By Omar Moulay, MD
You know the basics of infusion feeding:
The liquid or liquified solute (containing nutrients),
Is administered over some period of the day or night ;
- Continuous, 24h all day,
- Intermittent, more natural, bolus, per need, or
- Cyclic, more practical, same time, same hour each day or each night
Through the digestive tube (Enteral feeding) or through the veins (Parenteral feeding).
It can be useful when...
- -the natural digestive access (ie: conscious control over mouth opening, chewing, swallowing, progression all away to the stomach, then through the Intestines),
- -or digestive function (ie: processing the food to basic nutrients (Glucids, Lipids, Proteins, Vitamins, Minerals, Electrolytes) then transferring them to the bloodstream to be used or stocked by the body for some other time),
- or both,
It can be exclusive (Total Infusion Feeding)
or combined (Complementary, Partially Infusion Feeding) with oral intake when and as much as possible.
Ok.. Maybe you still feel you don’t quite understand all of it…as if you may be missing something…
Well then, you are at the right place, because here, we will help you feel better by helping you feed better.
A- Either the food and medication are having a hard time reaching the Intestines where they would normally be processed, because of loss of control, strictures or lack of progression to and through any level of the digestive tube, or because the digestive system can’t hold it in and keeps hurling it out.
In which case:
- a tube can shortcut the level of difficulty from Nose to stomach (nasogastric) or a little further to duodena-jejunum (nasoduodenal, nasojejunal)
- or through a skin surgical opening (ostomy), again at the gastric (gastrostomy) or jejunal level (feeding jejunotomy).
This tubing needs to be maintained, flushed, cleaned or changed, and constantly reevaluated until it is no more necessary because it is necessary no more (enough feeding through natural ways).
We will need:
1- Feeding container :
a- Bottle or Portable Bag that connects to tubing and lets gravity do its magic, only limiting the flow manually with a roller clamp.
c- or a simple Feeding Syringe for intermittent boluses, used manually or connected to a Feeding Pump, or even to an automatic syringe pump for precise small amount feeding needs (especially with infants). Again, different syringe tips are available !
2- Feeding Set to connect the container to the feeding tube.
Connection can be specifically designed ! (needle, cap, cone, screw…), so you will need to check with your medical health supplier.
3- Feeding tube, placed by a professional, with a nasal or percutaneous access (-ostomy)
B- Or maybe the food can eventually make it to the intestines, but the enzymatic soup the digestive system is supposed to secrete (stomach, bile, pancreas) to process the the food is missing an ingredient, or the Intestines are not doing their job correctly in transferring the normally processed food from the intestine lumen and to the bloodstream and into our body.
Then, sterile, already processed nutrients can be put right through a skin puncture and directly into the bloodstream.
The level of vascular access will depend on:
- the nature of solutes to be used (the more dense, complete they need to be, the bigger the used vein needs to be),
- and on the intended length of use (the longest is the predicted timeframe, the more profound and secure the used vein needs to be)
- That will dictates the choice of used vein for feeding : Peripheral (cephalic), Profound (basilic), central Veins (brachial, axillar, subclavian, internal jugular)
Now what nutrients are out there for you?
1- For intravenous (parenteral) feeding, it is simple : an elixir of basic nutrients cocktail will be progressively tailored on a case by case basis by your Chef team : Doctor and Nutritionist, using more or less, all life sustaining, necessary ingredients on their most basic form : Glucids for basic energy needs, lipid formulas containing essential lipids, protein formulas containing essential amino-acids, vitamins, minerals and electrolytes.
Only trained professionals can safely have access, connect and monitor the parenteral feeding, as very specific precautions need to be taken.
Nutrients are specifically prepared for intravenous administration in humans.
2- For enteral infusion products, it is more natural soup-like preparations and some even taste good!
A- HOMEMADE/BLENDERIZED ENTERAL FEEDINGS: By knowing our basic needs, one could seemingly prepare a balanced meal, mix it, filter it and just go with it. Although they may increase the chance of food borne illness, in addition to an increased work burden.
However, if you have a strong desire to provide “home-made” nutrition, there are plenty of resources that provide recipes adapted from the “olden days” (circa 1980 - https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2015/11/MaloneArticle-June-05.pdf).
B- But usually, interested persons would want to check with their doctor and nutritionist and go with more specific, goal oriented PHARMACEUTICAL or INDUSTRIAL PREPARATIONS.
There are well over 100 enteral formulas now available, making formula selection rather challenging. But no worries, we will walk you through the gist of it all.
1- And let’s begin at the beginning :
STANDARD FORMULAS tend toward the most natural balance of glucid to lipid ratio in its most natural nature found, polymeric form. They are known to be the least expensive feeding preparations and can successfully be used with most patients at a much lower cost.
2- Then, for specific needs, a lot of variants can be found :
THE ELEMENTAL diet offers a complete nutritional profile broken down into its most “elemental” form : amino acids, short-chain triglycerides and short-chain maltodextrins, combined with vitamins, minerals and electrolytes.
They are the easiest and the fastest to absorb and digest.
CALORIE DENSE Products are standard formulas with less water, hence, less volume to be ingested, with 1-2kcal/mL. They are most practical for use in patients requiring smaller volumes over shorter periods, or Intermittent Bolus feeding.
FIBER SUPPLEMENTED FORMULAS, Promotes digestive function through several mechanisms :
- Soluble fibers, such as pectin and guar, provide an energy source for colon cells, increase intestinal mucosal growth and promote water and sodium absorption.
- Insoluble fiber, such as soy polysaccharide, increases fecal weight, thereby increasing peristalsis and decreasing fecal transit time.
ENTERAL FEEDING IN PATIENTS WITH ALLERGIES:
Approximately 20% of the population in industrialized nations has been reported to suffer from adverse reactions to food.
Nuts, fruits and milk are the most common triggers,
with only about a third of the reactions in children and 10 percent of those in adults due to actual food allergy.
The majority of adverse reactions to food are non-immunologic in origin with lactose intolerance being the most common type of adverse reaction worldwide.
Allergy to cow’s milk, eggs, wheat and soy is more common in infants and young children
While seafood, peanuts and tree nuts are the more common causes of food allergy in adult life.
The 8 major food allergens in the food industry being crustaceans, egg, fish, milk, peanut, soy, tree nuts, and wheat.
Although not an allergy, but an autoimmune process, patients with celiac disease need to avoid gluten-containing enteral formulas.
DISEASE SPECIFIC FORMULAS
A lot can be said about these products, but scarce are conclusive proofs of efficacy.
Renal Disease: Generally are lower in protein, calorically dense (less water) and have lower levels of potassium, magnesium and phosphorus when compared to standard formulas.
Hepatic Disease: offer increased amounts of branched chain amino acids (BCAA): valine, leucine, and isoleucine; and reduced amounts of aromatic amino acids (AAA): phenylalanine, tyrosine and tryptophan, compared to standard products.
Supposedly reducing neurological symptoms that occur with hepatic encephalopathy.
Diabetes/Hyperglycemia: offer a lower amount of total carbohydrate and a higher amount of fat than standard formulas as well as a variation in type of carbohydrate consisting generally of oligosaccharides, fructose, cornstarch and fiber.
It has been shown to improve glycemic control in normal subjects as a result of delayed gastric emptying and reduced intestinal transit.
Pulmonary Disease: developed for two types of pulmonary disease:
Chronic Obstructive Pulmonary Disease (COPD): The high amounts of dextrose provided in standard parenteral nutrition formulas were suspected to induce adverse ventilatory effects. Substituting a portion of carbohydrate calories with fat calories (high fat formula) was thought to limit carbon dioxide production resulting in improved ventilatory status.
Acute respiratory distress syndrome (ARDS): contains borage and fish oils, sources of g-linolenic and eicosapentaenoic acids as well as increased amounts of antioxidants, designed to modulate the inflammatory cascade.
Disclaimer : Although some scientific and medical resources have been used or quoted on this blog, this is not a scientific review and its only purpose is general education on the feeding infusion industry. Please refer to your Doctor, Nutritionist or Medical Health Supplier before buying.