Transition to Peptide-Based Diet Improved Enteral Nutrition Tolerance and Decreased Healthcare Utilization in Pediatric Home Enteral Nutrition

Dietitian's approach to managing enteral nutrition intolerance when a formula change is indicated: A clinical practice survey

BACKGROUND

Enteral nutrition intolerance (ENI) is often defined as one or more gastrointestinal (GI) symptoms related to enteral nutrition (EN) and may have significant impact on patient outcomes. There are multiple strategies to help manage ENI, such as changing the EN formula. The objective of this practice survey was to understand prevalence of ENI, management of ENI symptoms, and EN formula features considered when changing formulas to manage ENI.

METHODS

Canadian clinical dietitians working across care settings (n = 4827) were invited to complete a 28-question online survey if involved in the management of adult and/or pediatric patients receiving EN.

RESULTS

Five hundred seventeen surveys were analyzed. Significantly more dietitians in adult vs pediatric settings (83.4% and 59.1%, respectively; P = 0.0012), reported ENI in <40% of patients. Assessing medications, elevating the head of the bed, and changing EN infusion rate, volume, or feeding regimen were the highest-ranked strategies to manage ENI symptoms. Most (>90%) respondents change the EN formula <50% of the time to manage ENI. Dietitians consider caloric density and protein form as the most important EN features to manage upper-GI symptoms vs fiber source, osmolality, and form of protein to manage lower-GI symptoms. EN with real-food ingredients was ranked higher in importance for managing upper- and lower-GI symptoms by dietitians in pediatric vs adult settings.

CONCLUSION

To manage ENI symptoms, dietitians consider multiple strategies before deciding to change the EN formula. When a formula change is indicated, dietitians consider different EN features for the management of upper- and lower-GI symptoms.

Peptide-based formula: Clinical applications and benefits

The use of enteral nutrition (EN) continues to increase given benefits. However, with this increase in use, it is also becoming evident that enteral feeding intolerance (EFI) is also quite prevalent, leading to the inability to meet nutrition needs in many patients. Given the wide variability in the EN population as well as the number of formulas available, there is not a clear consensus regarding the best approach to EFI management. One approach that is emerging to improve EN tolerance is the use of peptide-based formulas (PBFs). PBFs refer to enteral formulas containing proteins that have been enzymatically hydrolyzed to dipeptides and tripeptides. These hydrolyzed proteins are often combined with higher medium-chain triglyceride content to generate an enteral formula that is essentially easier to absorb and utilize. Emerging data demonstrate that the use of PBF in patients with EFI may improve clinical outcomes along with a corresponding reduction in healthcare utilization and potentially the cost of care. This review aims to navigate through key clinical applications and benefits of PBF and to discuss relevant data shared in the literature.

Enteral formula compared to Nissen-Fundoplication: Data from a retrospective analysis on tolerance, utility, applicability, and safeness in children with neurological diseases

Objectives and study

Approximately 46–90% of children with neurological disorders (NDs) suffer from gastrointestinal diseases, such as gastro-esophageal reflux disease (GERD), constipation, or malnutrition. Therefore, enteral feeding is often necessary to achieve nutritional requirements. The treatment of GERD could be based on pharmacological therapy, nutritional treatment (changing the type of formula), or surgical treatment (Nissen Fundoplication, NF). The aim of this study was to describe and compare resource consumption between NE based on different formulas and NF in patients with ND.

Methods

We performed a retrospective analysis on all children with neurological damage (age: 29 days−17 years) treated from January 2009 to January 2019 due to nutritional problems and food and/or gastrointestinal intolerances. For all patients, demographic and anthropometric characteristics, symptoms, type of nutrition (formula and enteral access), and number and type of outpatient or emergency room visits were collected. Patients with &lt;24 months of age at the closing of the database and with &lt;24 months of follow-up were excluded.

Results

Out of 376 children, 309 children (M: 158; median age: 4 IQR 1–10) were enrolled, among which, 65 patients (NF group M: 33; median age: 5.3 IQR 1.8–10.7) underwent NF. Vomit, GERD, and dysphagia were more represented in the NF group (p &lt; 0.05). Our analysis shows that the NF group seems to present a lower number of hospitalization and a lower number of visits for non-GI disorders, but a higher number of visits for GI disorders compared to non-NF. In the NF group, a higher prevalence of the use of amino-acid-based formula and free diet is observed, with a trend for the lower prevalence of casein-based or whey+casein-based formula (Fisher test p = 0.072). The median cost of a patient enrolled in the database is € 19,515 ± 540 ($ 20,742.32 ± 573.96) per year, with no significant difference between the two groups. Regarding formula, at baseline, 76 children consumed a free diet, 24 a casein-based formula, 139 a whey+casein-based formula, 46 a whey-based formula, and 24 an amino-acid-based formula.

Conclusions

In conclusion, compared to EN, NF may not improve the clinical aspect and related costs in children with NDs. Considering the psychological and QoL burden for patients, in a “step-up” strategy, EN could be proposed as an efficient alternative to NF.

Discharged on Enteral Nutrition: What Now? The Poor State of Outpatient Support for Patients on Enteral Nutrition Support

PURPOSE OF REVIEW

While the use of enteral nutrition (EN) has increased, and more medical centers have developed inpatient programs to address the unique needs of these patients, our collective experience at a few large institutions indicates that there is very little systemic support for patients after discharge. Here, we discuss what we have observed to be some of the barriers to providing outpatient follow up care, summarize the impact we have seen on patients, and propose some possible solutions.

RECENT FINDINGS

We have observed and identified some of the root causes to include financial barriers; uncoordinated care transitions; high complexity of care, including medication management; and diffuse leadership to a multidisciplinary problem. Systematic support for outpatient care for patients discharged on enteral nutrition is rare and limited, due to many root causes. There are a few tools and tips that we have summarized here for individual providers, and a few promising methods in development, but a systematic approach is in great need.