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:

Table 11: General Formula Selection for Enteral Feeding

Feed Type








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





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


  • protein is partially broken down into peptides and amino acids, fat and carbohydrate sources
  • malabsorption
  • short bowel syndrome
  • cost, poor palatability; access


  • 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


  • 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
  • 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.