Impact of a natural versus commercial enteral-feeding on the occurrence of diarrhea in critically ill cardiac surgery patients. A retrospective cohort study

The effect of blended tube feeding compared to conventional formula on clinical outcomes in adults: A systematic review

AIM

To explore the effect of blended tube feeding compared to conventional formulas on nutritional status, quality of life, anthropometry, diarrhoea and tube blockages in adults receiving tube feeding.

METHODS

The protocol was registered (PROSPERO CRD42022372443). Five databases (MEDLINE, EMBASE, CINAHL, Scopus, CENTRAL) were searched from commencement of database to 14th June 2023 to identify studies comparing blended tube feeding to conventional formulas in adults receiving tube feeding. Certainty assessment was conducted using the Cochrane Risk of Bias Tools and the Grading of Recommendations, Assessment, Development and Evaluations framework, and a narrative synthesis of results is provided.

RESULTS

From 4227 studies screened, eight were included (total n = 763 patients, 9-215 patients). Three studies were hospital-based and five were home-based with duration from 8 days-8 months. Blended tube feeding and conventional formulas were nutritionally equivalent in only three studies; energy and protein concentration of formulas ranged from 1.7-7.1 kJ/mL and 21-68.5 g/L for the blended tube feeding groups, and 4.2-6.7 kJ/mL and 39-100 g/L for the conventional groups. No studies assessed nutrition status or quality of life using validated measures. Blended tube feeding was associated with a clinically relevant reduction in diarrhoea with a low level of certainty. For remaining outcomes, there were inconclusive findings and an overall very low certainty of evidence for each.

CONCLUSION

The effect of blended tube feeding compared to conventional formulas on all outcomes remains uncertain. Blended tube feeding may reduce the incidence of diarrhoea. Future research using nutritionally equivalent comparisons and validated outcome measures is required.

Aspiration pneumonia in nursing literature-a mapping review

Introduction

Aspiration pneumonia (AP) is an infection of the lungs caused by inhalation of material. The reported incidences vary across literature and clinical populations and is associated with high morbidity and mortality. Management of AP is best carried out by a multidisciplinary team.

Methods

This aim of this review was to collate and describe the available evidence on AP to develop a greater understanding of the concept of AP as it is represented in the nursing literature. As a collaborative team, we undertook the six stages of a systematic mapping review. We searched for the term aspiration pneumonia in 200 peer reviewed nursing journals across 10 databases, over a ten-year period (2013-2023).

Results

In this review, 293 papers were coded. Dysphagia, oral health and tube feeding emerged as the most frequent risk factors for AP, and the most reported factors for preventing this condition. Mortality was the most commonly described consequence of AP, followed by hospitalisations and morbidity. Multiple management approaches were reported including dysphagia assessment, risk evaluation, oral care and texture modification of food and fluids. The role of nurses and interprofessional collaborations were described.

Discussion

Despite limited evidence related to the topic of AP in the nursing literature, the complexity of the causes, prevention, management and consequences of AP emerged. Certain factors, such as dysphagia, oral health, and tube feeding, were described under prevention, cause and management of AP. The importance of multidisciplinary approach in the management and prevention of AP was presented.

Incidence of Enteral Nutrition-Related Diarrhea Among Critically Ill Patients in Intensive Care Units

Enteral nutrition is a common nutritional modality in intensive care units. Despite its valuable benefits, it has many complications among which diarrhea is the most important. However, the incidence of enteral nutrition-related diarrhea is variable in the literature, with no established baseline in Jordan. The aim of this study was to investigate the incidence of enteral nutrition-related diarrhea in intensive care units of a major public hospital in Jordan. A prospective cohort design was adopted over 4 months. Using a consecutive sampling technique, 84 critically ill patients receiving enteral nutrition were recruited. King's Stool Chart was used. The incidence of enteral nutrition-related diarrhea calculated per patient and per feeding day was 63.1% and 13.2%, respectively. Significant positive associations were found between the incidence of diarrhea with feeding days (r = .356, p = .001) and intensive care unit length of stay (r = .254, p = .020). The same was found for the frequency of diarrhea (r = .633, p = .000; r = .439, p = .000, respectively). Conversely, a significant negative association was found between baseline serum albumin and frequency of diarrhea (r = -.250, p = .037). Enteral nutrition-related diarrhea is prevalent in Jordanian intensive care units, but it should not be a barrier to enteral nutrition delivery. It would be beneficial for intensive care unit nurses to improve their nutritional practices by following a nurse-led enteral nutrition protocol to guide the enteral nutrition practices utilizing multidisciplinary approaches.

Degradation kinetics of vitamins in different enteral feeding formulas during storage at different temperatures

Vitamin degradation may be affected differently by various food matrices. In this study, the kinetics of vitamin A, B1, and C degradation were directly compared in two types of enteral feeding formulas (EFFs) with different energy densities over a nine-month storage period at 4, 25, and 30 °C. The content of vitamins A, B1, and C was measured in the initial and stored formulas. The results justified the finding that the content of these vitamins was gradually decreased with storage time or temperature increases during the period. At each temperature during storage, the degradation of vitamins A, B1, and C followed first-order kinetics, and the rate constants calculated indicated the degradation of vitamins was temperature-dependent. The EFF-B exhibited a higher activation energy for vitamin degradation than that in the EFF-A, and the activation energy indicated an inverse relationship with the fat content of EFFs. The outcomes might provide a reference for the development and application of EEFs.

Clinical outcomes associated with blenderized tube feedings in adults: A systematic review

Nearly half a million individuals in the United States are dependent on enteral nutrition to meet their nutrition needs. Public interest in blenderized tube feeding (BTF) has increased over the past decade; however, medical professionals indicate a lack of knowledge about these products and their effects. The purpose of this review is to analyze clinical outcomes in adults who use a BTF formula as their primary nutrition source. A literature search was conducted in PubMed, Scopus, and CINAHL using search terms "adult," "enteral nutrition," "tube feeding," "BTF," blenderized," "blended," "homemade," and "pureed." Nine studies met the inclusion criteria and were analyzed in the review. Under close monitoring, BTF does not pose a higher risk for deterioration in anthropometric measurements. Furthermore, BTF use is consistently associated with improvements in diarrhea. As such, clinicians should consider the use of these formulas in the acute care or rehabilitation settings. Additional research is needed in patients with diverse clinical backgrounds in free-living communities. Larger populations sizes and longer intervention time frames are crucial to providing statistically significant results needed to strengthen the quality of evidence on this topic.

Blenderized tube feedings: Practice recommendations from the American Society for Parenteral and Enteral Nutrition

Prior to the 1970s, blending food and liquids and putting them through an enteral access device (EAD) was the most common form of enteral nutrition (EN). However, in the 1970s, blenderized tube feedings (BTFs) became less popular due to the emergence of modern commercial enteral formulas (CEFs). Recently, a cultural shift toward consuming a natural diet, consisting of whole foods, has led to a resurgence in the use of BTF. The increasing use of BTF in a variety of patient care settings identifies a need for practice recommendations that provide guidance for nutrition professionals and patients. Members of the American Society for Parental and Enteral Nutrition (ASPEN) Enteral Nutrition Committee identified salient clinical questions concerning BTF, conducted a comprehensive literature search, and subsequently developed practice recommendations pertaining to the use of BTF. This paper was approved by the ASPEN 2022-2023 Board of Directors.

The Impact of Blenderized Tube Feeding on Gastrointestinal Symptoms, a Scoping Review

Severe gastrointestinal symptoms are one of the main reasons for switching from conventional artificial tube feeding to blenderized tube feeding (BTF). This study aimed to describe and quantify the impact of BTF on gastrointestinal symptoms in children and adults. We analyzed four databases (PubMed, Scopus, Cochrane Library, and Google Scholar). The review was performed following the PRISMA extension for Scoping Reviews checklist. The methodological quality of articles was assessed following the NIH quality assessment tools. The initial search yielded 535 articles and, after removing duplicates and off-topic articles, 12 met the inclusion criteria. All included papers unanimously converged in defining an improvement of gastrointestinal symptoms during blenderized feeding: the eight studies involving pediatric cohorts report a decrease from 30 to over 50% in gagging and retching after commencing BTF. Similar rates are reported for constipation and diarrhea improvement in most critically ill adults. Experimental studies and particularly randomized controlled trials are needed to develop robust evidence on the effectiveness of BTF in gastrointestinal symptom improvement with prolonged follow-up and adequate medical monitoring.

Stability of vitamin A, E, C and thiamine during storage of different powdered enteral formulas

In this study, two different kinds of commercial enteral formulas were selected to evaluate the changes of vitamin A, E, C and thiamine during the different storage conditions of different temperature and relative humidity (60 ± 1 °C, 60 ± 5% for 5 and 10 days; 37 ± 1 °C, 75 ± 5% for 1, 2, 3, 5 and 6 months; 25 ± 1 °C, 60 ± 5% for 3, 6, 9, 12, 18 and 24 months). The results showed that as the temperature or time increased, the content of vitamin A, E and thiamine was gradually decreased whilst the level of vitamin C remained stable. The vitamins exhibited more stability at the storage of 25 ± 1 °C, RH 60 ± 5%. Vitamin A and thiamine decreased more in the polymeric formula (EFA) than that in the oligomeric formula (EFB), while, vitamin E decreased less in EFA than that in EFB. The kinetics of vitamin A, E and thiamine degradation during storage followed first order kinetic equations. Furthermore, the final levels of vitamins were higher than the minimum level recommended by legislation.

Low risk for microbial contamination of syringe and tube feeding bag surfaces after multiple reuses with home blenderized tube feeding

BACKGROUND

Guidelines for the reuse of enteral tube feeding (ETF) equipment guidelines are limited to manufacturer recommendations. ETF equipment reuse studies are needed as the enteral population has increased, along with blenderized tube feeding (BTF).

METHODS

This experiment tested microbial contamination of a reusable gravity feeding bag and syringe after 15 BTF reuses and cleanings. Eight bags and syringes were filled with the BTF, held at room temperature for 20 min, and then emptied, washed, and air dried. After the last air drying, the inner surfaces of the bag and syringe were swabbed, and aerobic microbial counts were performed using serial dilutions and plate counts.

RESULTS

The microbial counts for all syringes and six bags were <1 colony-forming unit (CFU)/cm² ; one bag was <5 CFU/cm² and one bag was 12.5 CFU/cm² . No legal guidelines for surface cleanliness exist for the food sector. Several studies propose a safe microbial level to be <2.5 CFU/cm² , and the European Commission recommended <10 CFU/cm² . Based on these proposed guidelines, microbial counts of all syringes and seven bags were within the proposed guidelines, except for one bag just above 10 CFU/cm² .

CONCLUSION

The feeding bag used in this study may be used multiple times for BTF with a reduced risk of microbial contamination when manufacturer's cleaning guidelines are followed. Although bolus tube feeding is an off-label use for syringes, they are frequently used for BTF, and in this study the cleaning after 15 uses over 5 days was effective to reduce microbial counts.

Blenderized formulations in home enteral nutrition: a narrative review about challenges in nutritional security and food safety

Blenderized formulations (BFs) are prepared by homogenization of food that is normally used in oral nutrition. BFs are mainly used in home enteral nutrition (HEN), although their use has also been reported by hospitals when commercial enteral formulas are not available. HEN is applied when the patient has been discharged from the hospital. This nutritional therapy promotes the patient's reintegration into the family nucleus and promotes humanized care, and decreases treatment costs. However, the patient should continue to receive health and nutritional care, ranging from periodic nutritional re-evaluation to adaptation of the dietary plan. HEN provides the patient a greater contact with the family, whereas BFs promote the adaptation of the diet with food, respecting the food diversity and culture, lower cost, and easier access to food. Disadvantages of BFs include more time spent by the professional to calculate the dietary plan, greater difficulty in adjusting daily needs, and less microbiological and chemical stability. In this review, the nutritional, food security, and safety aspects of BF used in HEN are discussed. Technological quality aspects that are essential knowledge in the preparation of the patient's dietary plan also are presented.

Introduction of blended diet for enteral tube feeding in paediatrics: A case report

Background: Advances in medical technology have resulted in changes to enteral tube feeding (ETF). Standard practice in the UK is to use commercial formula for ETF via the stomach or small intestine; however, blended diets are becoming increasingly popular. Emerging evidence shows benefits of a blended diet although evidence informing clinical guidance is sparse. Consequently, there is disparity in practice, and it remains unclear which patient groups may benefit most from a blended diet. Aim: To demonstrate the initiation of a blended diet in clinical practice. Methods: This case report features a 2-year-old child requiring ETF in the context of hypotonia, developmental delay and faltering growth. Results: In this instance, a blended diet resulted in improved gastrointestinal symptoms and adequate growth. Conclusion: This case demonstrates the successful implementation of a blended diet and associated benefits. Blended diets may benefit others requiring ETF and should be considered on an individualised basis.

Blenderized food tube feeding in patients with head and neck cancer

Background

Patients with headand neck cancer (HNC) are at high risk for malnutrition before and during chemoradiation treatment. Many will also require tube feeding to address declines in energy intake, weight, and quality of life (QOL) caused by the impact of treatment on gastrointestinal (GI) symptoms. Blenderized tube feeding (BTF) may ameliorate these adverse conditions.

Methods

In this open‐label, prospective pilot study, 30 patients with HNC who required feeding tube placement were recruited to switch from standard commercial formula after 2 weeks to a commercially prepared BTF formula. Weight, body mass index (BMI), GI symptoms, and QOL scores were tracked for 6 weeks from the first week of feeding tube placement.

Results

Of the 16 patients who completed the 6‐week assessment period, weights and BMI scores for 15 patients trended upward. For most patients, QOL and oral intake increased and GI symptoms decreased over the 6‐week period, particularly during weeks 3 and 4, when the impact of treatment is particularly exacting on patients with HNC.

Conclusion

BTF effectively mitigated weight loss, GI symptoms, QOL scores, and total energy intake in this group of patients with HNC who received tube feeding for 6 weeks.

Risks in Management of Enteral Nutrition in Intensive Care Units: A Literature Review and Narrative Synthesis

Critically ill patients in the intensive care unit (ICU) have a high risk of developing malnutrition, and this is associated with poorer clinical outcomes. In clinical practice, nutrition, including enteral nutrition (EN), is often not prioritized. Resulting from this, risks and safety issues for patients and healthcare professionals can emerge. The aim of this literature review, inspired by the Rapid Review Guidebook by Dobbins, 2017, was to identify risks and safety issues for patient safety in the management of EN in critically ill patients in the ICU. Three databases were used to identify studies between 2009 and 2020. We assessed 3495 studies for eligibility and included 62 in our narrative synthesis. Several risks and problems were identified: No use of clinical assessment or screening nutrition assessment, inadequate tube management, missing energy target, missing a nutritionist, bad hygiene and handling, wrong time management and speed, nutritional interruptions, wrong body position, gastrointestinal complication and infections, missing or not using guidelines, understaffing, and lack of education. Raising awareness of these risks is a central aspect in patient safety in ICU. Clinical experts can use a checklist with 12 identified top risks and the recommendations drawn up to carry out their own risk analysis in clinical practice.