Guidelines for planning home enteral feedings

Tube feeding at home is a viable option for maintaining optimum nutriture when oral intake is inadequate or impossible. Qualifying patients and their caretakers can be instructed in formula preparation, feeding administration, and related care techniques. Extra hospital support systems, including insurance agencies, home medical suppliers, and public health nurses, are available to facilitate the transition from hospital to home care. For patients who require enteral nutrition but not acute or extended medical care, home tube feeding can promote a less disrupted family unit, improved quality of life, and diminished health care costs.     

Efficacy of voluntary nasogastric tube feeding in female inpatients with anorexia nervosa

BACKGROUND: This investigation assesses the efficacy of a voluntary nasogastric tube feeding protocol on the weight gain of patients with anorexia nervosa, tube feeding's effect on recovery from the psychologic aspects of anorexia, patient satisfaction with treatment, and medical complications. METHODS: The study included a nonrandomized retrospective review of 381 female inpatients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of anorexia nervosa, both subtypes. A total of 155 patients received tube feeding and oral refeeding; 226 received oral refeeding alone. Recovery from the psychologic aspects of anorexia was measured by the change in Eating Disorder Inventory-2 scores between admission and discharge. Patient satisfaction with treatment was measured with a patient satisfaction questionnaire completed at discharge. Repeated measures and multivariate analyses were performed. RESULTS: When severity-of-illness and caloric intake differences between patients with and without tube feeding were controlled, patients who received tube feeding gained significantly more weight per treatment week than those who received oral kilocalories alone. Patients who received tube feeding for at least one-half their length of stay gained 1 kg/week versus 0.77 kg/week for patients receiving oral refeeding alone. Tube-fed patients evidenced no differences in recovery from anorexia's psychologic aspects, satisfaction with treatment, or medical complication frequency. CONCLUSIONS: In residential psychiatric treatment settings in which intensive therapeutic interventions and appropriate medical monitoring can manage potential psychologic and medical risks, tube feeding's weight gain benefits may be a viable and safe option in treating anorexia.     

The FOOD Trial Collaboration: nutritional supplementation strategies and acute stroke outcome

Results from three large, randomized, multicenter FOOD (Feed or Ordinary Food) Collaboration Trials showed no reduction in death or poor outcome with routine oral protein-energy supplementation of stroke patients who were primarily well nourished upon admission to the hospital. Nasogastric tube feeding was favored over percutaneous endoscopic gastrostomy as the early route of feeding in dysphagic stroke patients.     

Outcomes of Infants With Home Tube Feeding: Comparing Nasogastric vs Gastrostomy Tubes

Background: The aim of this study was to determine the tube‐related complications and feeding outcomes of infants discharged home from the neonatal intensive care unit (NICU) with nasogastric (NG) tube feeding or gastrostomy (G‐tube) feeding. Materials and Methods: We performed a chart review of 335 infants discharged from our NICU with home NG tube or G‐tube feeding between January 2009 and December 2013. The primary outcome was the incidence of feeding tube–related complications requiring emergency department (ED) visits, hospitalizations, or deaths. Secondary outcome was feeding status at 6 months postdischarge. Univariate and multivariate analyses were conducted. Results: There were 322 infants discharged with home enteral tube feeding (NG tube, n = 84; G‐tube, n = 238), with available outpatient data for the 6‐month postdischarge period. A total of 115 ED visits, 28 hospitalizations, and 2 deaths were due to a tube‐related complication. The incidence of tube‐related complications requiring an ED visit was significantly higher in the G‐tube group compared with the NG tube group (33.6% vs 9.5%, P < .001). Two patients died due to a G‐tube–related complication. By 6 months postdischarge, full oral feeding was achieved in 71.4% of infants in the NG tube group compared with 19.3% in the G‐tube group (P < .001). Type of feeding tube and percentage of oral feeding at discharge were significantly associated with continued tube feeding at 6 months postdischarge. Conclusion: Home NG tube feeding is associated with fewer ED visits for tube‐related complications compared with home G‐tube feeding. Some infants could benefit from a trial home NG tube feeding.     

锌缺乏对初生肉仔鸡血清瘦素、下丘脑AMPK活性、神经肽Y及其mRNA水平的影响

目的研究锌缺乏对初生肉仔鸡血清和下丘脑的一些摄食相关因子的影响。方法288只1d龄AA鸡公雏按体重随机分为3组:锌缺乏组(10.1mg/kgZn)、正常组(41.8mg/kgZn)和配对组。每组8个重复,每个重复12只鸡。结果锌缺乏显著降低了肉仔鸡出壳后前2w的日增重和饲料转化率,且与日龄相关的方式影响平均日采食量(ADFI),即对前2d的ADFI无显著影响,从D3起出现显著降低。锌缺乏显著降低了血清锌、葡萄糖和瘦素水平,显著提高了下丘脑神经肽Y水平及其基因表达,而对血清胰岛素、胰高血糖素、胰岛素/胰高血糖素摩尔比及下丘脑腺苷一磷酸激活的蛋白激酶(AMPK)活性无显著影响。结论锌缺乏可使一些摄食调节因子水平及基因表达发生变化,但变化趋势与其摄食调节功能及动物采食量降低结果不相符,机制尚需研究。     

A randomized trial on the efficacy of a 2-month tube feeding regimen in anorexia nervosa: A 1-year follow-up study

BACKGROUND & AIMS: Despite the high mortality rate in malnourished anorexia nervosa (AN) patients, very few trials have prospectively studied the efficacy of tube feeding. METHODS: This open prospective study was conducted in malnourished AN patients, who were randomized in tube feeding (n=41) or control (n=40) groups during a 2-month period. Thereafter, body weight, body mass gain, energy intake, eating behavior and relapse rates were compared during a 1-year follow-up, using paired Student t-test and ANOVA. RESULTS: At the end of the 2-months period, weight gain was 39% higher in the tube feeding group than in the control group (194+/-14 vs 126+/-19g/day; P<0.01). The fat-free mass gain was greater in the tube-feeding group: 109+/-14 vs 61+/-17g/day (P<0.01). Energy intake was higher in the tube feeding group than in the control group (P<0.05), as well as the decrease in bingeing episodes (P<0.01). Most patients thought that CEN improved their eating disorder. After discharge, the relapse-free period was longer in the CEN group than in the control one: 34.3+/-8.2 weeks vs 26.8+/-7.5 weeks (P<0.05). CONCLUSION: CEN is helpful in malnourished AN patients for weight restoration, without hindrance on the eating behavior therapy nor inducing a more rapid relapse.     

Tube feeding in dementia: a controversial practice

Primary care providers for patients with endstage dementia are often confronted with difficult tube feeding decisions. Decreased food intake occurs with increasing age which can be worsened by dementia. Often the solution is to provide food by way of tube feeding. However, no improvement in survival has been found with the use of tube feeding in anorexia caused by endstage dementia. Several complications involving pulmonary, gastrointestinal and renal systems are common. Ethical and legal considerations weigh tube feeding as basic care versus a medical treatment. Nursing home and state regulations designed to prevent abuse challenge patient's rights to refuse tube feeding as a medical treatment. This review discusses the complications and issues surrounding the use of this practice in end stage dementia.     

Fat‐Modified Enteral Formula Improves Feeding Tolerance in Critically Ill Patients: A Multicenter,Single‐Blind,Randomized Controlled Trial

Background: Improvement of fat digestion and absorption was supposed to relieve feeding intolerance. This trial aimed to evaluate the effect of a fat‐modified enteral formula on feeding tolerance in critically ill patients. Materials and Methods: This trial was conducted in 7 hospitals in China. In total, 144 intensive care unit (ICU) patients with estimated need of enteral nutrition (EN) for at least 5 days were randomly given fat‐modified enteral formula containing medium‐chain triglycerides (MCT), carnitine, and taurine (interventional feed group, n = 71) or standard enteral formula (control feed group, n = 73). EN intake, feeding intolerance (diarrhea, vomiting, gastric retention, and abdominal distension) and outcomes (mechanical ventilator‐free days of 28 days, length of ICU stay, length of hospital stay, and in‐hospital mortality) were collected. Results: Daily calories and protein intake were increased in the interventional feed group compared with the control feed group (P < .01). Total incidence of feeding intolerance was 42.3% in the interventional feed group and 65.7% in the control feed group (P < .001). Daily incidence of feeding intolerance was 11.3%, 18.3%, 14.1%, 25.4%, and 26.1% in the interventional feed group and 31.5%, 32.9%, 34.2%, 34.2%, and 30.4% in the control feed group from study days 1–5 (P = .0083). Incidence of feeding intolerance without abdominal distention was 32.9% in the interventional feed group and 49.3% in the control feed group (P = .047), while the incidence of abdominal distension was 26.8% in the interventional feed group and 43.8% in the control feed group (P = .03). No significant differences existed in outcomes between the 2 groups. Conclusions: The fat‐modified enteral formula containing MCT, carnitine, and taurine may improve feeding tolerance in critically ill patients.     

The impact of implementing an enteral tube feeding protocol on caloric and protein delivery in intensive care unit patients.

BACKGROUND: The purpose of this study was to determine the effect of an enteral tube feeding protocol on caloric and protein delivery to intensive care unit (ICU) patients. METHODS: This prospective study consisted of 2 phases: before and after the implementation on an enteral-feeding protocol. The following data were collected: demographics, Acute Physiology and Chronic Health Evaluation II score and Simplified Acute Physiology Score II, caloric and protein requirements, the location of the feeding tube tip, and prokinetic agents use. The primary endpoint was caloric and protein intake as a percentage of the requirement. Secondary endpoints were gastric residuals >150 mL, vomiting episodes, ICU and hospital lengths of stay, mechanical ventilation duration, and ICU and hospital mortality. RESULTS: There were no significant differences between the control (n = 100) and protocol groups (n = 103) in baseline characteristics. The protocol was associated with significant improvement in the 7-day average of caloric intake/requirement (53.9 +/- 2.3% vs 64.5 +/- 2.2%, p = .001) and protein intake/requirement (56.7 +/- 2.6% vs 67.4% +/- 2.7%, p = .005). Caloric and protein intake improved whether the patient was receiving prokinetic agent or not. There was a trend toward lower gastric residual volumes and vomiting episodes in the protocol group. Patients receiving gastric feeding showed significant improvement in caloric intake to levels comparable to patients with postpyloric feeding. CONCLUSIONS: Enteral tube feeding protocol is effective in improving feeding delivery in ICU patients independent of prokinetic agent use. Protocol for enteral tube feeding should be considered in the management of ICU patients, given the positive impact of this nonpharmacologic, non-interventional tool.     

An audit designed to assess the need for planned pretreatment PEG placement in patients with stage III & stage IV oral cancer

Background: Nutritional support is a crucial and challenging part of treatment for patients with oral cancer. The aim of this audit was to assess the need for planned pretreatment percutaneous endoscopic gastrostomy (PEG) placement in this group of patients and to assess diet consistency as a predictor of poor outcomes. Method: This was a retrospective study of 77 consecutive patients with stage III and IV squamous cell carcinoma of the oral cavity treated by radical surgery and post‐operative radiotherapy between January 1999 and December 2001. Information was taken from dietitians’ records. Patients were divided into two groups according to survival: group 1 (40 patients) comprised nonsurvivors and group 2 (37 patients), survivors. All patients were enterally fed post‐operatively. After approximately 10 days, swallowing was assessed and, if deemed competent, patients progressed to a fluid diet. Tube feeding was gradually reduced and then stopped when oral nutrition was sufficient to maintain weight. Patients progressed to soft diet as they were able. During radiotherapy, liquid diet or tube feeding was instigated as required. Results: In group 1, 65% required tube feeding for less than 30 days (mean 17 days), 20% for 31–100 days (mean 51 days) and 15% for over 100 days (mean 231 days). The overall mean length of tube feeding was 97 days. Thirty‐eight per cent of nonsurvivors developed recurrence and went on to subsequent operations necessitating further tube feeding for an average of 129 days. In group 2, 70% were tube fed for less than 30 days (mean 11 days), 14% for between 31–100 days (mean 43 days), and 17% for more than 100 days. The overall mean length of tube feeding was 72 days. The dietary consistency of nonsurvivors was worse than survivors throughout treatment. At first presentation, only 37% of nonsurvivors managed a normal diet, 8% managed a near normal diet and 3% required tube feeding, whereas 48% of survivors managed a normal diet and 16% a near normal diet. At 1 year, there was a significant difference between the two groups’ diets. No patients in group 1 managed a normal or near normal diet, whilst 62% required tube feeding. In group 2, 12 and 32% managed a normal and near normal diet, respectively and only 9% required or wished to remain on tube feeding to supplement their diet. Five per cent of patients in this group remained nil by mouth due to fistula. Conclusion: Deciding whether a patient has a naso‐gastric tube, PEG or radiologically inserted gastrostomy tube placed can be a difficult decision. However, a gastrostomy should be considered prior to treatment in patients whose diet is of poor consistency at presentation or who have an inadequate oral intake to maintain or increase weight and in those with a fistula, expected slow recovery of swallowing function, for example, pharyngeal tumour or undergoing brachytherapy or chemoradiotherapy.     

Pressure sores and tube feeding in patients with a fracture of the hip: a randomized clinical trial

Pressure sores are a frequent problem, especially in elderly patients. Nutritional status may influence the incidence, progression and severity of pressure sores, data, however, are contradictory (1). The purpose of this study was to determine the effect of supplemental feeding on the nutritional status and the development and severity of pressure sores. The effect of supplemental feeding overnight (tube +) on patients with a fracture of the hip and a high pressure-sore risk score, was studied in a randomized clinical trial. The control group (tube -) had no supplemental feeding. After informed consent, 140 patients were randomized, and 129 of these took part in the trial (62 tube +, and 67 tube -). Protein and energy intake, haemoglobin, serum albumin, total serum protein and pressure-sore grade were measured at admission and after 1 and 2 weeks. Of the 62 patients randomized for tube feeding (tube +), only 25 tolerated their tube for more than 1 week and 16 for 2 weeks. Nevertheless, energy and protein intake was significantly higher in the tube + group (P < 0.001). This, however, did not significantly influence total serum protein, serum albumin and development and severity of pressure sores after 1 and 2 weeks. Comparison of the actually tube fed group (n=25 at 1 week, n = 16 at 2 weeks) and the control group showed a 2-3 times higher protein and energy intake (P < 0.0001), and a significantly higher total serum protein and serum albumin after 1 and 2 weeks in the actually tube fed group (all P < 0.001). Pressure-sore development and severity were not significantly influenced in the actually tube fed group. We conclude that we were not able to show a significant decrease in development and severity of pressure sores, because the nasogastric tube for supplemental feeding was not well tolerated in this patient group. Nevertheless, tube feeding overnight does result in a significant higher protein and energy intake, and has a significant effect on nutritional status in the actually tube-fed group. Other means of supplemental feeding will have to be used in order to answer the question of whether supplemental feeding can decrease development and severity of pressure sores.     

Effect of ghrelin on feed intake and metabolites in lambs

The objective was to determine the effect of ghrelin on feed intake (FI) and energy metabolites in lambs. Sixteen lambs were randomly assigned to either a treatment (n=8) or a control group (n=8). Lambs in the treated group received ghrelin intramuscularly (5 μg/kg of body weight [BW]) and the control group received an equivalent volume of saline 3h after the morning feeding. Treatments were administered for 4 days. Feed intake was measured daily. Serum samples were collected on days 1, 3, 4, and 5 of the protocol, and levels of ?-hydroxybutyrate (BHB), insulin, and glucose were determined. Lambs treated with ghrelin showed a tendency for lower concentrations of serum insulin on day 5 and showed a tendency for increased FI on day 3. Concentrations of serum BHB and glucose were not different between treated and control lambs. It was concluded that ghrelin did barely affect FI and energy metabolites of lambs treated daily over a period of 4 days.     

Audit of nasogastric feeding practice at two acute hospitals: is early enteral feeding associated with reduced mortality and hospital stay?

Hospital malnutrition is common and thought to be a cause of morbidity and mortality. Nasogastric (NG) feeding is the most commonly used invasive technique of nutritional support used at the acute Bolton hospitals. A prospective observational study was initiated to audit the use of NG feeding in patients in whom oral energy intake was virtually nil at the time of commencement of tube feeding.
Patients who were starved for 0–5 days prior to commencement of NG feeding had a lower mortality than patients starved >5 days (a) during their feeding episode and (b) during their hospital stay subsequent to cessation of oral intake. The difference in mortality was not related to age or sex. However, in patients of <65 years mortality was only non-significantly higher in patients starved >5 days compared with those starved 0–5 days. In patients of >64 years the difference in mortality between those starved 0–5 vs. >5 days remained significant: (a) during the feeding episode and (b) during the hospital stay. The fact that starvation has a disproportionate effect on mortality in old patients may indicate that older patients are more susceptible to starvation. In surviving patients there was a positive correlation between the length of starvation and: (a) the duration of the NG feeding episode and (b) hospital stay subsequent to cessation of oral intake. Disease severity was not measured therefore its effect on outcome and speed of rehabilitation cannot be excluded.
The study indicates a possible relationship between the duration of starvation and mortality, the duration of NG feeding and the length of hospital stay. Definitive testing of this association would require a prospective trial which controls for age and disease severity.     

Dehydration due to gastro-enteritis in children

Gastroenteritis is the commonest cause of dehydration in children. Infants and young children dehydrate more easily than adults if fluid intake is insufficient or fluid loss too high because of the combination of a large extracellular volume, a large insensible loss and a mediocre concentrating capacity of the kidney. Fluid loss due to gastroenteritis is often accompanied by electrolyte and acid-base disturbances. Oral rehydration with oral rehydration salts (ORS) is nearly always possible. Re-evaluation after 6 hours is advised especially in young children. Early (< 6-24 hours) resumption of feeding is important. If rehydration with frequent small amounts of ORS at home fails, continuous nasogastric tube feeding in the hospital is a good alternative. In dehydration exceeding 10% of body weight intravenous rehydration is necessary.     

Anorexia nervosa: nocturnal supplementary nasogastric feeding in the community

Nocturnal supplementary nasogastric feeding in a domiciliary setting coupled with dietary counselling in 4 patients with a diagnosis of anorexia nervosa is detailed. The four patients were given nocturnal supplementary nasogastric feeds, for periods of 16 days to 12 weeks. In three of the four patients substantial weight gains of 4.3 to 11.5 kg were achieved and all four patients reported substantial increases in daily voluntary oral food intake.
We conclude that this approach may enable the patient to be managed at home and provides a basis for further psychotherapy treatment.     

养老院管饲老年人膳食及营养状况调查

目的 :了解养老院管饲老年人膳食与营养状况。方法 :自行设计调查问卷,对管饲者基本资料和膳食进行调查,采用简易营养评价调查表对其进行营养评价。结果 :MNA评分中位数为13,营养不良发生率为71.1%,膳食热量摄入较低,且营养不良者、潜在营养风险者膳食热量摄入显著低于营养良好者,各营养状态下蛋白质摄入量及蛋白供能比无显著差别,膳食中维生素A、B2、C、钾、钙、镁、铁、硒、膳食纤维摄入量均不到推荐摄入量的60%,膳食维生素E及钠摄入量为推荐量的200%以上。结论 :养老院管饲者营养不良高发,膳食摄入不合理,迫切需要营养支持小组对相关人员进行健康教育,提高养老院管饲者的整体健康水平。     

Post-oesophagectomy early enteral nutrition via a needle catheter jejunostomy: 8-year experience at a specialist unit

BACKGROUND AND AIMS: The purpose of this study was to prospectively evaluate post-operative jejunostomy feeding in terms of nutritional, biochemical, gastrointestinal and mechanical complications in patients undergoing upper gastrointestinal surgery for oesophageal malignancy. METHODS: The study included 205 consecutive patients who underwent oesophagectomy for malignancy. All patients had a needle catheter jejunostomy (NCJ) inserted at the conclusion of laparotomy. Patients were followed prospectively to record nutritional intake, type of feed administered, rate progression, tolerance, weight changes and complications either mechanical, biochemical or gastrointestinal. RESULTS: Ninety-two per cent of patients were successfully fed exclusively by NCJ post-oesophagectomy, and 94% of patients were tolerating a maintenance regimen of 2000 ml feed over 20 h by day 2 post-operatively. Patients spent a median of 15 days on jejunostomy feeding post-surgery (range 2-112 days); however, 26% required prolonged jejunostomy feeding (>20 days). Minor gastrointestinal complications were effectively managed by slowing the rate of infusion, or administering medication. Three (1.4%) serious complications of jejunostomy feeding occurred, all requiring re-laparotomy, one resulting in death. NCJ feeding was extremely effective in preventing severe post-operative weight loss in the majority of oesophagectomy patients post-op. However, oral intake was generally poor at discharge with only 65% of requirements being met orally. Sixteen patients (8%) patients required home jejunostomy feeding. By the first post-operative month, a further 6% (12) patients were recommenced on jejunostomy feeding. CONCLUSION: NCJ feeding is an effective method of providing nutritional support post-oesophagectomy, and allows home support for the subset that fail to thrive. Serious complications, most usually intestinal ischaemia or intractable diarrhoea, are rare.     

Early postoperative jejunostomy feeding with an immune modulating diet in patients undergoing resectional surgery for upper gastrointestinal cancer: a prospective, randomized, controlled, double-blind study

BACKGROUND: The provision of perioperative immune modulating enteral feeds after major surgery may result in reduced infective complications, but meta-analyses have not demonstrated a survival advantage. The aim of this study was to determine whether early postoperative immune modulating jejunostomy feeding results in reduced infective complications in patients undergoing resectional surgery for upper gastrointestinal cancer. METHODS: A total of 120 patients undergoing resection for cancers of the pancreas, oesophagus and stomach were randomized in a double-blind manner to receive jejunostomy feeding with an immune modulating diet (Stresson-Group A) or an isonitrogenous, isocaloric feed (1250 Calories and 75 g protein/l--Nutrison High Protein-Group B) for 10-15 days. Feeding was commenced 4h postoperatively and continued for 20 h/day. The target volume (ml/h) was 25 on day 0, 50 on day 1, and 75 thereafter. Outcome measures included complications, hospital stay and mortality. RESULTS: A total of 108 patients (54 in each group) were analysed. Feed delivery, although less than targeted, was similar in both groups. There were 6 (11%) deaths in each group. Median (IQR) postoperative hospital stay was 14.5 (12-23) days in Group A and 17.5 (13-23) days in Group B (P=0.48). A total of 24 (44%) patients in each group had infective complications (P=1.0). A total of 21 (39%) patients in Group A and 28 (52%) in Group B had non-infective complications (P=0.18). Jejunostomy-related complications occurred in 26 (48%) patients in Group A and 30 (56%) in Group B (P=0.3). CONCLUSION: Early postoperative feeding with an immune modulating diet conferred no outcome advantage when compared with a standard feed.     

Attenuation of stress-induced anorexia in brown trout (Salmo trutta) by pre-treatment with dietary l-tryptophan

The general consensus is that brain serotonin (5-HT) inhibits feed intake in teleost fishes and other vertebrates. Dietary manipulations with the 5-HT precursor tryptophan (TRP) have, however, yielded contradictory effects on feed intake, while studies of the endocrine response to stress indicate that the effects of TRP-enriched feed are context dependent. A characteristic behavioural response to stress is a reduction in feed intake, and in the present study we investigated whether pre-treatment with TRP-enriched feed affected stress-induced changes in feeding behaviour in brown trout (Salmo trutta). After acclimatisation in observation aquaria, isolated fish were fed control or TRP-supplemented feed for 7 d, whereupon they were transferred to a novel environment, in which all fish were fed control feed. Transfer to a new environment resulted in decreased feeding in both the TRP pre-treated and the control-treated group. However, this decrease was more pronounced in the control-treated group. Previous experiments have concluded that stimulation of brain 5-HT systems by TRP enhancement does not affect feed intake in salmonid fishes, but in these studies food intake was observed in unstressed animals only. The present study suggests that pre-treatment with dietary TRP attenuates stress-induced anorexia. Hence, it appears that the effect of dietary manipulations of TRP on feeding behaviour is dependent on the stress levels experienced by experimental animals. These behavioural data are discussed in the context of the involvement of 5-HT in appetite regulation.