Specialized Nutrition Care

This level of care includes continuation of Standard and Advanced Nutrition Care strategies and includes nutrition support and individualized treatment and monitoring.

ENTERAL NUTRITION

Enteral nutrition (EN) should be considered if:

• The child’s underlying disease is worsened by poor nutritional status
• Oral intake is deemed unsafe or underdevelopment of skills prevent adequate intake

Strategies for using EN include bolus feeding between meals when meal intake has been poor.

• Example 1:  Patient consumed less than 25% of meal, a bolus feed can be given when meal ends to achieve caloric intake.
• Example 2:  Infant has only consumed 30 mL formula when goal is 90 mL at a feed.  Bolus remaining volume of formula to equate to 90 mL.  Note: this example is often referred to as a top-up.

These strategies are often used to help patients achieve optimal nutrition for healing and growth and mimic normal feeding physiology.  However they may limit the child’s movement if the time required to deliver the feed is long or occurs multiples times a day.

• Example 3: Patient has high calorie needs due to illness and does not achieve all their caloric and protein requirements orally.  The patient goes about the day consuming daily meals and snacks but has enteral formula delivered during the night when they are sleeping.

Formula Selection

Selection of the appropriate tube feeding formula is based on the individual patient’s medical condition, nutritional status and digestive/absorptive capabilities. A wide variety of commercially prepared formulas are currently available. Due to periodic contract changes, formulas available may change in your area. In addition, since the composition of commercial products periodically changes, readers are advised to review product labels whenever exact nutrient content is required.

Enteral formulas are often categorized as polymeric, monomeric, oligomeric , disease specific formulas and modular nutrient sources.

Polymeric Formulas (Standard):

Polymeric formulas contain unaltered molecules of proteins, carbohydrates, and fats. 

They require effective digestive and absorptive processes for utilization and therefore are suitable only for patients with a functional gastrointestinal tract. When sufficient volume is provided, these formulas are nutritionally complete and supply all necessary vitamins, minerals and trace elements.

Monomeric/Oligomeric Formulas(Elemental/Semi-Elemental):

Monomeric formulas contain free amino acids, glucose, oligosaccharides and small but variable amounts of lipids, usually MCTs and/or essential fatty acids. They contain all established essential minerals, vitamins, trace elements and essential fatty acids. It has been shown that the presence of di and tripeptides actually enhances intestinal nitrogen absorption, there has been a shift towards the use of oligomeric formulas particularly in malabsorption, however, monomeric diets are still considered to have therapeutic efficiency for example in acute Crohn’s disease.  

Oligomeric formulas contain dipeptides and tripeptides as the nitrogen source with varying amounts of free amino acids. Carbohydrates are provided by disaccharides and maltodextrins. Lipid content is variable, consisting mainly of long chain triglycerides (LCT), source of u-3 and u-6 essential fatty acids, and MCTs as a source of energy. Oligomeric formulas contain the recommended doses of all micronutrients, and are therefore nutritionally complete. These formulas  may be useful in patients with inflammatory bowel disease, short bowel syndrome, or intestinal obstruction and/or fistulas. 

Disease Specific (Specialty) Formulas:

Specialty formulas include products designed for patients with specific diseases/medical conditions that may respond to nutrient manipulation. These products are usually expensive and may or may not be nutritionally complete.

Modular Nutrient Sources:

Protein, carbohydrate and fat are available in modular form. They are not nutritionally complete in themselves. However, they can be added to commercial formulas to alter the nutrient content/caloric density, which creates a unique formula that more closely meets a specific patient’s nutritional requirements.

The American Society for Parenteral and Enteral Nutrition (ASPEN) has created an enteral formula guide which may be helpful.

PARENTERAL NUTRITION

Parenteral nutrition (PN) is the administration of intravenous nutrients in patients whose gastrointestinal tract is not functional or cannot be accessed.  It may also be administered to patients who cannot meet all their nutritional needs enterally (orally or via tube feeds) in the form of supplemental PN. 

Approach:

• Perform nutrition assessment to establish the need for nutrition support. 
• Ensure that the enteral route has been fully considered.  “If the gut works – use it”.  If the GI tract is not functional, initiate parenteral nutrition.
• Consult your parenteral dietitian and team.

ASPEN has helpful resources for PN use

POST DISCHARGE NUTRITION CARE

If the patient is malnourished upon admission or during hospitalization and receiving Advanced or Specialized Nutrition care, nutrition is an active issue in the discharge summary. Details should include:

• Education provided to patient and family
• Referral to community resources
• Discharge summary with patient and family physician or care provider in the community