Enteral feeding

In this review, topics with scientific strength, topical interest, and controversy were selected. Over the past 50 years, malnutrition has become increasingly recognized as a cause of increased morbidity and mortality in hospital patients. From 1970 to 1980, parenteral nutrition was advocated as the most appropriate form of nutritional therapy for hospital patients. Since then, parenteral nutrition has been replaced by enteral nutrition as the best way of delivering nutrients to hospital patients. The timing of enteral nutrition has been debated. Should it be instituted early, within the first 24 hours? In addition, enteral nutrition containing immune-enhancing nutrients such as arginine, omega-3 fatty acids, glutamine, and nucleotides has been advocated for critically ill patients. The relative merits of enteral versus total parenteral nutrition continue to be debated. Questions about possible complications related to enteral nutrition have been raised. Patients are at risk of nosocomial pneumonia from aspiration and at risk of bowel ischemia because enteral nutrition increases intestinal oxygen consumption. Steroids are often used to treat Crohn disease, but because of undesirable side effects, various techniques have been used to reduce steroid dependency. Enteral nutrition has been advocated as a way of reducing steroid dependency. Finally, enteral nutrition is routinely used to feed demented patients and those in a vegetative state. It is not clear whether this practice alters outcome or quality of life.     

Person-centered feeding care: A protocol to re-introduce oral feeding for nursing home patients with tube feeding

Background

Although the literature on nursing home (NH) patients with tube feeding (TF) has focused primarily on the continuation vs. discontinuation of TF, the reassessment of these patients for oral feeding has been understudied. Re-assessing patients for oral feeding may be better received by families and NH staff than approaches focused on stopping TF, and may provide an opportunity to address TF in less cognitively impaired patients as well as those with end-stage conditions. However, the literature contains little guidance on a systematic interdisciplinary team approach to the oral feeding reassessment of patients with TF, who are admitted to NHs.

Methods

This project had two parts that were conducted in one 170-bed intermediate/skilled, Medicare-certified NH in Honolulu, Hawai‘i. Part 1 consisted of a retrospective observational study of characteristics of TF patients versus non-tube fed patients at NH admission (2003-2006) and longitudinal follow-up (through death or 6/30/2011) with usual care of the TF patients for outcomes of: feeding and swallowing reassessment, goals of care reassessment, feeding status (TF and/or per oral (PO) feedings), and hospice status. Part 2 involved the development of an interdisciplinary TF reassessment protocol through working group discussions and a pilot test of the protocol on a new set of patients admitted with TF from 2011-2014.

Results

Part 1: Of 238 admitted patients, 13.4% (32/238) had TF. Prior stroke and lack of DNR status was associated with increased likelihood of TF. Of the 32 patients with TF at NH admission, 15 could communicate and interact (mild, moderate or no cognitive impairment with prior stroke or pneumonia); while 17 were nonverbal and/or bedbound patients (advanced cognitive impairment or terminal disease). In the more cognitively intact group, 9/15 (60%) were never reassessed for tolerance of oral diets and 10/15 (66.7%) remained with TF without any oral feeding until death. Of the end-stage group, 13/17 (76.5%) did not have goals of care reassessed and remained with TF without oral feeding until death. Part 2: The protocol pilot project included all TF patients admitted to the facility in 2011-2014 (N=33). Of those who were more cognitively intact (n=22), 21/22 (95.5%) had swallowing reassessed, 11/22 (50%) resumed oral feedings but 11 (50%) failed reassessment and continued exclusive TF. Of those with end-stage disease (n=11), 100% had goals of care reassessed and 9 (81.8%) families elected individualized oral feeding (with or without TF).

Conclusion

Using findings from our retrospective study of usual care, our NH’s interdisciplinary team developed and pilot-tested a protocol that successfully reintroduced oral feedings to tube-fed NH patients who previously would not have resumed oral feeding.

     

Maternal-channelled infant feeding

Proper feeding of the mother during pregnancy and lactation -- preferably with locally available foods -- will optimize the volume and composition of breast milk (both as the sole food for the young baby and as a supplement for the transitional). This approach will avoid the economic, infective and distributive complexities of introducing cow's milk and bottle feeding unnecessarily, and will also help to retard the decline in breast feeding on a community basis.     

Enteral feeding techniques

Major technical advances in enteral nutrition include the use of erythromycin or magnetic guidance for the placement of the feeding tube into the duodenum, the development of new enteral tubes, and bedside methods to control the tube position. Percutaneous endoscopic jejunostomy is becoming a safe procedure with a high success rate. Specialized diets offer little or no clinical advantages when compared with standard polymeric diets.     

The feeding relationship

The feeding relationship is the complex of interactions that takes place between parent and child as they engage in food selection, ingestion, and regulation behaviors. Successful feeding demands a caretaker who trusts and depends on information coming from the child about timing, amount, preference, pacing, and eating capability. An appropriate feeding relationship supports a child's developmental tasks and helps the child develop positive attitudes about self and the world. It helps him/her learn to discriminate feeding cues and respond appropriately to them. It enhances the ability to consume a nutritionally adequate diet and to regulate appropriately the quantity eaten. The feeding relationship is characteristic of the overall parent-child relationship. Distortions that show up in feeding are likely to appear in other aspects of the interaction. Dietitians who intervene with feeding must be aware of the implications for the relationship. A primary objective with any feeding intervention is to increase or protect the parents' sensitivity to the child's feeding cues. If the feeding relationship is disrupted, the dietitian should consider a referral for psychosocial evaluation.     

Parent-reported feeding and feeding problems in a sample of Dutch toddlers

Little is known about the feeding behaviors and problems with feeding in toddlers. In the present questionnaire study, data were collected on the feeding behaviors and feeding problems in a relatively large (n = 422) sample of Dutch healthy toddlers (i.e. 18-36 months old) who lived at home with their parents. Results show that three meals a day was standard and the mean mealtime duration was 22 minutes. Most children eat independently and sit in a high chair. All of the generally recommended foods were consumed with a decreasing tendency across age groups. Of the total sample, 65% had at least one type of feeding problem. In seven percent of the cases feeding problems were moderate to severe and significantly related to parental concern. However, few had sought professional help. Two dimensions of feeding problems (i.e. pickiness and disturbing mealtime behavior) and three dimensions of parental management techniques could be identified. Several significant associations were found. For example, associations were found between pickiness and variables such as parental concerns, difficulties in learning to eat solid foods, and several food items. No associations were found between pickiness and mealtime duration. In conclusion, implications of the findings are discussed in relation to the treatment of severe feeding problems in toddlers with developmental disabilities.     

Use of breast feeding indicators for assessment of current feeding practices

To investigate the current breast feeding practices, a survey was conducted cross sectionally on 2000 children aged less than 2 years recruited from 6 MCH centers in Alexandria governorate. The median duration of breast feeding was 19.4 months. Only one quarter of infants were exclusively breast fed for the first four months of age with a mean duration of 2.4+2.5 months. Predominantly breast feeding rate was 0.36, while timely complementary breast feeding rate(6-9 months) was 0.66. Continued breast feeding rate(one year) was 0.73 while that for two years was 0.3. Results also indicated that 40% of infants were receiving food from a bottle with a nipple/teat regardless of whether or not the infant was breast fed. These findings implicate that promotion of breast feeding should receive priority in health programs activities.     

Enteral feeding contamination: comparison of diluents and feeding bag usage

This quasi-experimental study compared bacterial growth in enteral feeding solution in six Kangaroo feeding bags filled with enteral formula diluted with sterile water vs six of the same diluted with tap water. Feeding bags, which were on continuous pumps in patient-occupied rooms, were rinsed and refilled every 8 hours, and formula cultures were obtained at 0, 24, and 48 hr. Acceptability of cultures was based on published recommended standards. Low levels of nonpathogenic staphylococci were found in sterile water bags; high levels of bacilli and Gram negative rods were found in tap water bags. No significant differences were found in the relationship between type of formula diluent and outcomes. Type of water diluent and acceptability were not related. There was a systematic relationship between length of use and outcome; with both diluents, bags used over 24 hr became unacceptably contaminated. Further study with a larger sample is needed to determine the effects of using tap water rather than sterile water as diluent.