6 Nutrition (oral)
Enteral nutrition
Overview
Children have higher nutrient requirements per kg
bodyweight, different metabolic rates, and physiological
responses compared to adults. They have low nutritional
stores and are particularly vulnerable to growth and
nutritional problems during critical periods of development.
Major illness, operations, or trauma impose increased
metabolic demands and can rapidly exhaust nutritional
reserves.
Every effort should be made to optimise oral food intake
before beginning enteral tube feeding; this may include
change of posture, special seating, feeding equipment, oral
desensitisation, food texture changes, thickening of liquids,
increasing energy density of food, treatment of reflux or
oesophagitis, as well as using age-specific nutritional
supplements.
Enteral tube feeding has a role in both short-term
rehabilitation and long-term nutritional management in
paediatrics. It can be used as supportive therapy, in which
the enteral feed supplies a proportion of the required
nutrients, or as primary therapy, in which the enteral feed
delivers all the necessary nutrients. Most children receiving
tube feeds should also be encouraged to take oral food and
drink. Tube feeding should be considered in the following
situations:
.unsafe swallowing and risk of aspiration
.inability to consume at least 60 % of energy needs by
mouth
.total feeding time of more than 4 hours per day
.weight loss or no weight gain for a period of 3 months (less
for younger children and infants)
.weight for height (or length) less than 2 nd percentile for
age and sex
Most feeds for enteral use contain protein derived from cows’
milk or soya. Elemental feeds containing protein
hydrolysates or free amino acids can be used for children
who have diminished ability to break down protein, for
example in inflammatory bowel disease or pancreatic
insufficiency.
Even when nutritionally complete feeds are given, water
and electrolyte balance should be monitored.
Haematological and biochemical parameters should also be
monitored, particularly in the clinically unstable child. Extra
minerals (e.g. magnesium and zinc) may be needed in
patients where gastro-intestinal secretions are being lost.
Additional vitamins may also be needed.
Choosing the best formula for children depends on several
factors including: nutritional requirements, gastro-intestinal
function, underlying disease, nutrient restrictions, age, and
feed characteristics (nutritional composition, viscosity,
osmolality, availability and cost). Children have specific
dietary requirements and in many situations liquid feeds
prepared for adults are totally unsuitable and should not be
given. Expert advice from a dietician should be sought before
prescribing enteral feeds for a child.
Infant formula feeds
Child 0 – 12 months.Term infants with normal gastro-
intestinal function are given either breast milk or normal
infant formula during thefirst year of life. The average
intake is between 150 mL and 200 mL/kg/day. Infant milk
formulas are based on whey- or casein-dominant protein,
lactose with or without maltodextrin, amylose, vegetable oil
and milk fat. The composition of all normal and soya infant
formulas have to meet The Infant Formula and Follow-on
Formula Regulations (England and Wales) 2007 , which enact
the European Community Regulations 2006 / 141 /EC; the
composition of other enteral and specialist feeds has to meet
the Commission Directive ( 1999 / 21 /EC) on Dietary Foods for
Special Medical Purposes.
A high-energy feed, which contains 9 – 11 % of energy
derived from protein can be used for infants who fail to grow
adequately. Alternatively, energy supplements may be added
to normal infant formula to achieve a higher energy content
(but this will reduce the protein to energy ratio) or the
normal infant formula concentration may be increased
slightly. Care should be taken not to present an osmotic load
of more than 500 milliosmols/kg water to the normal
functioning gut, otherwise osmotic diarrhoea will result.
Concentrating or supplementing feeds should not be
attempted without the advice of a paediatric dietician.
Enteral feeds
Child 1 – 6 years (body–weight 8 – 20 kg). Ready-to-use
feeds based on caseinates, maltodextrin and vegetable oils
(with or without added medium chain triglyceride (MCT) oil
orfibre) are well tolerated and effective in improving
nutritional status in this age group. Although originally
designed for children 1 – 6 years (body–weight 8 – 20 kg),
some products have ACBS approval for use in children
weighing up to 30 kg (approx. 10 years of age). Enteral feeds
formulated for children 1 – 6 years are low in sodium and
potassium; electrolyte intake and biochemical status should
be monitored. Older children in this age range taking small
feed volumes may need to be given additional
micronutrients. Fibre-enriched feeds may be helpful for
children with chronic constipation or diarrhoea.
Child 7 – 12 years (body-weight 21 – 45 kg).Depending on
age, weight, clinical condition and nutritional requirements,
ready-to-use feeds formulated for 7 – 12 year olds may be
given at appropriate rates.
Child over 12 years (body-weight over 45 kg).As there
are no standard enteral feeds formulated for this age group,
adult formulations are used. The intake of protein,
electrolytes, vitamins, and trace minerals should be carefully
assessed and monitored. Note: Adult feeds containing more
than 6 g/ 100 mL protein or 2 g/ 100 mLfibre should be used
with caution and expert advice.
Specialised formula
It is essential that any infant who is intolerant of breast milk
or normal infant formula, or whose condition requires
nutrient-specific adaptation, is prescribed an adequate
volume of a nutritionally complete replacement formula. In
thefirst 4 months of life, a volume of 150 – 200 mL/kg/day is
recommended. After 6 months, should the formula still be
required, a volume of 600 mL/day should be maintained, in
addition to solid food.
Products for cow’s milk protein intolerance or lactose
intolerance.There are a number of infant formulas
formulated for cow’s milk protein intolerance or lactose
intolerance; these feeds may contain a residual amount of
lactose (less than 1 g/ 100 mL formula)—sometimes described
as clinically lactose-free or‘lactose-free’by manufacturers.
If the total daily intake of these formulas is low, it may be
necessary to supplement with calcium, and a vitamin and
mineral supplement.
Soya-basedinfant formulas have a high phytoestrogen
content and this may be a long-term reproductive health
risk. The Chief Medical Officer has advised that soya-based
infant formulas should not be used as thefirst choice for the
management of infants with proven cow’s milk sensitivity,
lactose intolerance, galactokinase deficiency and
galactosaemia. Most UK paediatricians with expertise in
inherited metabolic disease still advocate soya-based
formulations for infants with galactosaemia as there are
concerns about the residual lactose content of low lactose
formulas and protein hydrolysates based on cow’s milk
protein.BNFC 2018 – 2019 Nutrition (oral) 621
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