Home Enteral Nutrition in Adults-Nationwide Multicenter Survey

Patients' and caregivers' perspective on challenges and outcomes with tube feeding: Analysis of home enteral nutrition survey data

BACKGROUND

Given the growing use of home enteral nutrition (HEN), assessing the experience of consumers and caregivers is crucial to understanding the real-world subjective and objective challenges of administering HEN.

METHODS

After obtaining institutional review board approval, a survey was distributed to HEN consumers and caregivers between January 16, 2020, and July 16, 2021. Data collected included information regarding demographics, primary diagnosis, tube and connectors, HEN regimen, and overall HEN experience.

RESULTS

A total of 884 individuals responded to the survey: 673 (76.1%) responses by caregivers and 211 (23.9%) responses by patients. The study cohort included 566 (64%) children and 318 (36%) adults. The leading primary diagnosis of participants was developmental delay and motility disorder for children and adults, respectively. Low-profile gastric tubes were the most used (75.7% of children and 30.3% of adults). Notably, legacy connectors were utilized for more patients (46.7% children, 52.6% adults) compared to ISO-80369-3 connectors (38.9% children, 29.7% adults). HEN complications were prevalent, including enteral tube site infections and other tube-related complications, including clogging and kinking.

CONCLUSION

This real-world data reveals that HEN complications remain prevalent. Additionally, despite introducing ISO-80369-3 connectors many years ago, most patients continue to use legacy tubes with a significant lack of knowledge about ISO-80369-3 connectors. The survey results guide HEN providers to focus on several areas to reduce complications.

Oral Drug Product Administration via Enteral Feeding Tubes: In Vitro Testing

Medication administration via enteral feeding tubes (EFT) is a necessary practice for patients unable to swallow oral dosage forms due to a medical condition or treatment that affects the ability to swallow or the function of the gastrointestinal tract. Off-label administration of oral drug products via EFT raises concerns for pharmaceutical sponsors, regulators, and healthcare practitioners (HCPs) because of the potential risks this practice introduces to both the patient and the caregiver. These risks can be mitigated by generating data-supported instructions that patients and HCPs can use to ensure safe and accurate administration of oral drug products via EFT. This commentary presents an industry perspective on the testing that should be conducted to enable development of product-specific instructions in the labeling to support or advise against administration of oral drug products via enteral feeding tube. The proposal outlined in this commentary takes a risk-based approach, addressing recommendations from both regulatory agencies as well as considerations for expanding this testing to address needs specific to neonatal and pediatric populations.

Trends and challenges in home enteral feeding methods for children with gastrointestinal disorders: an expert review on bolus feeding delivery methods

INTRODUCTION

New evidence supports the benefits of bolus feeding for children receiving home enteral feeding (HEN). Current home methods of bolus feeding have certain limitations, particularly in mobile or restless patients. Therefore, innovative delivery methods have been introduced to provide more flexible methods of reducing feeding time and formula handling.

AREAS COVERED

This manuscript presents an expert review of the updates in HEN for children and the results of an online user experience questionnaire about an innovative new cap-based bolus feeding system. A literature bibliographic search was conducted on Medline via PubMed up to September 2023 to collect relevant studies. We presented recent evidence demonstrating a dramatic increase in HEN use among children requiring EN and its benefits on patients' nutritional status and quality of life. In addition, the article examined the clinical and social benefits of bolus feeding and current challenges in delivery methods. We described the benefits of the new system and its user experience.

EXPERT OPINION

The uses and indications for bolus feeding in HEN are increasing among children. However, there are still some unmet needs regarding traditional delivery methods. Innovative techniques can improve flexibility, reduce feeding time, and improve user experience and quality of life.

Experiences and perceptions of multidisciplinary paediatric teams of blended tube feeding in children

Background: Blended tube feeding (BTF) is the administration of pureed whole foods via gastric feeding tubes. There is some evidence to suggest that BTF may have clinical and psychosocial benefits when compared to commercial formula, but further investigation of how BTF is understood and recommended by health professionals is needed. This study aims to investigate awareness and knowledge of BTF among multi-disciplinary paediatric staff in Ireland. Methods: A cross-sectional observational study was conducted among paediatric staff in Children's Health Ireland (CHI). The 16-item anonymous online survey gathered information on awareness of BTF, willingness to recommend BTF, confidence in BTF knowledge, and self-assessed competence in managing BTF. Results: Of the 207 responses, doctors (n68), nurses (n66), and dietitians (n32) provided 80.3% of responses. Two-thirds (n136, 66%) of the total group were aware of BTF. Of these, 68.1% had cared for a child on BTF and 70% (n = 63/90) were willing to recommend BTF. Three in five (n = 39/63, 61.9%) stated they were somewhat confident in their BTF knowledge and one in five (n = 12/56, 21.4%) were not yet competent in managing children on BTF. The most common reasons for recommending BTF were parental desire (n17, 39.5%) and commercial formula intolerance (n15, 34.9%). The most common barrier to recommending BTF was family logistics (n18, 41.9%). The most valuable sources of information on BTF for two-thirds (68.3%) of participants were other healthcare professionals (HCPs) and patients/caregivers. Conclusion: Healthcare settings should provide evidence-based training to HCPs on BTF to optimise the treatment and safety of children under their care.

Patients Participating in Nasogastric Tube Insertion through Hypnoanalgesia during High-dose Chemotherapy-induced Aplasia

The insertion of a nasogastric (NG) tube is often a difficult experience for both patients and caregivers. This often results in a high failure rate of NG insertion. This pilot study aimed to evaluate the effectiveness, tolerance, and acceptability of hypnoanalgesia to assist self-insertion of an NG tube. Patients undergoing high-dose chemotherapy for autologous or allogeneic hematopoietic stem cell transplantation (HSCT) or acute leukemia and with high risk of aplasia were included in the study. A total of 38 patients were included during 6 consecutive months. They all achieved successful NG tube self-insertion. The NG tube remained in place during hospitalization in 32 cases for an average duration of 15 days. Six patients rejected the NG tube during vomiting but they all voluntarily attempted it again later on and succeeded. The discomfort related to NG-tube insertion was mild. This pilot study suggests that NG tube self-insertion assisted by hypnoanalgesia may be effective, well-accepted, and well-tolerated in patients. These promising findings will need further confirmation.

Micronutrient deficiency risk in long-term enterally fed patients: A systematic review

BACKGROUND AND AIMS

The micronutrient status of those receiving long-term enteral nutrition (EN) is poorly characterised. This systematic review was undertaken to determine prevalence of micronutrient deficiency in those receiving EN; the impact of the route of feeding; whether underlying disease or clinical factors were associated with micronutrient status; and the efficacy of interventions utilised to treat identified micronutrient deficiency.

METHODS

Electronic databases (CINAHL, Embase, PubMed, Web of Science) were searched to June 2021 for publications of primary investigation of micronutrient status in adults or children (>5yrs) receiving EN for >2 months in their usual residence. Independent assessment of compliance with inclusion criteria (Covidence®), data extraction of predefined data points, assessment of basis (Academy of Dietetics Quality Checklist) and certainty of evidence (GRADE) was assessed by at least two authors. (PROSPERO Registration: CRD42021261113).

RESULTS

Thirty-one studies (n = 744) met inclusion criteria. Deficiency was reported for copper, zinc, selenium, beta-carotene, and vitamins A, D and E: Only copper, zinc and selenium were associated with physical/haematological manifestations of deficiency. Jejunal feeding was associated with the development of copper deficiency and often required gastric or parenteral replacement to resolve the issue. Circumstances leading to deficiency included receiving feed products formulated with inadequate amounts of the implicated nutrient, low feed product volumes in the context of low macronutrient requirements, and nutritional decline prior to commencement of EN. Potential confounding factors such as inflammation were rarely accounted for. No studies investigated the contribution of underlying clinical condition on micronutrient status, and no other clinical or demographic features appeared to impact outcomes. Reported methods for treating identified deficiencies were usually successful in reversing deficiency symptoms. The certainty of evidence is very low, and the level of bias moderate to high.

CONCLUSION

While the evidence is very uncertain about the effect of long-term enteral feeding on the development of micronutrient deficiencies, clinicians should be alert to the possibility of micronutrient deficiency developing in long-term EN fed patients. Those who may be at increased risk are those receiving nutrition into the jejunum, those who meet macronutrient requirements in low volumes of EN product, and those commencing EN in a nutritionally deplete state. Further research and surveillance of micronutrient status with contemporary EN products and practices is required.

Foods for Special Medical Purposes in Home Enteral Nutrition-Clinical Practice Experience. Multicenter Study

Background

Enteral nutrition (EN) with foods for special medical purposes (FSMP) is recommended for most patients on home enteral nutrition (HEN). Although there are disease-specific guidelines for energy, protein, and micronutrient provision, only a few studies are showing real-life experience in the long-term use of FSMP.

Methods

In a multicenter study, the influence of the FSMP composition and administration technique (bolus vs. continuous) on protein and energy provision in HEN was analyzed. Provision of vitamins and minerals was compared to recommended daily allowance (RDA) and upper tolerable limit (UL).

Results

Approximately, 772 patients on HEN, mostly (88.6%) with oncological and neurological diseases, were enrolled. The patients on standard FSMP received less protein and energy than those on hypercaloric and protein enriched despite receiving higher volumes of EN (p < 0.05). No differences were observed in jejunal feeding with oligomeric vs. polymeric FSMP in terms of energy, protein, and volume. Continuous gastric feeding provided more protein, energy, and volume vs. bolus feeding (p < 0.05). Significant number of patients received less than 100% RDA of vitamin D (50.5%), vitamin B3 (49%), vitamin K (21.8%), vitamin B5 (64.3%), vitamin B9 (60%). Majority of the patients received less than 100% RDA of sodium (80.2%), potassium (99%), chloride (98%), calcium (67%), magnesium (87%), fluoride (99%), and iodine (43%). Approximately, 43.63% of cancer and 49.9% of neurological patients received less than 1 g/kg/day of protein and 51.7% of cancer and 55.5% of neurological patients received less than 25 kcal/kg/day.

Conclusion

Awareness of the available compositions of FSMP and advantageous profiles of specific diets may lead to the implementation of recommendations for EN. HEN professionals need to analyze all the patient's needs and requirements to provide more tailored matching of nutritional support.

Home Parenteral and Enteral Nutrition

While the history of nutrition support dates to the ancient world, modern home parenteral and enteral nutrition (HPEN) has been available since the 1960s. Home enteral nutrition is primarily for patients in whom there is a reduction in oral intake below the amount needed to maintain nutrition or hydration (i.e., oral failure), whereas home parenteral nutrition is used for patients when oral-enteral nutrition is temporarily or permanently impossible or absorption insufficient to maintain nutrition or hydration (i.e., intestinal failure). The development of home delivery of these therapies has revolutionized the field of clinical nutrition. The use of HPEN appears to be increasing on a global scale, and because of this, it is important for healthcare providers to understand all that HPEN entails to provide safe, efficacious, and cost-effective support to the HPEN patient. In this article, we provide a comprehensive review of the indications, patient requirements, monitoring, complications, and overall process of managing these therapies at home. Whereas some of the information in this article may be applicable to the pediatric patient, the focus is on the adult population.

Prevalence and Trends in Percutaneous Endoscopic Gastrostomy Placement: Results From a 10-Year, Nationwide Analysis

Background

Percutaneous endoscopic gastrostomy (PEG) is the most commonly used access for long-term enteral nutrition. Only a few studies report the prevalence and epidemiology of PEG placements. No previous data concentrated on the healthcare system issues influencing the qualification rates and professional nutritional support for individuals with PEG.

Methods

We conducted a retrospective nationwide analysis of PEG placements in Poland from 2010 to 2020. The central data on ICD-10 coding of adult patients with PEG reported to the insurance company were used for the analysis of general and regional prevalence, age, and primary and secondary diseases. Rates of patients with home enteral nutrition (HEN) were calculated with a special focus on patients with cancer. A secondary aim was to determine the causes of regional disparities among administrative regions.

Results

A total number of 90,182 PEGs were placed during the observation period. The number was increasing each year with statistical significance. Malnutrition, dysphagia, and cardiorespiratory/metabolic diseases were the most frequently reported primary diseases. A total of 11.98% of all patients were diagnosed with cancer; 49.9% of oncological patients suffered from head and neck cancer (HNC) and 19.9% from esophageal cancer. In total, 6.61% of HNC and 27.46% of patients with esophageal cancer from the Polish National Cancer Registry (NCR) had PEG. The rates of patients in more advanced ages (65–74 and over 85 years) were growing and decreased in younger groups (18–24, 45–54, and 55–64 years). Overall, 27.6% of all (11.86% of cancer) patients with PEG were reimbursed HEN. A high number of patients in nursing care facilities, lower education of citizens, and lower number of hospital beds were associated with more PEG insertions in the administrative regions.

Conclusion

The number of PEG placements has been increasing, particularly in the elderly. Systemic solutions must be found to address the problems of regional disparities in PEG’s prevalence as well as the lack of inclusion criteria for nutritional support.

Growing use of home enteral nutrition: a great tool in nutrition practice toolbox

PURPOSE OF REVIEW

Home enteral nutrition (HEN) is a well-established practical nutrition therapy tool that is typically managed by an interdisciplinary team. Prevalence of HEN is increasing across the globe given significant evidence for utility, feasibility, efficacy, safety, and reliability of HEN in helping patients meeting their nutrition needs. The current review highlights the growing use of HEN in the context of what is novel in the field including trends in HEN practice with regards to tubes and connectors, feeding formula and real food blends, and common complications. The review also highlights that the use of HEN is expected to expand further over coming years emphasizing the need for national consensus recommendations and guidelines for HEN management.

RECENT FINDINGS

The growing use of HEN has always been parallel to adoption of holistic definitions and concept of malnutrition in clinical nutrition practice and more understanding of the need for malnutrition risk stratification, meeting unmet needs in practice and addressing challenges that lead to suboptimal enteral nutrition.

SUMMARY

Research and advancements in technology as well as in tube feeding formula industry have led to the development of more solutions and have helped identify and implement best HEN practices.

A benchmarking study of home enteral nutrition services

BACKGROUND & AIMS

Patients receiving home enteral nutrition (HEN) via an enteral feeding tube often have complex healthcare requirements. There is limited information regarding how HEN care is provided within Australia and New Zealand. This study aimed to investigate the characteristics of HEN services and the provision of nutrition care to individuals receiving HEN within Australia and New Zealand.

METHODS

A cross-sectional study, surveying lead HEN dietitians for HEN services was conducted from the period 09 July 2019 to 20 September 2019 inclusive. An online survey was used to obtain data relating to the demographics, funding and clinical resources of respondents' HEN services. Services were benchmarked against a HEN service implementation checklist adapted from the Agency for Clinical Innovation (ACI).

RESULTS

Responses were received from 107 HEN services, with an estimated combined population of 7122 HEN patients. Services were predominantly government-funded (n = 102, 95.3%) and operated from acute hospitals (n = 57, 53.3%). The reported combined cost of all HEN equipment to the patient ranged from $0-$77 per week or $0-$341 per month. Fifty-two services were reported to have a dedicated HEN dietitian/coordinator, which was positively associated with the undertaking of quality improvement activities (p = 0.019). Mean compliance to the ACI HEN implementation checklist was 70.4% (±15.7%) with a range of 13.0-98.2%. Mean compliance was significantly higher in services with a HEN dietitian/coordinator than services without one (75.5% (±12.0%) vs 64.3% (±16.6%); p < 0.001).

CONCLUSIONS

This study provides detailed information regarding the characteristics of HEN services and nutrition care provided to enterally-fed patients across Australia and New Zealand. The majority of HEN services are not adhering to the ACI HEN service guidelines and there is considerable variation in cost burden for consumers indicating inequitable delivery of care to patients.

The experience of family caregivers of patients receiving home nasogastric tube feeding in China: A descriptive qualitative study

Background

The value of caregivers with respect to ensuring safety during home nasogastric tube (NGT) feeding is increasingly acknowledged. However, little attention has been given to the experience of caregivers.

Methods

A qualitative descriptive design using semi‐structured interviews via purposive sampling at a comprehensive hospital in China was employed. Family caregivers of patients with home NGT feeding were recruited. Interviews were recorded, transcribed verbatim and analysed qualitatively using inductive content analysis.

Results

Thirteen family caregivers of patients with home NGT feeding were interviewed. Four main themes were generated: negative experience (uncertainty and ambivalence, transition gaps between hospitals and home care services), new role: adapting to the lifestyle (participating in decision‐making, being responsible for everything, adjusting own life to NGT feeding), perceived benefit of caregiving (personal growth, development of positive attitudes and achievements) and expectations (expectations from continuity health system services, expectations from social support).

Conclusions

The present study highlights the vulnerability and perceived benefits embedded in the role of a family caregiver. Improving communication and standardising practices between home and hospitals should be considered.

Organizational issues of home parenteral nutrition during COVID-19 pandemic: Results from multicenter, nationwide study

Objectives

Patients on home parenteral nutrition (HPN) are prone to severe complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The pandemic requires adaptation of the health care standards, including epidemiologic surveillance, logistics of home supply, and monitoring. Potential lack of medical professionals may worsen the standard of care. The aim of this study was to evaluate the medical staff resources in HPN units.

Results

The study was conducted by major Polish scientific societies in clinical nutrition. A questionnaire was distributed among all Polish adult HPN centers concerning statistics from the first 3 mo of the pandemic (March through May 2020). Data on medical staff resources and organizational issues of the units were collected. Modifications of the home procedures, SARS-CoV-2 infection rates of HPN patients and health care workers (HCW) were analyzed. Influence of the pandemic on the rates of new qualifications for home artificial nutrition (HAN) was estimated. Fourteen of 17 adult Polish HPN units took part in the study. The point prevalence of HPN in Poland was 30.75/1 million citizens. Of HCWs, 344 were involved in patient care in Polish HPN units; 18.9% were physicians (49% surgeons, 18.46% internal medicine specialists, 15.38% anesthesiologists, 7.69% pediatricians, 1.54% palliative care specialists), 32.27% nurses, 5.23% dietitians, 9.01% pharmacists, 4.94% pharmacy technicians, 3.2% pharmacy assistants, 5.81% administrative workers, 3.49% physiotherapists. HAN patient-to-HCW ratios for physicians, nurses, pharmacists, dietitians were 49.5, 29.15, 111.6, and 181.6, respectively. Medium ages of physicians and nurses were 45.6 and 44.15 y, respectively. Slightly less than half (53.8%) of physicians and 31.53% of nurses worked parallelly in hospital wards. Thirty-one pharmacists overall were working in all HPN units (2.21 per unit) as were 18 dietitians (1.3 per unit). Nine patients had a confirmed COVID-19 infection (four HPN, five home enteral nutrition). All the units introduced telemedicine solutions in the first months of the pandemic. The number of new qualifications for HPN and home enteral nutrition in the units did not significantly decline from March through May in comparison with a similar period in 2019.

Conclusions

A shortage of HPN medical professionals requires attention when planning health care organization, especially during a pandemic. Severe restrictions in public health systems may not reduce the number of new qualifications for the HPN procedure. There is a need for the continuation of data collection during the evolution of the pandemic as it may have a detrimental effect on HPN including serious issues with access to professional HCWs.