Manual of Clinical Nutrition

Enteral Nutrition Support Therapy for Adults

Manual of Clinical Nutrition Management B- 43 Copyright © 2013 Compass Group, Inc.

 Residue: Milk-based formulas and other formulas with intact nutrients are generally low residue.
Blenderized and fiber-supplemented formulas leave a moderate to high residue.
 Fiber: See the previous discussion of formulas containing fiber in the nutrient-modified formulas list.
 Sodium and potassium: Select formula according to the patient’s nutrition prescription and laboratory
profile.
 Renal solute load: The main contributors to renal solute load are protein, sodium, potassium, and
chloride. A high–renal solute load in sensitive patients can result in clinical dehydration.
 Safety: A ready-to-use closed bag or system is recommended, as it is more sterile and provides less risk
for contamination than canned or powdered products (52). Formulas that are made in a blender in the
facility are discouraged because they carry a greater risk of infection, require careful handling, tend to
clog tubes, and need a high volume to meet nutrient needs. If formulas are mixed, follow the
organization’s Hazard Analysis and Critical Control Point Enteral Nutrition Guidelines to ensure safety (52).
 Viscosity: Blenderized, high-fiber, and high-density formulas should not be administered through tubes
with a diameter smaller than 10 French unless a pump is used. Formulas may flow through an 8-French
diameter tube when a pump is used (15).
 Vitamin K: Patients who are receiving enteral nutrition support while on anticoagulant therapy should
be monitored closely. Significant vitamin K intake from enteral formulas can antagonize the effect of the
anticoagulant drug warfarin and result in treatment failure (53). Most enteral formulations contain
modest amounts of vitamin K and provide daily vitamin K intake similar to the average dietary intake
from foods (53). Consistent intake of an enteral formulation containing less than 100 mcg of vitamin K per
1,000 kcal is not expected to cause warfarin resistance (53). Refer to Section III: Anticoagulant Therapy for
specific guidelines for enteral nutrition regimens in this group of patients.
 Cost: Amino acid–based formulas and peptide-based formulas are usually more expensive than synthetic
formulas containing intact nutrients.

Enteral Feeding Administration (52,54)^
Continuous feeding/delivery: Continuous feedings require that the enteral formula be administered at a
controlled rate with a pump over a 24-hour period. The pump should deliver the controlled rate within 10%
accuracy and be calibrated periodically to ensure accuracy (52). Continuous feedings are indicated for unstable
critically ill patients, patients unable to tolerate high-volume feedings, patients with malabsorption, and
patients at increased risk for aspiration (5). Feedings may be initiated at full strength in the stomach or at an
isotonic strength in the small bowel at a rate of 10 to 30 mL/hour. Then, the rate may be gradually increased
as tolerated in increments of 10 to 25 mL/hour every 4 to 8 hours to the goal rate. Strength and volume
should not be increased simultaneously.

Intermittent or cyclic feeding/delivery: Intermittent or cyclic feedings are administered over an 8- to 20-
hour period by using a pump to control the rate of delivery. This method of tube feeding is most beneficial for
patients who are progressing from complete tube feeding support to oral feedings as discontinuation of
feedings during the day may help to stimulate the appetite. Intermittent or cyclic feeding is also beneficial for
ambulatory home-care patients who are unable to tolerate bolus feedings because it allows freedom from the
pump and equipment. Since this method of delivery usually requires a higher infusion rate, monitoring for
formula and delivery tolerance is necessary. Formula and delivery intolerance can be avoided by a gradual
transitioning of the patient from continuous feeding to an intermittent feeding schedule.

Bolus formula delivery not requiring a pump: The syringe bolus-feeding method involves the delivery of
240 to 480 mL of formula via a feeding tube over a 20- to 30-minute period, three to six times a day, to meet
estimated nutritional requirements. This method is usually restricted to gastric feedings and may be
contraindicated in patients who have a high risk of aspiration, disorders of glucose metabolism, or fluid
management issues.

Enteral Feeding Formula and Equipment Maintenance Guidelines (52)
Formula:
 Bring formula to room temperature before feeding, but do not allow the formula to remain
unrefrigerated for more than 12 hours (52).
 The hang time for formula in an open system should be less than 8 hours or as specified by the
manufacturer. Formula from a closed system is provided in ready-to-hang, prefilled containers and may
hang for 24 to 48 hours per manufacturer’s guidelines (52). Discard any formula remaining in the
container after the hang time has expired.
 Opened, unused formula should be kept refrigerated for no longer than the manufacturer’s specifications
(usually 24-48 hours) (52).