Method of Delivery,

Formula Selection &

Implementation
Siti Hawa Mohd Taib

Clinical Dietitian

UM Medical Center

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 Polymeric

Disease-specific

Peptide-Based

Modular

FORMULA SELECTION
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 Enteral Formulas

Liquid diets intended for oral

use or tube feeding

Ready-to-use or powdered
form

Designed to meet variety of

medical and nutrition needs

Can be used alone or given

with foods

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 Formula Selection
Should be evaluated based on

• Functional status of GI tract

• Digestion and absorption capability
• Physical characteristics of formula
• Osmolality, fiber content, caloric density, viscosity
• Macronutrient ratios
• Fluids and electrolytes needs
• Specific metabolic needs
• Cost-effectiveness

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 Polymeric Formula
Ready-To-Use Powder
(RTU)

Standard

Fiber

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 Sip Feeding/Oral Supplement

EnSure EnSure Plus

• Vanilla
• Vanilla
• Chocolate
• Strawberry
2009 6
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 Oral Supplements
To boost energy and protein intake
• Between meals
• Added to foods
Enhances otherwise poor intake

Indication
• Cooperative patient with adequate appetite
• Example: patient with depression, cognitive problem

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 Selecting an Oral supplement

Degree of inability to meet needs

Presence or absence of dysphagia

Taste preference or sensitivity

Availability of labor and resources for preparation

Tolerance to lactose or other components

Tolerance to osmotic loads

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Promoting Intake of Oral Supplements
Ensure that any oral supplement is at an appropriate
temperature
Ensure that oral supplement packaging can be opened
by patient
Monitor intake of prescribed supplements

Promote a sip style of supplement consumption

Include supplement as part of medication protocol

Encourage eating frequently

Serve a nourishing beverage after the evening meal

Nursing interventions to minimise undernutrition in older

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patients in hospital. Nursing Standards. 22, 41:35-40 (2008)
 Disease-specific Formulas
Ready-To-Use Powder
(RTU)

Diabetes
Formula

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 Diabetes Specific Formula

Use of
diabetes • 23 studies (784 pts)
• Oral supplement and tube feeding
specific • Short and long term use
formulas • Associated with improved
for patients glycemic control and reducing
complications of diabetes (long
with term)
diabetes
Elia M et al (2005) Enteral nutritional support and use of
diabetes specific formulas for patients with diabetes.
Diabetes Care 28:2267-2279
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 Disease-specific Formulas

Pulmocare Nepro
• COPD • Hemodialysis

2009
ProSure (RTF) ProSure (powder) 12
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• Oncology • Oncology
 ASPEN/SCCM 2009
Disease Specific Formulation in the ICU
Pulmonary Failure
• ICU formulations designed to alter RQ, i.e. reducing CO2 production have not
shown benefit – Grade E
Renal Failure
• Most ICU patients with ARF do not require protein restrictions, if electrolyte
abnormality is the issue these formulations may be considered
Hepatic Failure
• EN is preferred over PN, nutrition regimen should avoid restricting protein in
liver failure
• Standard enteral formulations should be used in acute and chronic liver
disease, BCAA should be reserved for the rare encephalopathic refractory to
standard therapy luminal acting antibiotics and lactulose – Grade C

Martindale RG, Mc Clave SA et al. Guidelines for the provision and assessment of nutrition
support therapy in the adult critically ill patient: SCCM and ASPEN: Executive Summary.
CCM 2009 ;37(5):1757 031109 13
 ASPEN/SCCM 2009
Disease Specific Formulation in the ICU

Acute Pancreatitis
• Severe acute pancreatitis should be fed enterally by
gastric or jejunal route – Grade C
• Tolerance to EN in severe acute pancreatitis may be
enhanced by the following measures:
• Minimize period of non-use of gut – Grade D
• Feed more distal – Grade C
• Change the content to small peptides, MCT, low-fat –
Grade E
• PN when EN not feasible – Grade C
Martindale RG, Mc Clave SA et al. Guidelines for the provision and assessment
of nutrition support therapy in the adult critically ill patient: SCCM and ASPEN:
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Executive Summary. CCM 2009 ;37(5):1757
Elemental Formula

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Formulas for Impaired GI Function

Whey peptide-based formula

• High-end formula
• For poor feeding tolerance with
standard formula and continuous
feeding
• Diarrhoea 2° to
hypoalbuminaemia
• High gastric aspirate

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 Implementation of EN

Is a peptide-
based • Whole-protein formulae
are appropriate for
formulae
most patients because
preferable
no clinical advantage of
to a whole- peptide-based formulae
protein could be shown (C)
formulae?
ESPEN Guidelines on Enteral Nutrition: Intensive Care.
Clinical Nutrition (2006) 25, 210-223
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 Polymeric Vs Peptide-based Formula
Studies failed to show a difference in clinical outcome & caloric
delivery

Diarrhea

• Meta-analysis revealed no difference in incidence of diarrhea

• Individual study results noted a decrease in stool frequency with elemental
formula
• Critically ill geriatric patients who are at nutritional risk, indicated by albumin
<25 g/L tolerated semi-elemental with fiber better than polymeric formula

Potential benefit for peptide-based for patient with GI

complications (SBS, pancreatitis)

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 Modular Supplements

Glucose Polymers Glucose Polymers Protein supplement

•  Energy (BCAA)
• For liver patients

Protein supplement MCT Oil (fat) Glutamine powder

•  protein •  Energy
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 Thickening Agent

Thick & Easy Thixer

To thicken liquid into various consistency

• Nectar-like (Syrup)
• Honey-like
• Spoon thick

Useful in the management of stroke and dysphagia patients

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Cost ?

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 Blenderized Diets
Disadvantages

High batch to batch variability in

nutrient content
• Varying in nutrients
• Low energy density

Inconsistent viscosity

• Frequent occlusion of tubes

Increase risk for bacterial
contamination
• Food borne illness
• Hospital acquired infections
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 Benefits of Commercial Formulas
Commercial Formulas Blenderized Formulas

Uniform contents Daily nutrient variability

Sterile Non-sterile; high bacterial
content and other pathogens
High viscosity
Low viscosity
Suitable for fine bore tube
Lactose free
Defined caloric density Does not provide adequate
caloric density
Gallagher-Allred. Nutrition Supp Svc 1983; Tanchoco CC, et al. Respirology 2001;6:43-50
Sullivan MM, et al. J Hosp Infect 2001;49:268-273
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 Implementation of EN
Is a immune-modulating formulae (formulae
enriched with arginine, nucleotides and ω-3-fatty
acid) superior to standard enteral formulae?
• Elective upper GI surgical patients [A]
• In patients with mild sepsis (APACHE II<15) [B]
• Not recommended in patients with severe sepsis, may be
harmful [B]
• In patients with trauma [A]
• In patients with ARDS (ω-3-fatty acid, and antioxidants) [B]
ESPEN Guidelines on Enteral Nutrition: Intensive Care. Clinical Nutrition (2006)
25, 210-223

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 Implementation of EN

• ICU patients with very severe illness who do

not tolerate >700 ml enteral formulae/day
should not receive an immune-modulating [B]
Immune- • Glutamine should be added to standard
enteral formula in
modulating • Burned patients [A]
formulae • Trauma patients [A]
• No sufficient data to support glutamine
supplementation in surgical or critically ill
patients

ESPEN Guidelines on Enteral Nutrition: Intensive Care.

Clinical Nutrition (2006) 25, 210-223
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 ASPEN/SCCM 2009
E1 – Selection of appropriate enteral formulation

Immune-modulating enteral formulations (supplemented with agents

such as arginine, nucleic acid, omega-3 fatty acids, and antioxidants)
should be used for the appropriate patient population (major elective
surgery, trauma, burns, head and neck cancer, and critically ill patients
on mechanical ventilation), being cautious in patients with severe sepsis
• For surgical patients – Grade A
• For medical patients – Grade B

ICU patients not meeting criteria for immune-modulating formulations

should receive standard formula – Grade B

Martindale RG, Mc Clave SA et al. Guidelines for the provision and assessment of nutrition
support therapy in the adult critically ill patient: SCCM and ASPEN: Executive Summary.
CCM 2009 ;37(5):1757 031109 26
 ASPEN/SCCM 2009
E2 – Selection of appropriate enteral formulation

Patients with ARDS and severe acute

lung injury should be placed on
enteral formulation characterized by
an anti-inflammatory lipid profile
(such as omega-3 fish oils, borage oil,
antioxidants) – Grade A
Martindale RG, Mc Clave SA et al. Guidelines for the provision and assessment of nutrition
support therapy in the adult critically ill patient: SCCM and ASPEN: Executive Summary.
CCM 2009 ;37(5):1757 031109 27
 ASPEN/SCCM 2009
E3-E4 – Selection of appropriate enteral formulation

E3- To receive optimal therapeutic benefit from the

immune-modulating formulations, at least 50-65% of
goal energy requirements should be delivered –
Grade C
• Exact quantity??

E4 – If there is evidence of diarrhoea, soluble fibre-

containing or small peptide formulations may be
utilized – Grade E

Martindale RG, Mc Clave SA et al. Guidelines for the provision and assessment of nutrition
support therapy in the adult critically ill patient: SCCM and ASPEN: Executive Summary.
CCM 2009 ;37(5):1757 031109 28
 ASPEN/SCCM 2009
Adjunctive Therapy

• Administration of probiotic agents has been shown

F1 – Probiotic to improve outcome (most consistently by
decreasing infection) in specific critically ill patient
agents populations involving transplantation, major
abdominal surgery, and severe trauma – Grade C

F3 – Consider • Most agree PN glutamine superior to enteral

additional • Grade B – 2 of 6 level 2 studies showing benefit
(trauma & burn)
glutamine
Martindale RG, Mc Clave SA et al. Guidelines for the provision and assessment of nutrition
support therapy in the adult critically ill patient: SCCM and ASPEN: Executive Summary.
CCM 2009 ;37(5):1757 031109 29
 Bolus feeding

Intermittent feeding

Continuous feeding

METHOD OF DELIVERY
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 Method of Administration

INTERMITTENT

• PUMP-ASSISTED
• GRAVITY

CONTINUOUS BOLUS
• PUMP-ASSISTED • Patient condition
Method, • Age
initiation and • Enteral route
advancement
• Gastric vs small bowel
of enteral
regimens • Nutrition requirements
• GI status
2009 031109 31
31
 The individual is fed a relatively large amount
at stated intervals
• E.g. 2000 ml/24 hours in 8 bolus feeding of 250 ml/
feeding

Formula delivered by gravity via a syringe

Bolus
Feeding High incidence of complications

Holding syringe too high or using force to

instill feeding can causes rapid administration
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32
 Bolus
Feeding

Feeding regimen
• May be initiated with full strength formula 3 – 8
times per day
• Increases of 60 – 120 ml every 8 – 12 hours as
tolerated up to goal volume
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ASPEN. Enteral Nutrition Practice Recommendations.
031109 JPEN 2009;33:122 33
 Method of delivery
Bolus Feeding
More physiologic Associated with longer

Disadvantages
Advantages

• Mimic a normal feeding time to reach

schedule nutritional goals
Less expensive Reduced nutrient
Greater flexibility in absorption in
feeding schedule malabsorption
Freedom from infusion Larger bore tube may
pump be required
More time required for
administration

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 Intermittent Feeding
• Given over 24 hours with intervals
of rest, e.g., 200 ml every 4 hours,
infused over 1 hour
• Allows patient to be more mobile
• Complications – similar to bolus
feeding

35 031109
Administration of Bolus or Intermittent
Feeding

Residuals checked more frequently

• every 3 to 4 hours
• Before each feedings

Few patients can tolerate more than 450 ml

per feeding

Patient needs to be monitored for several

potential problems
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 Continuous Feeding
Pump-assisted
Generally required for small-bowel feedings

Preferred for gastric feedings in critically ill

patients

Initiation and advancement

• Initiation: may range from 20 - 50 ml/hour Ventilator??

• Increments : may range from 10 - 25 ml/hour every 8- Severe TBI -
24 hours as tolerated GCS <8
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ASPEN. Enteral Nutrition Practice Recommendations. JPEN 2009;33:122
 Continuous Feeding

How should patients be tube fed after surgery?

• TF should be initiated within 24h after surgery

• Should start with a low flow rate (e.g. 10 – max
20 ml/h) due to limited intestinal tolerance [C]
• May take 5 – 7 days to reach the target intake
• Not considered harmful

ESPEN Guidelines on Enteral Nutrition: Surgery including Organ

Transplantation. Clinical Nutrition (2006) 25, 224-244
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 Method of delivery
Continuous feeding
Ability to increase More expensive

Disadvantages
Advantages

volume more rapidly feeding method

Improved absorption in
patients with intestinal • Pump
diseases • Feeding set
Reduced incidence of Restricts patient
GI intolerance ambulation
Greater caloric intake Less physiologic
when volume tolerance
is a problem

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 Tube Feeding Administration

Caution when initiating tube feeding

• If the gut has not been used lately
• If the formula is hyperosmolar
If intolerance develops
• Decrease to previous rate and advance as
tolerated

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 Feeding Pumps

Kangaroo Patrol Pump Kangaroo 924

℮pump

2009 031109 41
41
Feeding Pump with Flush Bag

• Using fine bore

Patient’s tubes 8 – 12F
Criteria • To prevent
for Flush blockage
Bag: • Needs additional
free water

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Flush Bag 42
 Polyurethane Feeding Tubes

12F & 14F 12F 12F

PVC Feeding Tubes

16F 031109 43
43
Implementation

Hydration
Flushing
Drug administration

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 Guidelines For Feeding Policies and
Procedures
Feeding system design
• Closed systems, and systems with fewer connections are
recommended
• Closed systems reduce nursing time and formula waste
• Systems with medication ports are also recommended

Provider preparation
• Wash hands
• Wear nonsterile disposable gloves
• Wear a mask if you have a cold or URTI
Enteral Feedings: What the Evidence Says. AJN. July 2004; 104 (7): 62 - 69
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Contamination of Enteral Formula
Always perform hand hygiene

Wipe the lid with a clean cloth, before opening a can

Storage
• Cover
• Label – time & date
• Refrigerate
• Discard after 24 hrs

Feeding hang time

• Premixed/diluted: 4 hrs
• RTU: 8 – 12 hrs
• Replace feeding bag & tubing after 24 hrs
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 Guidelines For Feeding Policies and
Procedures
Preparing Enteral Formulas
• With open systems, use RTU, sterile feeding formulas – avoid
those that require dilution, reconstitution, or additions
• Required mixing should take place using aseptic technique
• Discard dented or damaged cans and expired formulas
• Cover, label, and refrigerated opened or prepared formula at
< 4C, and use within 24 hours
• Sterile water should be considered when patient is critically ill
• Assemble feeding systems on a disinfected surface. Disinfect
the opening and the rim of the formula can
• Label each container and discard after 24 hours
Enteral Feedings: What the Evidence Says . AJN July 2004; 104 (7): 62 - 69
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 Guidelines For Feeding
Policies and Procedures

Administering
enteral feedings
• Handle the feeding
system and the ports
as little as possible
• Avoid adding new
formula to that
remaining in the
container
Enteral Feedings: What the Evidence Says
AJN. July 2004; 104 (7): 62 - 69
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 Continuous Feeding

• Assemble feeding systems on the

patient’s bed
• Top up fresh formula until all the
Do formula hanging in the feeding bag has
finished

not • Overfeed patient

• High caloric density formula
• 1.5 kcal/ml : Pulmocare
• 2.0 kcal/ml : Nepro

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 Hydration

The amount of water in tube feeding

formulas varies

Water flushes via tube can be given for

additional hydration

Tubes need to be flushed on a schedule:

before and after meds and feed

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 Tube Flushing
Water is the best liquid for flushing

Tubes need to be flushed on schedule

• Before, between and after medications
• Before and after bolus feedings
• Before and after checking gastric residuals
• When feeding is being stopped (pump)

Syringe size >30 mL to prevent rupture

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 Medicines and Feeding Tube
“Avoid the Crush”
Use oral route if possible

Use liquid medications when available

• Diluted with 30 ml water – to reduce osmolality
• Crush tablets and mix with 30 ml water

Medicines NOT to be given through feeding tubes

• Sublingual/buccal tablets
• Melt tablets
• Chewable tablets
• Enteric-coated
• Destruction by gastric acid
• Stomach irritation
• Extended release
• Overdosing
• Injections

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Drug Administration
Flush tubes with water before and after
giving meds

Administer medication separately, flush

well between doses

Do not

• Mix a medication with another medication

• Mix any medications with the feeding formula
• Add medications in the feeding bag
• Reclamp the tube without flushing it

Systems with medication port are

recommended
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 Drug-nutrient Interactions
Drug Recommended Action
Ciprofloxacin  Stop feed 1 h before & 2 h after
 Consider higher dose or IV

Flucloxacillin  Stop feed ½ -1 h before & after

Levofloxacin  Stop feed 2 h before & 4 h after
Penicillin V  Stop feed 1 h before & 2 h after
Rifampicin  Stop feed ½ h before & 1 h after
Warfarin  Monitor INR
 Avoid feed with >75-80 mg Vit K/1000 kcal

Phenytoin  Stop feed 2 h before & after

 Give as a single daily dose

Sucralfate  Stop feed 1 h before & after

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 Summary
Nutritional assessments/goals
• Requirements
• Constraints on nutrient delivery (protein, glucose, fat, fluid)
Location, size of feeding tube

Identify the appropriate enteral formula to meet individual needs

• Select formula and volume needed

Method of administration

Avoid tube feeding complications

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