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    NEW CONCEPTS IN ENTERAL FEEDINGS

    Historical Perspective

    ? Rectal feedings

    ? Naso-enteral feedings

    ? Oral-enteral feedings

    ? Enterostomies

    Rectal Feedings

    ? Egyptians

    - Ritual nutrient enemas and emetics

    ? Greeks

    - Nutritional support / laxative therapy

    - Wine, milk, whey, wheat, barley

    ? Western Europe

    - Beef and chicken broths

    - Raw eggs, brandy

    Rectal Feedings

    ? Great Britain

    - Lancet, 1878: Brown-Seguard recipe

    - 2/3 lb beef and hog pancreas, ground

    ? United States

    - President Garfield received peptonized beef broth with whiskey x 79 days after being wounded

    ? Europe

    - Proctoclysis in WWI and WWII

    - Administeredwater, N.S., glucose and isotonic amino acids

    Upper GI Feedings

    ? 1598 -- Capivacceus

    - First to report esophageal feeds

    ? 1617 -- Fabricius ab Aquapendente

    - Nasopharyngeal feeds with silver tube

    ? 1646 -- Boerhaave

    - Leather tubes for gastric feeding

    ? 1790 -- John Hunter

    - Catheter and syringe for gastric feeds

    Upper GI Feedings

    ? 1800's -- Stomach pump

    - Used for feeding mentally ill patients

    ? 1874 -- Ewald and Oser

    -Soft rubber tube for gastric intubation

    ? 1876 -- Dukes

    - Nasal feeding of child with rubber tube

    ? 1894 -- L. Emmett Holt

    - Gavage feeding acutely ill infants

    - 4-6 oz milk, 1 oz brandy with digitalis

    Gastrostomy

    ? 1822 -- William Beaumont

    - Studied Alexis St. Martin (gastric fistula)

    ? 1850's --

    - Gastrostomies in children after caustic ingestion

    ? 1894 -- Stamm gastrostomy

    ? 1982 -- Gauderer develops PEG

    ? 1984 -- Gauderer develops gastrostomy "button"

    Small Bowel Feedings

    ? 1910 -- Einhorn

    - Weighted tube for duodenal and jejunal feeds

    ? 1939 -- Jejunal feeds after gastrostomy

    ? 1952 -- Feeding jejunostomy

    ? 1950's

    - Polyethylene tubes, elemental and chemically defined formulas

    ? 1972 -- Feeding tube jejunostomy

    Indications for Enteral Nutrition

    ? Poor nutrient retention

    ? Prolonged NPO status

    ? Insufficient intake

    Indications for Enteral Nutrition

    Hospitalized children

    ? Up to 54% are malnourished

    Malnourished Hospitalized Children

    ? Etiologies

    - Underlying disease process

    - Anorexia

    - Prolonged NPO status

    - Nutritional needs not assessed

    Indications for Enteral Nutrition

    ? Gastrointestinal Disease

    - Short bowel syndrome

    - Inflammatory bowel disease

    - Intractable diarrhea of infancy

    - Extrahepatic biliary atresia

    - Intestinal pseudo-obstruction

    - Chronic liver disease

    - Glycogen liver disease

    Indications for Enteral Nutrition

    ? Preterm infants

    ? Neurologic

    - Static encephalopathy

    - Dysphagia

    - CNS tumor

    ? Cardiorespiratory

    - Cystic fibrosis

    - Bronchopulmonary dysplasia

    - Congenital heart disease

    Indications for Enteral Nutrition

    ? Malignancy

    - Poor intake: radiation / chemotherapy

    - Terminal support

    ? Hypermetabolic states

    - Burns

    - Trauma / head injury

    ? Other

    - Anorexia nervosa

    - Chronic renal disease

    Approach to Nutritional Support

    Enteral Nutrition Algorithm

    Approach to Nutritional Support

    ? Enteral vs Parenteral Nutrition?

    - Is the GI tract functional?

    - What is the goal of nutritional support?

    Approach to Nutritional Support

    ? Enteral Nutrition

    - What type of nutrition is required?

    - How long is support needed?

    - Is there risk for aspiration?

    Enteral Nutrition vs Parenteral Nutrition

    ? Advantages

    - Economy

    - Ease

    - Safety

    - Physiology

    Advantages of Enteral Nutrition

    ? Physiology

    - Promotes mucosal growth and function

    - Decreased bacterial translocation

    - Improved nutrient utilization

    - Less hepatobiliary complications

    Mucosal Growth and Function

    Enteral Nutrition

    ? Contraindications

    - Peritonitis

    - Obstruction

    - Ileus

    - Vomiting

    - Enteric fistulae

    Route of Enteral Administration

    ? Nasoenteral

    - Nasogastric

    - Nasoduodenal

    - Nasojejunal

    Route of Enteral Administration

    ? Tube Enterostomy

    - Gastrostomy

    - Jejunostomy

    Gastrostomy Feedings

    Possible Possible

    AdvantagesDisadvantages

    Simulates normal feedingAspiration

    Intermittent bolus regimenGE Reflux

    PEG placementDumping

    Conversion to transpyloricGas bloat

    route

    Jejunostomy Feedings

    Possible Possible

    AdvantagesDisadvantages

    Decreased risk ofGeneral

    aspirationanesthesia

    Transpyloric Feedings

    ? Indications

    - Gastroesophageal reflux

    - Altered mental status

    - Intractable emesis

    - Delayed gastric emptying

    - Abnormal swallowing

    Enteral Feeding Supplies

    ? Feeding tubes

    ? Enteral containers

    ? Enteral pumps

    Enteral Feeding Tubes

    ? Tube Composition

    - Polyvinylchloride (PVC)

    - Silicone (Silastic)

    - Polyurethane

    Enteral Feeding Tubes

    Composition

    TubeAdvantagesDisadvantages

    PVCEasy to placeRisk of perforation

    Resists collapseReplace every 3 days

    SilasticPliableSmaller diameterMore comfortablethan polyurethane

    PolyurethanePliable

    Good patient tolerance

    Feeding Tubes

    NameSizeLength Composition

    (Fr)(cm)

    Keofeed ped7.375Silicone

    Keofeed neo5.050Silicone

    Corsafe ped6.0/8.056/91Polyurethane

    Corsafe neo5.038Polyurethane

    Enterostomies

    ? Approaches and Devices

    - Stamm gastrostomy vs PEG

    - Low profile devices

    - Jejunostomy:Surgical vs PEJ

    Enteral Feedings

    ? Formula Selection

    - Blenderized

    - Polymeric

    - Chemically defined

    - Elemental

    - Modular

    Enteral Diets......（后略) ......