
2. Oropharyngeal malignancies
3. Nasopharyngeal malignancies
4. Head and neck malignancies
5. Esophageal malignancies
6. Gastric malignancies
7. Chemotherapy
8. Radiotherapy
Resistance to oral intake
1. Anorexia
2. Dysphagia
3. Severe depression
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Malnutrition
1. Protein energy malnutrition with inadequate oral intake for at least 5 days
2. Malnutrition preoperatively and postoperatively
3. Malnutrition in cancer patients
4. Malnutrition in-patients with Acquired Immune Deficiency Syndrome (AIDS) unable to take
oral nutrition.
5. Malnutrition in debilitated aged patients
Organ system failure:
1. Respiratory failure
2. Renal failure
3. Cardiac failure
4. Central nervous system failure
5. Hepatic failure
6. Multiple organ system failure
Transition from parenteral nutrition
For children
1. Malnutrition
2. Malabsorption
3. Hypermetabolism
4. Failure to thrive
5. Prematurity
6. Disorders of absorption, digestion, excretion, utilization, or storage of nutrients
Contraindications:
1. Malfunctioning of GI tract or conditions requiring extended bowel rest
o Insufficient absorptive capacity of intestinal tract e.g. short-bowel syndrome ( intestinal span
suggested for sufficient absorption of nutrients)
o Mechanical obstruction of GI tract
o Prolonged ileus
o Severe GI hemorrhage
o Severe diarrhea
o Intractable vomiting
o High output GI tract fistula (> 500 ml/ day)
o Severe enterocolitis

2. Harm may exceed benefit for incompetent patients with end-stage illness, minimal levels of
consciousness, and lack of advance directives, whose anticipated benefits may be uncertain or short-
term; is likely against the patient’s best interests.
Advantages of Enteral feeding
1. Provides good nutritional care plan
2. Nourishing child who can not take adequate nutrients orally
3. Helps family and health care professionals to see enteral alimentation as positive and optimal
way rather than a punitive and optimal way of nourishing the malnourished child.
Nutritional requirements
1. The recommended dietary allowances serve as initial guidelines in the selection and modification
of a formula
o All nutrients of the final formula should be calculated and compared with RDA for age or for
the developmentally delayed child for height age
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 o Vitamin mineral supplementation may be needed
1. The disease process itself indicates whether the requirements are changed
2. Drug induced nutritional deficiencies may develop from long-term use of medication that affects
o nutrient function and metabolism
o decrease nutrient absorption or synthesis
1. Feeding tube
The small-caliber tubing requires a finely dispersed product with low viscosity whereas the
gastrostomy tube can accommodate blenderized feed
2. Fluid requirement
Enteral formulas
Selection of an appropriate enteral formula requires assessment of patient’s digestive and absorptive
capacity as well as the knowledge of the substrate source and form.
1. Protein components:
Components of protein are intact protein (larger molecular weight protein), partially hydrolyzed
protein (protein enzymatically hydrolyzed into shorter polypeptide fragments such as oligopeptide),
dipeptides and tripeptides (type of partially hydrolyzed proteins to di and tri-peptide fragment.
a. Protein quality attributed to amino acid profile: an amino acids of at least 40% amino acids as
essential amino acids is suggested for anabolism.
b. Predominant sources of protein include soy and casein.

2. Carbohydrate components
Components of carbohydrate are starch, glucose polymers (derived from partially hydrolyzed corn
starch), disaccharide (sucrose: glucose – fructose; maltose (glucose – glucose; lactose: glucose –
galactose), monosaccharides (glucose: dextrose; fructose)
a. Primary differences in carbohydrate components are related to the form and concentration
of carbohydrate
b. The most predominant form of carbohydrate found in enteral formula is hydrolyzed
cornstarch or maltodextrin
3. Fat components
Components of fat are polyunsaturated fatty acids (PUFA), medium chain triglycerides (MCT) and
saturated fatty acids (SFA)
a. Fat enhances palatability and flavor of formula
b. Vegetable oil contains variable amount of essential fatty acids (EFA).
c. Suggested EFA intake specially linoleic acid is 3% to 4% total calorie needs.
d. Sources of fat commonly found in formulas include a variety of vegetable oils
4. Fiber components
Component of fiber is insoluble (cellulose, noncellulose: hemicellulose), or soluble fiber (pectin,
mucilage, algal polysaccharide, gum).
a. Content of fiber-supplemented formula ranges from 5 to 14 g of fiber per liter.
b. Recommended intake of dietary fiber is approximately 20 to25 g / day
c. Preliminary studies have shown that fiber intake of less than 30 g / day did not seem to
impair vitamin, mineral or drug bioavailability in the gut.
d. Most predominantly used from of fiber in enteral formulas is soy polysaccharide.
5. Water
a. Quantity water in the enteral formulas is often described as water content or moisture content
b. Quantity of water ( frequently reported in milliliters of water per 1000 ml of formula or
milliliters of water per liter of formula)

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 c. Most of enteral formulas contain water in the general range of 690 to 860 ml per 1000ml of
enteral formula. Standard infant formulas are 0.67 calories/cc. Whereas adult formulas are
either 1 calorie/cc or 1.5 to 2.0 calories/cc

Table 6 water content of Enteral formula for adults

Caloric density (kcal/ml Water content (ml/1000 ml Water content
formula) formula)

1.0 – 1.2 800-860 80-86

1.5 760-780 76-78

2.0 690-710 69-71

6. Vitamin and minerals

a. Most nutritionally complete commercial formulas contain adequate vitamin and minerals
when a sufficient volume of formula to meet energy and macronutrient needs is provided.
b. Some disease specific formulas are nutritionally incomplete in relation to vitamin and
mineral content
c. Liquid vitamins and mineral supplements may be indicated for patients receiving
nutritionally incomplete or diluted formulas for prolonged periods
d. Fat-soluble vitamins such as vitamin K may be indicated for patients with fat absorption or
for patients with vitamin K deficiency; vitamin K deficiency is rare in as much as vitamin K
is synthesized by intestinal flora, and most commercial formulas includes vitamin K.
Physical characteristic of enteral formula
1. Osmolality
a. Definition: function of size and quantity of ionic and molecular particles (protein, carbohydrate,
electrolytes, and minerals ) within a given volume
o Unit of measure for osmolality is mOsm/kg of water Vs unit of measure of osmolality
mOsm/L.
b. Factors affecting osmolality are:
o Minerals/electrolytes: due to dissociation properties and small size
o Protein: more hydrolyzed components such as amino acids have greater osmotic effect than
larger molecular weight component such as intact protein.
o Carbohydrate: more hydrolyzed components such as glucose have a greater osmotic effect than
larger molecular weight such as starch;
c. Formulas with greater hydrolyzed nutrient components have proportionately higher
osmolalities.
d. Effect of osmolality on GI tolerance: gastric retention, abdominal distention, diarrhea, nausea,
and vomiting.
2. PH
a. Gastric motility is reportedly slowed with solution lower than pH 3.5.
b. The pH level of most commercial formulas is > 3.5.
1. Calorie and nutrient density : gastric emptying time may be slowed by formulas containing
higher calorie-nutrient density

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Classification of formulas
1. Polymeric formulas:
a. Most of patients who are critically ill may be enterally fed with polymeric formulas.
b. Nitrogen balance has been reported to be similar for patient with normal digestive and absorptive
capacity who were fed intact protein, partially hydrolyzed protein, and amino acids with
approximately the same amino acid profiles.
c. Intrajejunal digestion, nutrient absorption, and nitrogen balance have been reported to be similar
between intact protein and polymeric formulas compared with partially hydrolyzed (small
peptides and amino acids) formulas in jejunal feedings in under nourished patients.
2. Partially hydrolyzed formulas:
a. Characteristics:
o Macro-nutrients may be partially or completely hydrolyzed via enzymatic activity into
smaller components (e.g., free amino acids and peptides)
o Some formulas may have unpleasant odors and taste,
o Most of the formulas are expensive.
b. Composition may vary in free amino acids and peptides, type and quantity of fat, content of
carbohydrate content.
c. Indicated for patients with partial digestive and absorptive capacity; patients with resolved
acute illness might be capable of transition form partially hydrolyzed formulas to
polymeric formulas.
3. Disease-specific formulas: some formulas are designed for specific organ dysfunction and some are
for metabolic stress. Efficacy of the disease specific formulas is controversial
4. Modular formulas:
a. One purpose for using modular formulas is supplemental use
o May add calorie or protein density
o Tailor tube feeding to individual nutritional needs as a supplement to commercial enteral
formulas.
b. Another advantage is that it can be de novo formulated for individualized designed of nutrient
formula to meet specific nutrient needs of an individual.
c. Advantages of de novo enteral formulation include
o Customizing the formula to meet specific nutrient composition of the patient
o Select cases using de novo formulas have reported cost savings.
a. Disadvantages of de novo formula include
o Complexity of ordering specific nutrient composition as well as the method and rate of tube
feeding administration unless a standardized orders form is used.
o Increased cost of labor
o Complexity of calculating nutrient composition
o Potential risk of bacterial contamination from excessive handling of formulas
o Potential physical incompatibilities with insoluble components.
Determining an optimal access route for enteral nutrition depends upon
1. Anticipated duration of enteral feeding
2. Risk of pulmonary aspiration, e.g.. In patients with diminished mental status or esophageal
reflux
Guidelines for selection of product:
Substrate source – individual requirements and ability to tolerate various sources of intact or elemental
carbohydrate protein and fiber.

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Calorie concentration – The calorie-to –volume ratio will affect the volume required to meet nutritional
requirements. Increasing the calorie-to-volume ratio will affect the osmolality of the solution.
Available feeding equipment – The size of the feeding tube, drip chamber, and availability of pumps
may affect the choice of solution. Blenderized feeding and those containing soy polysaccharide fibers
usually require pumps for the infusion through smaller bore tubes due to higher viscosity.

Initiation of feeding
a. Prior to initiating enteral feeds, tube placement must be verified.
b. Placement can be confirmed by the aspiration of gastric contents.
1. It is recommended that a small syringe (10 to 30 cc) be used when checking small bore tubes to
prevent exerting negative pressure and collapsing the tube.
2. If gastric content can not be aspirated through the tube, then radiographic confirmation of tube
location should be done.
a. Isotonic solution can be initiated full strength at a rate of 25 to 50 cc per hour and advanced
every 12 to 24 hours until the desired rate is achieved.
b. If intolerance develops at any time appropriate adjustment should be made.
c. Rate of the feeding is advanced to desired volume and then strength of the formula is gradually
increased until calorie and protein needs are achieved.
d. Strength and rate should not be advanced concurrently.
Determining the method for the tube feeding administration
1. The method selected depend upon
a.Central access route
b. Stability of the patient (whether patient is critically ill or not.)
c.Gastric emptying rate
d. GI tolerance of tube feeding
e.Type of formula use
f. Calorie and protein needs
g. Ease of administration
h. Patients mobility.
1. The Feeds are given either by continuous drip, intermittent infusions, and bolus feed.
a. Continuous drip- Tube feedings are administered at constant, steady rate usually over 24 hrs of
period. Use of an infusion pump is recommended, as accuracy of volume delivered is assured.
However most enteral feeding is administered by gravity of force.
b. Intermittent infusions- Tube feeds are administered at specific intervals through out the day.
The volume of desired feeding is divided into equal portion and been fed 4 to 6 hourly per day.
The feedings are usually given by gravity drip over period of 30 min. to 1 hour.
c. Bolus feed – Rapid installation of feeding into GI tract by syringe or funnel. The majority of
patients tolerate this method of feed.
For optimal results of enteral feeding the following points to be considered:
Temperature:
o Solution can be administered chilled if they are infused by continuous drip
o Decreased incidence of GI side effects may occur if intermittent and bolus feedings are
allowed to reach room temperature prior to administration.
Bacterial contamination:
o Use close feeding containers to decrease risk of organism contamination.
o Extension tubing administration set and bag should be changed daily.
o Never add new formula to old formula.
o Prepared formulas should be refrigerated if not used immediately.
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 o Feeding solutions should not be allowed to hang for longer than 8 to 12 hrs.

Prevention of aspiration:
o Placement of tube should be checked prior to feeds.
o Head of bed should be elevated at least 30 to45 degrees.
o Few drops of food color may be added to enteral formulas. This will help in detection of
aspirated of tube feeding from pulmonary secretions but does not protect against aspiration.
o The technique of aspirating gastric residuals via the feeding tube is common practice although
not based on scientific studies. Tube position or mechanical difficulty may give inaccurate
assessment. In general the practice is limited to larger bore feeding tubes. The smaller tubes
collapse when aspiration is attempted. Generally feeds are held if aspirate is between 75 to 150
cc.
Patency:
o Feeding tube should be irrigated every shift washed with 40 to 50 cc of warm water after its use.
o Even after each feed stopped, tube should be flushed with 40 – 50 cc of warm water.
o In case of clogging flush the tube, using a syringe containing 30 to 50 cc of warm water.
o Medicine should be liquid if it has to pass through tube. The tube should be flushed with 20cc
water before and after administration of medication.
Monitoring:
A. Complications associated with enteral tube feeding may be prevented and managed with
appropriate monitoring.
1. Monitoring schedules are diversified because of patients stability, institutional protocol, and
feeding duration.
o Tube position confirmation prior to initiation of feeding or prior to intermittent feeding
o Daily weight
o Daily intake and output of urine fractionals every six hours until maximal tube feeding rate is
established.
o Patients with history of diabetes mellitus should have urine fractionals daily until therapy
terminated.
o Record of gastric residuals every four hours when feeding intragastric.
o Record of bowel movements/consistency
o Weekly serum electrolytes and blood count
o Weekly profile of liver function tests, phosphorus, calcium, and magnesium, total protein
albumin, nitrogen balance.
o Weekly reassessment of nutritional indices with appropriate readjustment in energy and protein
provisions needed.
A. Prevention of mechanical, GI, and infectious complications of tube feeding
B. Total quality care of tube feeding patients requires interdisciplinary team management.
Home blend formulas
Occasionally patient requests or is required to prepare tube feeding at home. Though this is possible and
does have some benefits, there are some significant points to be considering when home blend formulas
are prescribe to the patient. The table no will show the advantages and disadvantages of home blend
formulas.

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Advantages and Disadvantages of home blenderized tube feeding
Advantages Disadvantages

Family can take an active part in food Blenderized feeding require more time and energy to
preparation for patient prepare than commercial products
Less costly Special equipment is needed i.e. blender or food
Commercially prepared products can be 10% to processor, measuring utensils, access to refrigeration
50% more expensive etc
Cost of commercial products is not always  
reimbursable. Special care must be taken to liquefy the contents of the
Payment is depend upon necessity of use as blender completely, as food particles can clog the
dictated by disease process feeding tube
Increased amount of fiber can be provided  
Sense of " being different " is lessened since Feeding must be prepared daily
the patient can enjoy the same table food as his Daily ingredient selection should be carefully made to
or her family ensure nutrition adequacy of diet.
  May need vitamin and mineral supplementation
  Extra amount of blenderized feed must be kept
Manipulation of individual nutrients is easier in refrigerated and must slightly warmed before feeding.
blenderized feedings than with commercial Higher incidence of bacterial contamination may occur.
products Clean food preparation technique must be emphasized
Unpleasant taste from eructations is less likely  
to occur Blenderized feeding are difficult to sue if the patient is
away from home

The home tube feeding recipes is a teaching tool for use by either the patient or the primary caretaker.
The content of feeding are determined by the dietician to provide the requirement of the nutrients such as
protein, calories, carbohydrate fat, vitamins, minerals and water. The feeding can be prepared either by
blender or using hand mixer.
Directions:
1. Measure all ingredients accurately. Pour into large mixing bowl and stir contents to combine.
o Blender method; add three cups of mixture to blender. Set at medium speed for three
minutes. Pour into separate large bowl. Repeat above procedure until formulas have been
thoroughly mixed.
o Mixer method: using an electric mixer, blend at medium speed five minutes or until
thoroughly mixed
1. If mixture is thick, thin with water until the desire consistency is achieved.
2. Pour formula into individual jars. Cover and refrigerate immediately. Discard any unused
formula within 24 hours
3. Take individual serving out one hour before needed and allow it to warm to room
temperature before use. Always keep it covered.
4. The patient/caretaker should follow the direction given to him regarding feeding

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