Choosing an Appropriate Enteral Feeding Regimen

In order to enhance motility and nutrient metabolism in the child with an enteral feed, the preferred method of enteral feeding is by bolus feeding (Schanler, Shulam, Lau, Smith, & Heitkemper, 1999) (Patel, Piazza, Layer, Coleman, & Swartzwelder, 2005) (Rovekamp-Abels, et al., 2015). Enteral feeds can also be administered by continuous, intermittent/bolus, cycled or a combination of these, each method with its own advantages and disadvantages.

Refer to:

Appendix 10 - Tube Feeding Schedules/Regimens for Enteral Feeding
Figure 7 - Nutrition Support Decision Making Tree
Provincial Enteral Nutrition Insite Page (AHS Staff Login required)

Table 11: General Formula Selection for Enteral Feeding

Feed Type	Composition	Indications	Considerations
INFANT FEEDING
Expressed Breastmilk (EBM)	optimal nutrition for infants when available and safe for use	contraindicated for galactosemia and illicit drug exposure as defined by the AHS Breastmilk Safe Management Policy	age of the infant, breastmilk supply, composition, route (breast, bottle or enteral tube)
Infant formula	standard formulas are cow’s milk based and contain lactose, although soy based and modified cow’s milk based formulas are available to meet specific needs of the infant	recommended alternative for infants when breastmilk is not available or not in sufficient quantities	composition, format (powder, liquid concentrate, ready-to-feed), safe preparation of equipment and formula, tolerance
Pasteurized donor human milk (DHM)	mature breastmilk from screened donors that is pooled, pasteurized, and lower in protein than a parent’s own breastmilk in the early stages of lactation	indications are outlined in the AHS DHM procedure if used for preterm infants, fortification is needed to meet nutrient needs	low protein, high cost, and access limitations
Extensively hydrolyzed infant formula	protein broken down into peptides and amino acids, variable medium chain triglyceride (MCT) content	cow’s milk protein allergy malabsorption short bowel syndrome	cost, palatability
Amino acid-based infant formula	protein is broken down into amino acids, variable MCT content	cow’s milk protein allergy multiple food protein intolerance malabsorption short bowel syndrome	cost, palatability, access
Specialty formula	fat-modified formula, carbohydrate-modified formula, preterm, post-discharge preterm	used in disease-specific circumstances, e.g. chylothorax, carbohydrate metabolism disorders, preterm infants	cost, palatability, access, may need recipe from dietitian to ensure nutritionally complete
PEDIATRIC
Polymeric – includes high energy or high protein formulations	contains intact nutrients and requires normal digestive and absorptive function of the gastrointestinal tract	recommended as first line formula for most children (Koletzko, et al., 2015)	some formulas may contain fibre and/or prebiotics
Semi-elemental	protein is partially broken down into peptides and amino acids, fat and carbohydrate sources	malabsorption short bowel syndrome	cost, poor palatability; access
Elemental	amino acid-based formula	intolerant to semi-elemental cow’s milk protein allergy multiple food protein intolerance malabsorption short bowel syndrome	poor palatability, cost powdered preparation
Blenderized or home blended food	commercially prepared blenderized formulas, home blended food for tube feeding, or a combination	whole foods approach retching, tolerance patient preference	age of child (around 6 months or older), complementary or sole source of nutrition
Modulars/Additives	separate macronutrients (carbohydrate, fat, protein)	can be added to formulas to tailor nutrition needs	safe preparation of formula, administration, and changes in osmolarity and nutrient balance

When choosing an enteral feeding regimen, consider the following (Bauer, 2002) (American Society for Parenteral and Enteral Nutrition Board of Directors, 2009):

current medical condition, nutrition and biochemical status
tolerance to any previous enteral nutrition regimens
safety of ongoing oral intake to complement enteral feeding, general consumption
child’s age, activity level, preferences, lifestyle, development, and family routine
nutrition needs, and specific nutrient requirements for optimal growth and development, volume required to optimize tolerance, and water flushes to support hydration needs
route of delivery and formula type
refeeding risk
expected duration of nutrition support
cost effectiveness and/or implications
parent ability to safely administer the regimen
sustainability of the proposed regimen, e.g. complex routines may be ok for short-term success, but may not be sustainable for longer term intervention, requires reassessment

Enteral feeding should only be started following medical confirmation of tube placement. In most cases, enteral feeds can be started at full strength with the volumes being gradually increased in stages either as an increased infusion rate or as a larger bolus (Shaw & Lawson, 2007).

Consideration of advancing feeding regimens should be undertaken upon review of the above-mentioned factors. As feeds progress towards goal rate or schedule, the child’s tolerance and medical stability should be monitored.

Clinical condition, tube type, tolerance and family needs may influence administration of enteral feeds requiring an enteral pump (See Table 12). Continuous pump feeding is required for jejunal feeding due to the lack of reservoir capacity in the small bowel. Bolus feeds are contraindicated for jejunal feeding (Boullata, et al., 2017) (Braegger, Decsi, Dias, Hartmann, & Kolacek, 2010) (NSW Office of Kids and Families, 2016). Intermittent pump feeding may be possible and should be determined based on individual needs and tolerance. However, particularly for infants, consultation with the medical team is recommended due to potential risk of hypoglycemia when ceasing jejunal feeds (NSW Office of Kids and Families, 2016).

Table 12: Feeding Pump Criteria

Medical indications requiring a feeding pump	continuous cycled (i.e. overnight) bolus/intermittent Feeds > 60 minutes	Required for management of: increase risk of aspiration pneumonia inborn errors of metabolism dumping Syndrome chronic Diarrhea vomiting intolerance to enteral feeds delivered by gravity high volume enteral feeds post-pyloric/jejunal tube
Indications for feeding pump discontinuation	able to tolerate a transition to bolus feeds < 60 minutes	Examples: gravity feeds tolerated jejunal feeds discontinued
Non medically supported requests for feeding pump (and suggested responses)	formula is too viscous to run by gravity family is familiar with pump use family preference without supporting rationale *It is important to note that families who source feeding pumps on their own will be responsible for purchasing their own pump supplies (i.e. feeding sets)	Education provided: how to use large bore feeding bags, dilute formula (in consultation with a dietitian), or push feed with syringe provide education for gravity of bolus feeding exceptional and short-term circumstance, e.g. palliation

The indications for feeding pump use may change with time. A child should be reassessed and transitioned from a pump to gravity or syringe feed administration when the original indication for the pump has resolved.