Pediatric Nutrition in Practice

Enteral Nutritional Support 155

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with pulmonary disease due to lower CO 2 pro-
duction, formulae with reduced protein content
for patients with renal disease, or formulae with a
specific amino acid profile that may benefit pa-
tients with hepatic encephalopathy. The most re-
cent research topics in enteral formula design are
contents of anti-inf lammatory cytokines (trans-
forming growth factor-β) or nutrients (e.g. gluta-
mine, arginine and n–3 fatty acids), which, if pro-
vided in high doses, may exert immune-regulat-
ing effects. However, for all of these there are very
few controlled studies of sufficient quality on pe-
diatric patients and, therefore, claims of benefi-
cial effects should be evaluated critically [7].
In formula selection, the following should be
considered: (a) nutrients and energy require-
ments adjusted for age and clinical condition of
the patient; (b) history of food intolerances or al-
lergy; (c) level of intestinal function; (d) site and
route of formula delivery; (e) formula character-
istics such as osmolality, viscosity and nutrient
density; (f) taste preference; and (g) cost.

A d m i n i s t r a t i o n o f E N

Sites of Delivery
EN can be administered either into the stomach
or into the proximal small intestine. Among the
two sites, intragastric feeding is associated with a
more flexible feeding schedule, antimicrobial
properties, larger volume and higher osmotic tol-
erance, and lower frequency of diarrhea and of
dumping syndrome because (a) of stimulation of
normal digestive and hormonal responses, (b) of
a preserved acid barrier, (c) tubes are more easily
placed, and (d) the stomach serves as a reservoir
gradually releasing nutrients. Postpyloric access
is reserved for clinical conditions in which tra-
cheal aspiration, gastroparesis and gastric outlet
obstruction preclude gastric feeding. However,
results of studies comparing both sites are con-
flicting, often not showing benefits either in
adults or in children [8, 9].

Routes of Delivery

If the expected duration of EN is short (<6–12

weeks), it is preferentially delivered by NG or na-

soenteric tube, but if the expected duration is lon-

ger, a feeding gastrojejunostomy is recommend-

ed, placed by endoscopy, which is the quickest

and cheapest procedure with only a low rate of

complications [10, 11].

Among different tubes, those made of PVC

are the least desirable, because of the potential re-

lease of toxic phthalate esters into the lipid-con-

taining feeds – and if left in place for >4 to 6 days,

they may become rigid and cause lesions of the

upper gastrointestinal tract. Silicon and polyure-

thane tubes are more convenient and can be safe-

ly kept in place for several weeks. Considering the

required length of the tube, it equals the distance

from the nose over the ear lobe to the xiphoid in

children, and from the nose over the ear lobe to

the mid-umbilicus in neonates. Placement into

the stomach is confirmed by measuring the pH of

the aspirate, which should be <4 in children and

≤ 5 in neonates. Radiologic confirmation must be

obtained if (a) the pH is >5, (b) an aspirate cannot

be obtained, or (c) the patient’s condition changes

du r i n g NG t u b e i n s e r t ion , w it h pr olon ge d c ou g h-

ing, restlessness and discomfort or hoarseness [8,

12, 13].

Modes to Deliver EN

EN delivery modes are intermittent, continuous

or combined. Intermittent/bolus delivery is phys-

iological, provides a cyclical hormone surge and

regular gallbladder emptying, and, if delivered

orally, supports the development of age-appro-

priate feeding habits and oromotor skills. Con-

tinuous formula infusion is often recommended

for malnourished children with severe chronic di-

arrhea and intestinal failure because reduced sur-

face and transport proteins can be more efficient-

ly used and the osmotic load is better tolerated [1,

14]. An appropriate and constant flow is ensured

by the use of a peristaltic enteral pump. When the

child can eat, both methods of feed delivery can

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 152–157
DOI: 10.1159/000360330