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.

Exclusive Enteral Nutrition Mediates Beneficial Gut Microbiome Enrichment in Acute Severe Colitis

BACKGROUND

Exclusive enteral nutrition (EEN) supplementation of the standard of care (SOC) augments steroid responsiveness in patients with acute severe ulcerative colitis (ASUC). EEN is known to alter gut microbial composition. The present study investigates EEN-driven gut microbial alterations in patients with ASUC and examines their correlations with clinical parameters.

METHODS

Stool samples from patients with ASUC (n = 44) who received either EEN-supplemented SOC (EEN group; n = 20) or SOC alone (SOC group; n = 24) for 7 days were collected at baseline (day 0) and postintervention (day 7). Microbiome analysis was carried out using 16S ribosomal RNA gene sequencing followed by data processing using QIIME2 and R packages.

RESULTS

Seven-day EEN-conjugated corticosteroid therapy in patients with ASUC enhanced the abundances of beneficial bacterial genera Faecalibacterium and Veillonella and reduced the abundance of Sphingomonas (generalized linear model fitted with Lasso regularization with robustness of 100%), while no such improvements in gut microbiota were observed in the SOC group. The EEN-associated taxa correlated with the patient's clinical parameters (serum albumin and C-reactive protein levels). Unlike the SOC group, which retained its preintervention core microbiota, EEN contributed Faecalibacterium prausnitzii, a beneficial gut bacterial taxon, to the gut microbial core. EEN responders showed enhancement of Ligilactobacillus and Veillonella and reduction in Prevotella and Granulicatella. Analysis of baseline gut microbiota showed relative enhancement of certain microbial genera being associated with corticosteroid response and baseline clinical parameters and that this signature could conceivably be used as a predictive tool.

CONCLUSIONS

Augmentation of clinical response by EEN-conjugated corticosteroid therapy is accompanied by beneficial gut microbial changes in patients with ASUC.

Nutritional support during the first week for infants with bronchopulmonary dysplasia and respiratory distress: a multicenter cohort study in China

BACKGROUND

Bronchopulmonary dysplasia (BPD) is a major complication affecting the survival rate and long-term outcomes of preterm infants. A large, prospective, multicenter cohort study was conducted to evaluate early nutritional support during the first week of life for preterm infants with a gestational age < 32 weeks and to verify nutritional risk factors related to BPD development.

METHODS

A prospective multicenter cohort study of very preterm infants was conducted in 40 tertiary neonatal intensive care units across mainland China between January 1, 2020, and December 31, 2021. Preterm infants who were born at a gestational age < 32 weeks, < 72 h after birth and had a respiratory score > 4 were enrolled. Antenatal and postnatal information focusing on nutritional parameters was collected through medical systems. Statistical analyses were also performed to identify BPD risk factors.

RESULTS

The primary outcomes were BPD and severity at 36 weeks postmenstrual age. A total of 1410 preterm infants were enrolled in this study. After applying the exclusion criteria, the remaining 1286 infants were included in this analysis; 614 (47.7%) infants were in the BPD group, and 672 (52.3%) were in the non-BPD group. In multivariate logistic regression model, the following six factors were identified of BPD: birth weight (OR 0.99, 95% CI 0.99-0.99; p = 0.039), day of full enteral nutrition (OR 1.03, 95% CI 1.02-1.04; p < 0.001), parenteral protein > 3.5 g/kg/d during the first week (OR 1.65, 95% CI 1.25-2.17; p < 0.001), feeding type (formula: OR 3.48, 95% CI 2.21-5.49; p < 0.001, mixed feed: OR 1.92, 95% CI 1.36-2.70; p < 0.001; breast milk as reference), hsPDA (OR 1.98, 95% CI 1.44-2.73; p < 0.001), and EUGR ats 36 weeks (OR 1.40, 95% CI 1.02-1.91; p = 0.035).

CONCLUSIONS

A longer duration to achieve full enteral nutrition in very preterm infants was associated with increased BPD development. Breastfeeding was demonstrated to have a protective effect against BPD. Early and rapidly progressive enteral nutrition and breastfeeding should be promoted in very preterm infants.

TRIAL REGISTRATION

The trial was registered in the Chinese Clinical Trial Registry (No. ChiCTR2000030125 on 24/02/2020) and in www.ncrcch.org (No. ISRCTN84167642 on 25/02/2020).

Pre-Diagnosis Diet Predicts Response to Exclusive Enteral Nutrition and Correlates with Microbiome in Pediatric Crohn Disease

Exclusive enteral nutrition (EEN) is effective in inducing remission in pediatric Crohn disease (CD). EEN alters the intestinal microbiome, but precise mechanisms are unknown. We hypothesized that pre-diagnosis diet establishes a baseline gut microbiome, which then mediates response to EEN. We analyzed prospectively recorded food frequency questionnaires (FFQs) for pre-diagnosis dietary patterns. Fecal microbiota were sequenced (16SrRNA) at baseline and through an 18-month follow-up period. Dietary patterns, Mediterranean diet adherence, and stool microbiota were associated with EEN treatment outcomes, disease flare, need for anti-tumor necrosis factor (TNF)-α therapy, and long-term clinical outcomes. Ninety-eight patients were included. Baseline disease severity and microbiota were associated with diet. Four dietary patterns were identified by FFQs; a "mature diet" high in fruits, vegetables, and fish was linked to increased baseline microbial diversity, which was associated with fewer disease flares (p < 0.05) and a trend towards a delayed need for anti-TNF therapy (p = 0.086). Baseline stool microbial taxa were increased (Blautia and Faecalibacterium) or decreased (Ruminococcus gnavus group) with the mature diet compared to other diets. Surprisingly, a "pre-packaged" dietary pattern (rich in processed foods) was associated with delayed flares in males (p < 0.05). Long-term pre-diagnosis diet was associated with outcomes of EEN therapy in pediatric CD; diet-microbiota and microbiota-outcome associations may mediate this relationship.

An Elemental Diet Reduces Chylous Ascites of Patients Undergoing Pancreatoduodenectomy in the Setting of Early Enteral Feeding

OBJECTIVES

The elemental diet (ED) is a formula to support nutritional status without increasing chylous burden. This study evaluates the efficacy of early ED feeding after pancreatoduodenectomy (PD).

MATERIALS AND METHODS

A prospective phase II study of consecutive patients who underwent PD with early ED feeding was conducted. Patient backgrounds, surgical outcomes, and ED feeding tolerability were compared with a historical cohort of 74 PD patients with early enteral feeding of a low residue diet (LRD).

RESULTS

The ED group comprised 104 patients. No patient in the ED group discontinued enteral feeding because of chylous ascites (CAs), whereas 17.6% of the LRD group experienced refractory CAs that disrupted further enteral feeding. The CAs rate was significantly decreased in the ED group compared with the LRD group (3.9% and 48.7%, respectively; P < 0.001). There was no significant difference in the incidence of major complications (ED: 17.3%, LRD: 18.9%; P = 0.844). Postoperative prognostic nutritional index was similar between the 2 groups ( P = 0.764). In multivariate analysis, enteral feeding formula, and sex were independent risk factors for CAs (LRD: P < 0.001, odds ratio, 22.87; female: P = 0.019, odds ratio, 2.78).

CONCLUSIONS

An ED reduces postoperative CAs of patients undergoing PD in the setting of early enteral feeding.

The Effect of Lullabies and Classical Music on Preterm Neonates' Cerebral Oxygenation, Vital Signs, and Comfort During Orogastric Tube Feeding: A Randomized Controlled Trial

OBJECTIVE

This study investigated the effect of lullabies and classical music on preterm neonates' cerebral oxygenation, vital signs, and comfort during orogastric (OG) tube feeding.

METHODS

This was a parallel-group pretest-posttest randomized controlled study. The research was conducted between December 2020 and May 2022. The sample consisted of 51 preterm neonates hospitalized in the neonatal intensive care unit (NICU) of Selçuk University Faculty of Medicine Hospital in Konya, Türkiye. Participants were randomized into three groups (17 preterm infants in each group). The first group listened to lullabies sung by their mothers and the second group listened to classical music during OG tube feeding. The control group received routine care with no music. Data were collected using a Neonatal Identification Information Form, Physiological Parameters and rSO2 Monitoring Form, and the Newborn Comfort Behavior Scale (Comfort-Neo). The study was registered on the ClinicalTrials database (NCT05333575).

RESULTS

The lullaby group had stable peak heart rates and oxygen saturation levels (p = .002). Both lullaby and classical music groups had significantly higher cerebral oxygenation levels than the control group. The classical music group had the highest cerebral oxygenation level (p = .001). Both lullaby and classical music groups had significantly higher mean Comfort-Neo scores than the control group. The classical music group had the highest mean Comfort-Neo score (p = .040).

CONCLUSION

Preterm neonates who listen to lullabies and classical music are likely to have higher cerebral oxygen and comfort levels. Listening to lullabies helps stabilize vital signs. These results suggest that healthcare professionals should encourage parents to get their preterm neonates to listen to lullabies and classical music.

Early enteral nutrition versus early supplemental parenteral nutrition in patients undergoing major abdominal surgery: a secondary analysis of 2 randomized clinical trials

BACKGROUND

The effect of early isoenergetic feeding routes [early enteral nutrition (E-EN) or early supplemental parenteral nutrition (E-SPN)] on the outcome of patients undergoing major abdominal surgery is controversial.

OBJECTIVES

The aim of this study was to investigate the impact of early isoenergetic EN compared with early isoenergetic SPN on nosocomial infections in patients undergoing major abdominal surgery.

METHODS

This study is a secondary, post hoc analysis of data from 2 open-label randomized clinical trials. Participants were recruited from the general surgery department of 11 academic hospitals in China undergoing major abdominal surgery and with Nutritional Risk Screening 2002 score ≥3. All eligible patients were categorized into 2 groups based on their achievement of the 100% energy target on postoperative day (POD) 3: the E-EN group (n = 199) and the E-SPN group (n = 115). The primary outcome was the incidence of nosocomial infections between POD 3 and hospital discharge.

RESULTS

In total, 314 patients [mean (SD) age, 59.2 (11.4) y; 113 (36.0%) females] were included. Patients in the E-EN group showed no significant difference in nosocomial infections compared with those in the E-SPN group {17/199 [8.5%] compared with 10/115 [8.7%], risk difference, 0.2% [95% confidence interval (CI): -6.3, 6.6]}. The hematological nutritional status of the E-EN group showed a significant improvement at discharge compared with the E-SPN group (albumin: 38.0 ± 6.0 g/L compared with 35.5 ± 7.6 g/L; mean difference, -2.5 g/L; 95% CI: -4.0, -1.0 g/L; prealbumin: 200.0 ± 8.0 mg/L compared with 158.4 ± 38.1 mg/L; mean difference, -41.6 mg/L; 95% CI: -41.7, -36.1 mg/L). Other indicators were comparable between groups.

CONCLUSION

E-EN compared with isoenergetic SPN may not be associated with a reduced rate of nosocomial infection in patients undergoing major abdominal surgery, but may be associated with improved hematological nutritional status.

TRIAL REGISTRATION NUMBER

This trial was registered at clinicaltrials.gov as NCT03115957 (https://clinicaltrials.gov/ct2/show/NCT03115957) and NCT03117348 (https://clinicaltrials.gov/ct2/show/NCT03117348).

Early enteral nutrition in patients with out-of-hospital cardiac arrest under target temperature management was associated with a lower 7-day bacteremia rate: A post-hoc analysis of a retrospective cohort study

INTRODUCTION

Early enteral nutrition (EN) is a nutritional strategy for reducing the incidence of in-hospital infections. However, the benefits of early EN, under targeted temperature management (TTM) in patients with out-of-hospital cardiac arrest (OHCA), remain unclear. We aimed to evaluate the effect of early EN on the infective complications of OHCA patients who underwent TTM.

METHODS

We retrospectively searched the clinical databases of two adult emergency tertiary referral hospitals in southern Taiwan and identified patients admitted for OHCA who underwent TTM between 2017 and 2022. The 85 enrolled patients were divided into two groups based on timing: early EN (EN within 48 h of admission) and delayed EN (EN > 48 h after admission). Clinical outcomes of 7-day infective complications between the two groups were analyzed.

RESULTS

Early EN was provided to 57 (67 %) of 85 patients and delayed EN was provided to the remaining 28 (33 %) patients. No significant differences in baseline patient characteristics were observed between the two groups. In addition, no differences in clinical outcomes were observed, except that the early EN group had a lower 7-day bacteremia rate (5.3 % vs. 26.9 %, p = 0.013). Gram-negative bacteria were the major pathogen among the 7-day infective complications.

CONCLUSION

In OHCA patients treated with TTM, early EN was associated with a lower 7-day bacteremia rate. Furthermore, the application of early EN in this population was well tolerated without significant adverse events.

Feeding after congenital heart surgery: a mixed-methods study of the caregiver experience

OBJECTIVES

Feeding difficulties after congenital heart surgery are a common concern for caregivers of children with CHD. Insight into the intricacies of their experience is lacking. With a better understanding, healthcare providers can continue to optimize the approach and support mechanisms for these families. This study will explore the psychosocial impacts on caregivers, define barriers to care, and identify areas to improve their care.

STUDY DESIGN

This mixed-methods study combined semi-structured interviews with surveys. Purposive sampling targeted caregivers of a child who underwent heart surgery and was discharged with alternative enteral feeding access. A hybrid inductive-deductive methodology was used to analyse interview transcripts. Survey scores were compared to interview content for concordance.

RESULTS

Fifteen interviews were conducted with socio-demographically diverse caregivers. Feeding difficulties were often identified as their greatest challenge, with the laborious feeding schedule, sleep deprivation, and tube management being common contributors. Most caregivers described feeling overwhelmed and worried. Time-intensive feeding schedules and lack of appropriate childcare options precluded caregivers' ability to work. Barriers to care included imperfect feeding education, proximity of specialist clinics, and issues with medical supply companies. Caregiver proposals for improved care addressed easing the transition home, improving emotional support mechanisms, and intensifying feeding therapy for expedited tube removal.

CONCLUSION

This study describes the psychosocial toll on the caregiver, typical barriers to care, and ideas for improved provision of care. These themes and ideas can be used to advance the family-centered approach to feeding difficulties after heart surgery.

The Safety and Efficacy of Early Enteral Nutrition After Paediatric Enterostomy Closure - The EPOC Study

INTRODUCTION

Keeping children nil by mouth until return of bowel function after intestinal anastomosis surgery is said to reduce complications. Fasting may extend up to five days, risking malnourishment and usage of parenteral nutrition. This study aims to establish the efficacy and safety of early enteral nutrition in children undergoing intestinal stoma closure.

METHODOLOGY

A retrospective cohort study of children aged three months to 16 years who underwent an intestinal stoma closure between 1/1/2019 and 31/12/2021 at two tertiary paediatric hospitals was undertaken. Children fed clear fluids within 24 h (EEN) were compared to those commencing feeds later (LEN). The primary outcome was length of post-operative stay (LOS) and secondary outcomes included: time to feeds; time to stool; and complications.

RESULTS

Of the 129 children that underwent a stoma closure, 69 met inclusion criteria: 35 (51 %) in the LEN group and 34 (49 %) in the EEN group. Children in the EEN group had a significantly shorter LOS (92.6 h vs 121.7 h, p = 0.0045). Early feeding was also associated with a significantly decreased time to free fluids (p < 0.001) and full enteral intake (p = 0.007). There was no significant intergroup difference in complications.

CONCLUSION

Commencing feeding within 24 h of stoma closure is efficacious and safe, with clear reductions in LOS, time to full feeds and time to stool, and no increase in complications. Further research is required to extrapolate these findings to other populations.

LEVEL OF EVIDENCE

III.

Nutritional Support in Critically Ill Trauma Patients

Enteral nutrition should be initiated within 24 to 48 hours of injury, starting at a trophic rate and increasing to goal rate after hemodynamic stability is achieved. The modified Nutritional Risk in the Critically Ill score can help identify patients who will benefit most from aggressive and early nutritional intervention. In the first week of critical illness, the patient should receive only 70% to 80% of estimated calories and protein should be targeted to 1.5 to 2 g/kg. Parenteral nutrition can be provided safely without increased adverse events. Peri-operative (and intra-operative) feeding has been shown to be safe in selected patients.

Factors Associated with Growth in a Cohort of Children with Complex Biventricular Congenital Heart Disease

OBJECTIVES

To evaluate patterns and determinants of longitudinal growth among children requiring complex biventricular repair for congenital heart disease, as well as to assess for associations of growth with early feeding modality, comorbidities, postoperative complications, and socioeconomic characteristics.

STUDY DESIGN

A single-institution retrospective cohort study was performed in children born February 1999 to March 2009 with complex congenital heart disease who underwent biventricular repair before age 4 years, defined by Risk Adjustment in Congenital Heart Surgery-1 category 3-5. Clinical characteristics, height, weight, and body mass index (BMI) from ages 2-12 years were collected by chart review. Neighborhood-level socioeconomic data were identified using a geographic information system approach. The adjusted association of covariates with growth outcomes was estimated using multivariable linear regression models using generalized estimating equations.

RESULTS

Compared with population growth curves, the cohort (n = 150) trended toward early decrease in age-adjusted weight and height. Early tube feeding was significantly associated with decreased BMI before adolescence (-0.539; 95% CI -1.02, -0.054; P = .029). In addition, other clinical and perioperative characteristics had significant associations with growth, including low birth weight, preoperative tube feeds, need for multiple bypass runs, and diagnosis of feeding disorder.

CONCLUSIONS

Early childhood growth in children with complex biventricular repair may be impaired. Early tube feeding was associated with decreased BMI over the course of early childhood, which may indicate a need for continued close nutrition follow-up and support even beyond the duration of tube feeds.

Identification of enteral nutrition errors in a single-center quality-improvement audit

BACKGROUND

Enteral nutrition (EN) therapy is a multistep process including evaluation, prescription, procurement, dispensing, labeling, administration, and monitoring. EN therapy is prone to human errors, but these are poorly defined in the literature. The purpose of this study was to audit EN administration practices to quantify errors of execution and identify which components of the EN order were labeled, administered, or documented incorrectly.

METHODS

On 2 nonconsecutive days, we identified all hospitalized patients with active EN orders and prospectively collected the following information: EN formula hanging/documented, formula hang time, infusion rate/documented rate (continuous EN), infused volume and documented schedule (intermittent EN), and EN modular documentation. Mismatches to the EN order were considered errors. We reviewed 1 month of hospital EN-related safety events for comparison.

RESULTS

Of 1045 data points collected from 160 patients, we identified 275 errors of execution: 135 labeling errors and 140 administration errors. The most common were hang time >48 h (85%), wrong number of modulars documented (48%), and wrong infusion rate (19%). We found one reported safety event (wrong formula delivered but not infused).

CONCLUSION

We identified a 15.9% error rate in EN order execution/documentation and 14% compliance with documentation of 48-h hang time. Errors (safety events) were grossly underreported. This highlighted several areas of opportunity to improve current EN use process, consistent with previous research on EN and oral nutrition supplement administration. Based on our findings, we plan to recommend implementation of EN barcoding at our institution, to model the familiar medication administration record.

A quality improvement initiative standardizing the antibiotic treatment and feeding practices in patients with medical necrotizing enterocolitis

OBJECTIVE

Evaluate the impact of a multidisciplinary guideline standardizing antibiotic duration and enteral feeding practices following medical necrotizing enterocolitis (mNEC).

STUDY DESIGN

For preterm infants with Bell Stage 2 A mNEC and negative blood culture, antibiotic treatment was standardized to 7 days. Trophic feeds of unfortified human milk began 72 h after resolution of pneumatosis. Feeds were advanced by 20 cc/kg/day starting on the last day of antibiotics. Primary outcomes were antibiotic days and days to full feeds, defined as 120 cc/kg/day of enteral nutrition. Secondary outcomes included central line days and length of stay (LOS).

RESULTS

Antibiotic duration decreased 23%. Time to start trophic feeds and time to full feeds decreased 33 and 16% respectively. Central line use dropped (98 to 72% of infants) and central line days were reduced by 59%.

CONCLUSION

Implementation of a mNEC QI package reduced antibiotic duration, time to full feeds, central line use and CL days.

Outcomes and Experiences of Patients and Their Caregivers After Severe Stroke Requiring Tube Feeding in Peru

OBJECTIVES

Evaluate clinical outcomes of stroke survivors in Peru discharged with artificial nutrition via a feeding tube (FT), and explore perspectives and experiences of these patients and their caregivers.

METHODS

Retrospective chart review to describe the prevalence of FT placement and characteristics of patients admitted with stroke to the Instituto Nacional de Ciencias Neurológicas in Lima, Peru between January 2019 and 2021. Follow-up calls to stroke survivors discharged home with FTs or their caregivers included quantitative and qualitative questions to assess long-term outcome and explore perspectives around poststroke care and FT management. We analyzed quantitative data descriptively and applied thematic analysis to qualitative data using a consensus-driven codebook.

RESULTS

Of 812 hospitalized patients with stroke, 146 (18%) were discharged home with FT, all with nasogastric tubes (NGTs). Follow-up calls were performed a median of 18 months after stroke with 96 caregivers and three patients. Twenty-five patients (25%) had died, and 82% of survivors (n = 61) remained dependent for some care. Four themes emerged from interviews: (1) perceived suffering (physical, emotional, existential) associated with the NGT and stroke-related disability, often exacerbated by lack of preparedness or prognostic awareness; (2) concerns around compromised personhood and value-discordant care; (3) coping with their loved-one's illness and the caregiving role; and (4) barriers to NGT care and skill acquisition.

CONCLUSION

We identified a high burden of palliative and supportive needs among severe stroke survivors with NGTs and their caregivers suggesting opportunities to improve poststroke care through education, communication, and support.

Current fistula management

PURPOSE OF REVIEW

Enterocutaneous fistulas (ECFs) pose a significant impact in the healthcare system, both financially and in resource utilization. Delivery of optimal care is complex and involves intensive wound care, complex nutritional delivery and multidisciplinary care teams for optimization. Recently, there have been pushes to modernize the traditional approach to ECF care to a new paradigm of protocol-based individualized delivery of care.

RECENT FINDINGS

There is an increased trend towards pushing enteral nutrition for the management of ECF patients. Adjuncts, including improved fistuloclysis devices, supplements and absorptive aides have challenged the conventional dogma of ECF treatment. There has also been increased focus on surgical prehabilitation and the ability to improve patient outcomes.

SUMMARY

ECF care is complex and requires a multidisciplinary approach focused on source control, nutritional optimization with focus on enteral nutrition, wound care and prehabilitation.

Effect of thickened water swallow training in tube-feeding and dysphagia patients in the acute and early subacute phases of stroke: A quasi-experimental study

BACKGROUND

Thickened water has been widely used in patients with dysphagia who receive oral feeding, but there is little evidence for tube-feeding patients.

OBJECTIVE

To explore the effects of thickened water swallow training in tube-feeding and dysphagia patients in the acute and early subacute phases of stroke.

METHODS

A quasi-experimental study. Hospitalised patients with acute and early subacute stroke who received tube feeding due to dysphagia were recruited from March to December 2021. Patients assigned to the intervention group (n = 23) received thickened water swallow training three times daily until the feeding tube was removed or they were discharged, and patients in the control group (n = 23) received usual care. The main outcomes were duration of tube feeding and rates of weaning at discharge.

RESULTS

Patients in the intervention group had a shorter tube-feeding duration (p = .046) and a higher rate of weaning at discharge (p = .017) than those in the control group. Significant interaction effects between time and group were detected regarding quality of life except for the swallowing burden dimension.

CONCLUSIONS

Thickened water swallow training is feasible and effective for stroke patients with tube feeding and can shorten the duration of tube feeding and improve the rates of weaning and quality of life. Healthcare providers in nonrehabilitation units should actively conduct swallowing function intervention training to maximise the potential for acute and early subacute phase rehabilitation.

A clinical consensus paper on jejunal tube feeding in children

BACKGROUND

Feeding problems are common in children with complex medical problems or acute critical illness and enteral nutrition may be required. In certain situations, gastric tube feeding is poorly tolerated or may not be feasible. When feed intolerance persists despite appropriate adjustments to oral and gastric enteral regimens, jejunal tube feeding can be considered as an option for nutrition support.

METHODS

A multidisciplinary expert working group of the Australasian Society of Parenteral and Enteral Nutrition was convened. They identified topic questions and five key areas of jejunal tube feeding in children. Literatures searches were undertaken on Pubmed, Embase, and Medline for all relevant studies, between January 2000 and September 2022 (n = 103). Studies were assessed using National Health and Medical Research Council guidelines to generate statements, which were discussed as a group, followed by voting on statements using a modified Delphi process to determine consensus.

RESULTS

A total of 24 consensus statements were created for five key areas: patient selection, type and selection of feeding tube, complications, clinical use of jejunal tubes, follow-up, and reassessment.

CONCLUSION

Jejunal tube feeding is a safe and effective means of providing nutrition in a select group of pediatric patients with complex medical needs, who are unable to be fed by gastric tube feeding. Appropriate patient selection is important as complications associated with jejunal tube feeding are not uncommon, and although mostly minor, can be significant or require tube reinsertion. All children receiving jejunal tube feeding should have multidisciplinary team assessment and follow-up.

Safety and Efficacy of Insulins in Critically Ill Patients Receiving Continuous Enteral Nutrition

OBJECTIVE

There is a relative lack of consensus regarding the optimal management of hyperglycemia in patients receiving continuous enteral nutrition (EN), with or without a diagnosis of diabetes.

METHODS

This retrospective study examined 475 patients (303 with known diabetes) hospitalized in critical care setting units in 2019 in a single center who received continuous EN. Rates of hypoglycemia, hyperglycemia, and glucose levels within the target range (70-180 mg/dL) were compared between patients with and without diabetes, and among patients treated with intermediate-acting (IA) biphasic neutral protamine Hagedorn 70/30, long-acting (LA) insulin, or rapid-acting insulin only.

RESULTS

Among those with type 2 diabetes mellitus, IA and LA insulin regimens were associated with a significantly higher proportion of patient-days in the target glucose range and fewer hyperglycemic days. Level 1 (<70 mg/dL) and level 2 (<54 mg/dL) hypoglycemia occurred rarely, and there were no significant differences in level 2 hypoglycemia frequency across the different insulin regimens.

CONCLUSION

Administration of IA and LA insulin can be safe and effective for those receiving insulin doses for EN-related hyperglycemia.

Risk Factors of Enternal Nutrition Intolerance in Septic Patients: A Case-control Study

OBJECTIVE

This study aimed to investigate the incidence of enteral nutrition intolerance (ENI) in patients with sepsis and explore potential risk factors.

METHODS

A case-control study was conducted in patients with sepsis who were receiving enteral nutrition (EN) at a tertiary hospital in China. The included patients were divided into the ENI group and the non-ENI group. Univariate and multivariate analyses were performed to identify the risk factors for ENI.

RESULTS

A total of 859 patients were included in the study. Among them, 288 (33.53%) patients experienced symptoms of ENI, including diarrhea, vomiting, bloating, and gastric retention. Logistic regression analysis revealed that the Acute Physiology and Chronic Health Evaluation H (APACHE H) score, thoracocentesis, and usage of cardiotonic drugs (namely, inotropes) were independent predictors of the ENI.

CONCLUSION

The incidence of ENI is relatively high in patients with sepsis, especially in those who have higher APACHE H scores, have undergone thoracocentesis, and have received inotropes.