Isabella Carter
Enteral tube feeding is used when oral high-calorie diets and supplements are ineffective. It can be delivered via nasogastric tubes, gastrostomy tubes, and jejunostomy tubes. The osmolality of enteral formulas varies widely, but almost all are nutritionally complete when administered in the correct quantities. Isotonic formulas have an osmolality similar to normal body fluids, at around 300 mOsm/L. Complete or standard formulas are made of complex proteins, fats, carbohydrates, vitamins, and minerals. They are designed for patients with normal digestion who are unable to orally consume adequate calories and nutrients. These formulas have low osmolality, are usually lactose-free, and are palatable and easy to use.
| Characteristics | Values |
|---|---|
| Osmolality | Approximately 300 mOsm/L |
| Formula Volume for Infants | Calculated based on protein needs |
| Additional Energy Sources | Fat and/or calories |
| Formula Volume for Children | Calculated based on energy needs, with supplements added for other nutrients |
| Tube Feeding Types | Nasogastric tubes, gastrostomy tubes, jejunostomy tubes, and percutaneous jejunostomy (PEJ) |
| Tube Feeding Suitability | Nasogastric tubes for short-term support; gastrostomy tubes for long-term nutrition; jejunostomy tubes for patients with severe GERD |
| Formula Types | Standard (complete protein and long-chain fat), calorically dense (1.5–2.0 kcal/ml), predigested, or elemental |
| Formula Advantages | Nutritionally complete, low osmolality, lactose-free, palatable, easy to use, sterile, and with added fiber |
| Formula Tolerance | Well tolerated, with no reported carbohydrate malabsorption in healthy subjects |
| Possible Complications | Gastroesophageal reflux, formula intolerance, and hyperglycemia |
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What You'll Learn
- Isotonic formulas have an osmolality similar to normal body fluids, aiding tolerance
- Complete formulas are nutritionally whole, with low osmolality, and are usually lactose-free
- Elemental formulas are predigested, requiring little digestion, and minimising bile and pancreatic secretions
- Tube feeding is used when oral diets and supplements are ineffective, improving nutrition and respiration
- Gastrostomy tubes are better for long-term feeding, while nasogastric tubes are for short-term support
Isotonic formulas have an osmolality similar to normal body fluids, aiding tolerance
Osmolality and osmolarity are units of solute concentration that are often used in reference to biochemistry and body fluids. They are related to the tonicity of the formulation. Tonicity is a measure of the effective osmotic pressure gradient, defined by the water potential of two solutions. Osmolarity and osmolality are important clinical issues, as if the tonicity is too far from isotonic, certain products will cause stinging on application. For example, ophthalmic solutions and suspensions.
Isotonic formulas have an osmolality similar to normal body fluids, which is approximately 300 mOsm/L. This is considered isotonic as it falls within the range of 300-312 mOsm/L, with hypertonic solutions having a measurement of over 312 mOsm/L and hypotonic solutions measuring under 300 mOsm/L. Isotonic solutions are desirable for certain routes of administration, such as intraspinal, intraocular, or into any part of the brain.
Isotonic formulas are designed to alleviate gastrointestinal issues such as diarrhoea, nausea, cramping, and distention. They are easily tolerated by most children and are often used in pediatric enteral feeding formulas. Isotonic solutions do not cause cells to shrink or swell, as there is no osmotic stimulus for water movement. This means the remaining body fluids are unchanged in tonicity.
The osmolality of a formula has a direct influence on the gastrointestinal (GI) side effects that occur with enteral feeding. Therefore, it is important to maintain an isotonic osmolality in tube-feeding formulas to aid tolerance and prevent adverse effects.
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Complete formulas are nutritionally whole, with low osmolality, and are usually lactose-free
Tube feeding formulas are available in a variety of commercial forms. Complete formulas are nutritionally whole and are designed for patients with normal digestion who are unable to orally consume sufficient calories and nutrients. They are made of complex proteins, fats, carbohydrates, vitamins, and minerals.
The advantages of complete formulas are that they have low osmolality, are usually lactose-free, palatable, easy to use, and sterile. Some complete formulas also have added fibre to promote regular bowel movements.
Lactose-free formulas are suitable for babies and young children who are intolerant to lactose or sucrose or who are experiencing symptoms such as diarrhoea, abdominal pain, or wind caused by temporary lactose intolerance. They are designed to match the nutritional profile of breast milk and standard formulas as closely as possible. They should contain all essential nutrients, including calcium and vitamin D, which are crucial for bone development.
Isotonic formulas are another option for tube feeding. The osmolality of full-strength isotonic formulas is similar to the osmolality of normal body fluids, at approximately 300 mOsm/L. For infants, the volume of formula is determined by calculating protein requirements. If additional energy is needed, fat and/or calories can be added, and water must be provided to meet fluid requirements.
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Elemental formulas are predigested, requiring little digestion, and minimising bile and pancreatic secretions
A variety of commercial formulas are available for tube feeding. For most children between the ages of 1 and 10, pediatric enteral formulas such as Pediasure, Resource, or Kindercal are designed to meet their nutritional requirements. These formulas are complete and balanced, providing 100% of the DRI for vitamins and minerals. They are also isotonic, making them easily tolerated by most children.
For individuals who cannot orally consume adequate calories and nutrients, complete or standard formulas are available from various companies. These formulas are nutritionally complete and made of complex proteins, fats, carbohydrates, vitamins, and minerals. They are designed for individuals with normal digestion and offer advantages such as low osmolality, lactose-free content, palatability, ease of use, and sterility. Some formulas also include added fibre to promote regular bowel movements.
Elemental formulas are a type of complete formula that is made from predigested nutrients. They contain amino acids, hydrolyzed protein, carbohydrates, and fats in the form of medium-chain triglycerides or essential fatty acids. These formulas offer several benefits, including minimal stimulation of bile and pancreatic secretions, low stool volume, and ease of digestion. Since elemental formulas are predigested, they require little to no further digestion, making them suitable for individuals with impaired digestive function.
The advantage of predigested elemental formulas is particularly relevant in the context of pancreatic and bile function. The pancreas produces digestive juices, including pancreatic enzymes such as lipase, protease, trypsin, and chymotrypsin, which are crucial for breaking down fats and proteins in the small intestine. However, in certain conditions like cystic fibrosis or pancreatitis, the pancreatic ducts can become clogged, preventing the flow of these digestive juices and impairing digestion. Similarly, bile, produced by the liver and stored in the gallbladder, is essential for emulsifying hydrophobic lipids in the small intestine, facilitating the action of pancreatic lipase. Obstruction of the common bile duct, as seen in cholelithiasis (gallstones), can disrupt bile flow and affect digestion.
By using predigested elemental formulas, the stimulation of bile and pancreatic secretions is minimised, reducing the risk of complications associated with impaired bile or pancreatic function. This makes elemental formulas a suitable option for individuals with conditions affecting bile or pancreatic secretion, ensuring adequate nutrition without placing additional strain on these vital digestive processes.
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Tube feeding is used when oral diets and supplements are ineffective, improving nutrition and respiration
Tube feeding is a method of delivering nutrition directly into an individual's digestive system when they are unable to consume adequate calories and nutrients orally. This method, also known as enteral nutrition, is often recommended for individuals with conditions that make it difficult to chew or swallow, such as Parkinson's disease. It is also utilised for those with serious illnesses, such as cancer, who may lack the strength to consume sufficient nutrition orally.
Tube feeding involves inserting a flexible plastic tube into the nose, mouth, stomach, or intestines, depending on the individual's situation. The tube delivers a liquid nutrition formula composed of protein, carbohydrates, fats, vitamins, minerals, and other micronutrients tailored to the patient's needs. This formula can be delivered using a pump or syringe, or it may rely on gravity.
Tube feeding is particularly useful when oral diets and supplements are ineffective in meeting nutritional requirements. In such cases, tube feeding ensures that the body receives the necessary nutrients for maintaining health and supporting recovery. This is crucial for individuals who are unconscious, in a coma, or recovering from surgery, as their ability to consume food orally may be severely compromised.
Additionally, tube feeding can improve respiration by reducing the risk of aspiration, which is the inhalation of food or liquid into the lungs. This is especially relevant for individuals with swallowing difficulties, as tube feeding bypasses the mouth and taste buds, allowing for safe and direct delivery of nutrition to the digestive system.
The transition from tube feeding to oral feeding should be done gradually and under the guidance of healthcare professionals. This process may involve intermittent tube feeding, where the feeding pump is used for short periods, with breaks in between for oral intake. A speech-language pathologist may also be consulted to evaluate the individual's swallowing ability and determine the safety of oral intake.
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Gastrostomy tubes are better for long-term feeding, while nasogastric tubes are for short-term support
A nasogastric tube is a thin, flexible plastic tube that is inserted through the nose, down the throat, and into the stomach. It is used for short-term feeding, usually for up to six weeks, and can also deliver medications and draw substances out of the stomach, such as poisons or stomach contents to relieve pressure. Nasogastric tubes are useful in emergencies and for patients who need temporary nutritional support, but they are not designed for long-term use.
Gastrostomy tubes, on the other hand, are placed directly into the stomach or small intestine through a small incision in the abdomen and require minor surgery. They are safer for long-term feeding and are recommended if enteral nutrition is required beyond six weeks. Gastrostomy tubes are also better suited for delivering viscous, home-blended formulas, as these may clog a narrow nasogastric tube.
The decision to use a gastrostomy tube or a nasogastric tube depends on the patient's individual needs and the expected duration of tube feeding. For short-term nutritional support, medication administration, or gastric suctioning, a nasogastric tube is often the preferred choice. It can be quickly and safely installed in most people without the need for surgery, which is especially beneficial in urgent situations.
However, if long-term enteral nutrition is required, a gastrostomy tube is a safer and more sustainable option. It eliminates the risk of complications associated with prolonged nasogastric tube usage and ensures a more comfortable and permanent feeding solution. Additionally, gastrostomy tubes are better equipped to handle thicker, home-blended formulas, which may be more cost-effective for long-term feeding.
The composition of the feeding formula also plays a role in tube selection. Isotonic formulas, which have a similar osmolality to normal body fluids, are well-tolerated and suitable for tube feeding. Complete formulas, which are nutritionally balanced, tend to have low osmolality and are generally lactose-free, palatable, and easy to use. These formulas are suitable for patients with normal digestion who cannot orally consume adequate calories and nutrients.
In summary, gastrostomy tubes are indeed better suited for long-term feeding due to their safety, comfort, and compatibility with various formulas. Nasogastric tubes, with their ease of installation and versatility, are ideal for short-term nutritional support, medication delivery, and gastric suctioning.
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Frequently asked questions
Osmolality is the measure of the concentration of a solution, in this case, enteral feeding formulas. It is measured in mOsm/L or mOsm/Kg of water.
Osmolality above 300 mOsm/L is considered high. The normal osmolality of body fluids is around 300 mOsm/L, so formulas with higher osmolality may cause intolerance in some patients.
High-osmolality formulas are usually calorically dense, providing 1.5-2.0 kcal/ml. This ensures that patients receive adequate energy from their feedings.
High-osmolality formulas may be suitable for patients who require supplemental feeding for longer than 4 weeks, especially those with gastric resection, gastric dysmotility, or a high risk of aspiration. These formulas can provide sufficient energy and nutrition for patients who are unable to orally consume adequate calories.
