22.06.2024
This article draws insights from the chapter “Enteral Nutritional Support” by Sanja Kolaček, featured in the book “Pediatric Nutrition in Practice.” This chapter provides a comprehensive overview of enteral nutrition (EN) and its role in supporting the growth and development of children who are unable to meet their nutritional needs through regular oral intake.
Imagine a child struggling to eat enough due to a medical condition. Perhaps they have difficulty swallowing, experience chronic nausea, or are recovering from surgery. How can we ensure they receive the vital nutrients they need to heal and thrive? Enteral nutrition, a method of delivering nutrition directly to the stomach or small intestine, offers a lifeline in these challenging situations.
This article delves into the practical aspects of EN, exploring its indications, the various formulations available, methods of administration, potential complications, and the importance of a team-based approach to care. We’ll also examine areas where further research is needed to optimize the use of EN in pediatric patients.
When is Enteral Nutrition Necessary?
EN is recommended when a child has a functioning gastrointestinal tract but cannot consume enough food orally to meet their nutritional requirements. Think of EN as a bridge, providing essential nutrients when the normal route of eating is disrupted.
Here are some scenarios where EN may be indicated:
- Inadequate Oral Intake: This can occur due to conditions such as prematurity, cleft lip and palate, neuromuscular impairments like cerebral palsy, congenital abnormalities of the upper gastrointestinal tract, tumors, trauma, burns, critical illness, severe gastroesophageal reflux, and even psychiatric disorders like food aversion and anorexia.
- Disorders of Digestion and Absorption: Conditions like cystic fibrosis, short bowel syndrome, inflammatory bowel disease, pancreatic insufficiency, chronic liver disease, and intestinal fistulae can impair the body’s ability to break down and absorb nutrients, necessitating EN.
- Increased Nutritional Requirements: Certain medical conditions, such as cystic fibrosis, chronic organ diseases, and severe burns, increase the body’s demand for nutrients, making it difficult to meet those needs through oral intake alone.
- Growth Failure or Chronic Malnutrition: Children who are not growing adequately or are chronically malnourished, even without an underlying medical condition, may benefit from EN.
EN is generally preferred over parenteral nutrition (PN), a method of delivering nutrition intravenously, whenever possible. This is because EN preserves the function of the gastrointestinal tract, is more cost-effective, and carries a lower risk of complications. However, in certain situations, such as in critically ill patients with fluid restrictions or those undergoing frequent procedures, a combination of EN and PN may be necessary.
Navigating the World of Enteral Formulas
Choosing the right enteral formula is crucial for ensuring a child receives the specific nutrients they need. Think of enteral formulas like tailored recipes, designed to address individual nutritional requirements.
Here are the key factors to consider when selecting a formula:
- Age and Clinical Condition: Formulas are designed to meet the specific nutritional needs of different age groups, from infants to adolescents. The child’s underlying medical condition also plays a role in formula selection.
- Food Intolerances and Allergies: Many formulas are lactose-free and gluten-free to accommodate common intolerances. For children with specific food allergies, specialized hypoallergenic formulas are available.
- Level of Intestinal Function: The formula’s composition, such as the type of protein and fat it contains, should be tailored to the child’s ability to digest and absorb nutrients.
- Site and Route of Delivery: The formula’s characteristics, such as osmolality (concentration of dissolved particles) and viscosity (thickness), should be appropriate for the method of administration, whether it’s delivered to the stomach or small intestine.
- Taste Preferences: For children who are able to drink the formula orally, palatability is an important consideration.
The most commonly used pediatric enteral formulas are standard (polymeric) formulas. These formulas contain intact proteins, carbohydrates, and fats, providing a balanced mix of nutrients for most patients. Specialized formulas are available for specific medical conditions, such as formulas with higher fat content for children with insulin resistance or respiratory problems, and formulas with reduced protein for children with kidney disease. Elemental formulas, containing pre-digested proteins and easily absorbed nutrients, may be used for children with impaired intestinal function or severe allergies.
Delivering Enteral Nutrition: Methods and Monitoring
The method of EN administration is chosen based on the child’s age, clinical condition, and the anticipated duration of feeding.
Here’s an overview of the different delivery methods:
- Nasogastric or Nasojejunal Tube: A flexible tube is inserted through the nose and passed down into either the stomach (nasogastric) or the small intestine (nasojejunal). This method is typically used for short-term feeding, less than 6 to 12 weeks.
- Gastrostomy or Jejunostomy: A feeding tube is surgically or endoscopically placed directly into the stomach (gastrostomy) or the small intestine (jejunostomy). These methods are preferred for long-term feeding.
Once the feeding tube is in place, the formula can be delivered in different ways:
- Intermittent Feeding (Bolus): The formula is delivered in larger volumes, several times per day, often mimicking normal meal patterns.
- Continuous Feeding: The formula is infused continuously over a period of time, usually 10 to 24 hours, using a pump.
Close monitoring is crucial to ensure EN is delivered safely and effectively. Healthcare professionals should regularly assess the child’s growth, fluid and electrolyte balance, nutritional intake, and any potential complications.
Potential Complications of Enteral Nutrition
While generally safe, EN can be associated with certain complications:
- Gastrointestinal Problems: Diarrhea, nausea, vomiting, bloating, and abdominal distension can occur. These can often be managed by adjusting the formula, delivery rate, or feeding schedule.
- Tube-Related Issues: Tube occlusion (blockage), migration (movement out of position), and nasal irritation can occur. Proper tube placement and maintenance are essential for minimizing these problems.
- Metabolic Imbalances: Fluid, electrolyte, and glucose imbalances can occur, requiring close monitoring and management.
- Infections: Bacterial contamination of the formula or feeding equipment can lead to gastroenteritis or sepsis. Strict hygiene practices are crucial for preventing infections.
- Psychological Effects: Children who require long-term tube feeding may develop oral aversion (dislike of eating) or altered body image.
These complications can often be prevented or minimized by:
- Choosing the right formula and delivery method
- Gradually increasing the feeding volume and concentration
- Monitoring for and managing any adverse effects
- Maintaining strict hygiene practices
- Providing psychological support to the child and family
The Power of a Team-Based Approach
Managing EN effectively requires a collaborative effort. Ideally, a dedicated multidisciplinary team, including physicians, nurses, dieticians, pharmacists, and speech therapists, should work together to:
- Assess the child’s nutritional needs
- Choose the appropriate formula and delivery method
- Monitor for and manage complications
- Provide education and support to the child and family
This team-based approach is crucial for ensuring the child receives optimal nutritional care and achieves the best possible outcomes.
Looking Ahead: Future Research Directions
Despite significant advancements in EN, there are still areas where further research is needed to optimize its use in pediatric patients:
- Developing more precise criteria for initiating EN support
- Conducting more controlled studies to evaluate the benefits of disease-specific formulations in children
- Establishing practical and safe methods for confirming tube placement at the bedside
- Identifying risk factors for complications and developing strategies to minimize them
By addressing these research gaps, healthcare professionals can continue to enhance the efficacy and safety of EN, ensuring children receive the nutritional support they need to thrive.
Conclusion
- Enteral nutrition is a valuable tool for providing essential nutrients to children who are unable to meet their needs through oral intake.
- A careful and individualized approach, guided by best practices and evidence-based guidelines, is crucial for ensuring safe and effective EN delivery.
- A team-based approach, involving collaboration among healthcare professionals, is essential for optimizing outcomes.
- Ongoing research is vital for enhancing our understanding of EN and its role in supporting the health and well-being of children.
By embracing these principles, healthcare professionals can harness the power of EN to help children overcome nutritional challenges and achieve their full potential for growth and development.
