Comparison of Energy and Nutrient Contents of Commercial and Noncommercial Enteral Nutrition Solutions

Designing blenderized tube feeding diets for children and investigating their physicochemical and microbial properties and Dietary Inflammatory Index

BACKGROUND

Due to the benefits of blenderized tube feeding (BTF) diets, the interest in using them is increasing. This study aimed to design BTFs for children and investigate their physicochemical and microbial properties, as well as Dietary Inflammatory Index (DII).

METHODS

Five BTF diets were formulated mainly with fresh foods; their DII, physical (viscosity), and chemical (moisture, ash, protein, fat, energy, and micronutrients) characteristics were assessed. Also, the Hazard Analysis and Critical Control Points (HACCP) system was implemented for quality assurance of preparation, storage, and delivery of BTFs to patients in hospital. The microbial contamination (total count, Salmonella, Escherichia coli, Bacillus cereus, Listeria monocytogenes, coliforms, Staphylococcus aureus coagulase positive, mold, and yeast) was analyzed.

RESULTS

Energy and percentages of protein, fat, and carbohydrate in BTFs were in the range of 103-112 kcal/100 ml, 16%-22%, 28%-34%, and 48%-52%, respectively. The viscosity of the five developed BTFs was between 29 and 64 centipoises, which allows the formulas to flow without syringe pressure. The DII of all BTFs was between -0.73 and -2.24. Due to the implementation of HACCP, monitoring the production line of BTFs, and performance of corrective measures, no microbial contamination was observed by indicator pathogenic microorganisms.

CONCLUSION

A planned BTF diet can be an excellent selection for children using enteral nutrition with tube feeding especially when they are made from fresh and anti-inflammatory foods such as recipes prepared in this study.

Comparison of Home-Blenderized Formula and Commercial Enteral Formulas for Gastrostomy Tube-Fed Children: A Retrospective, Prospective Cohort Study

Background Blenderized gastrostomy tube feedings (BGTFs) consist of pureed table foods and liquids that are administered as enteral tube feedings. Compared to commercial enteral formulas (CEFs), BGTF has been shown to have fewer side effects. Despite these results, apprehensions have been raised about microbial contamination, nutritional deficiencies or surplus, risk of gastrostomy tube (GT) blockages, and lack of consistency in clinical outcomes. The goal of this retrospective, prospective, 18-month-long study is to report the clinical and nutritional outcomes of GT-dependent pediatric patients who attended a multidisciplinary feeding clinic. Methodology After Institutional Review Board (IRB) approval and consent were obtained, 25 children who were receiving tube feeding via G were enrolled in a retrospective, prospective, observational, cohort study from August 2019 to February 2021. A multidisciplinary team was formed, and multivariate logistic regression was performed comparing subjects on BGTF versus CEF, per os diet versus nil per os, CEF versus homemade blenderized tube feeding (HBTF) versus blenderized tube feeding (BTF), and how they compared at the beginning and end of the study. Results The mean age of the patients was 4.4 years (SD ±2.2). Gastroesophageal reflux disease (GERD) and short bowel syndrome (SBS) were the most common comorbid gastrointestinal (GI) conditions. Of the 25 patients enrolled in the study, seven were initially on BGTF, while 14 ended the study on BGTF. There were no statistically significant differences in malnutrition status, feeding intolerance, emergency room visits, hospitalizations, and GT blockages between all different comparison groups when comparing between the CEF versus HBTF versus commercial blenderized tube feeding (CBTF) groups. Of the patients who were in the BGTF group, there was a resolution of vitamin A deficiency, vitamin D deficiency, and anemia (n = 1). In total, two patients had resolved vitamin deficiencies, namely, vitamins A and D. Conclusions When comparing BGTF and CEF, there was no statistically significant difference in outcomes. This study suggests that BGTF is at least equivalent to CEF in clinical outcomes, meaning BGTF should be considered standard nutrition for GT-dependent patients.

Macronutrients and energy in home-prepared enteral tube feeding: Comparison between food composition table estimates, nutrition labels, and laboratory analysis

BACKGROUND

The effectiveness of home enteral nutrition depends on the supply and delivery of the prescribed nutrients. This study compared the macronutrient and energy values of home-prepared enteral tube feeding analyzed in the laboratory with the same information calculated from labels and food composition tables.

METHODS

A total of 107 enteral formulations were analyzed: 66 commercial enteral formulas (CEFs), 19 homemade enteral preparations, and 22 blended enteral preparations (BEPs). The values of macronutrients and energy and the ratio between the values found in the laboratory and the calculated values were all evaluated. The tolerance limit of acceptable variation was 20%. The results were subjected to chemometric methods using principal component analysis (PCA) and hierarchical cluster analysis (HCA).

RESULTS

In the three categories of the enteral formulations, the calculated values for protein and fat were higher than those obtained in the laboratory. The calculated values for energy were higher than those obtained in the laboratory for the BEPs and CEFs. The CEFs had the highest percentage within the limit of acceptable variation for carbohydrate and protein, whereas the BEPs presented the lowest values for fat and energy. In the exploratory analysis of data using PCA and HCA, it was possible to verify similarities and discrepancies between the enteral formulations analyzed in the laboratory with those calculated from the labels and food composition tables.

CONCLUSION

The enteral formulations showed differences between the values of macronutrients and energy analyzed in the laboratory and those calculated from labels and/or food composition tables.

Electrolyte disorders during the initiation of nutrition therapy in the ICU

PURPOSE OF REVIEW

To summarize recent evidence on prevalence, risk factors, significance, treatment, and prevention of electrolyte disorders in critically ill with a specific focus on disorders during the initiation of nutrition.

RECENT FINDINGS

Electrolyte disturbances appear to occur often during critical illness, and most of them seem to be associated with impaired outcome. However, a recent systematic review indicated insufficient evidence to answer clinically relevant questions regarding hypophosphatemia. Similar questions (which thresholds of serum levels are clinically relevant; how serum levels should be corrected and how do different correction regimens/approaches influence outcome) are not clearly answered also for other electrolytes. The most crucial feature of electrolyte disturbances related to feeding is refeeding syndrome. Recent evidence supports that additionally to the correction of electrolyte levels, a temporary restriction of calories (reducing the magnitude of this metabolic feature, including electrolyte shifts) may help to improve outcome.

SUMMARY

Diverse electrolyte disorders often occur in critically ill patients. Hypophosphatemia, hypokalemia, and hypomagnesemia that are encountered after initiation of feeding identify refeeding syndrome. Along with correction of electrolytes, reduction of caloric intake may improve the outcome of the refeeding syndrome.

The Microbial Quality and Safety of Blenderised Enteral Nutrition Formula: A Systematic Review

The use of blenderised enteral nutrition formula (ENF) is on the increase globally. However, concerns remain regarding the microbial quality and safety of blenderised ENF compared with standard recommendations and commercial ENF.

AIM

This was a systematic review which sought to compare the microbial quality of blenderised ENF and commercial ENF and to evaluate the effect of storage time on blenderised ENF.

METHOD

Four databases (Pubmed, EMBASE, PSYCInfo and Google scholar) were searched for relevant articles based on the Population, Intervention, Comparator, Outcomes framework.

RESULTS

Eleven studies which met the criteria were included in the systematic review. Two major areas were identified; Microbial Quality of Blenderised ENF versus Commercial ENF; and The Effect of Storage Time on Microbial Quality of Blenderised ENF. Overall, 72.7% of the studies showed microbial contamination in blenderised ENF compared with 57.1% of commercial ENF, and the storage time was another important factor in the rates of contamination. The extent of handling or manipulation of the enteral formula was critical in determining the level of contamination.

CONCLUSION

Preparation techniques for blenderised ENF need to be established and caregivers taught how to prepare and administer it appropriately in order to reduce contamination. Further, well-designed studies are required, which compare the microbial quality of blenderised ENF using adequate handling techniques and commercial ENF.

An Evaluation of the Nutritional Value and Physical Properties of Blenderised Enteral Nutrition Formula: A Systematic Review and Meta-Analysis

Background: Although there are merits in using commercial “enteral nutrition formula” (ENF) compared with blended ENF, there is a growing preference for the use of blended ENF in many countries globally. However, the nutritional value and physical properties of blended ENF compared with commercial ENF may be limiting its use. We have not found any evidence of a meta-analysis on the nutritional value of blended diets in the adult population. Aim: The aim of this review was to compare the nutritional value, physical properties, and clinical outcomes of blended ENF with commercial ENF. Methods: The preferred reporting items for systematic reviews and meta-analyses were used for this review. The search strategy was based on a Population, Intervention, Comparator, Outcome framework. The following databases; Pubmed, EMBASE, PSYCInfo, and Google scholar were searched for articles of interest using keywords, Medical Subject Heading (MeSH) and Boolean operators (AND/OR) from the inception of each database until 23 February 2020. The articles were evaluated for quality. Results: Based on the systematic review and meta-analysis, four distinct themes were identified; Nutritional value, Physical properties, Clinical outcomes; and Adverse events. The findings of this review showed inconsistencies in the macronutrient and micronutrient values of the blenderised ENF compared with the commercial ENF. The results of the meta-analysis demonstrated that there were no significant differences (p > 0.05) between the blenderised ENF and the commercial ENF in relation to the fat and protein contents of the diets. However, the blenderised ENF was significantly lower (p < 0.05) than the commercial ENF regarding the energy content of the diets, with an overall mean difference of −29.17 Kcal/100 mL (95% CI, −51.12, −7.22) and carbohydrate content with an overall mean difference of -5.32 g/100 mL (95% CI, −7.64, −3.00). In terms of sodium, potassium, and vitamin A, there were no significant differences (p > 0.05) between the blenderised and commercial ENF, although significant differences (p < 0.05) were observed between the two diets with respect to calcium, phosphorus, magnesium, zinc, iron, and vitamin C contents. Furthermore, the blenderised ENF showed significantly higher levels (p < 0.05) of viscosity and osmolality than the commercial ENF. The significantly lower levels of some of the macro-nutrients and micro-nutrients in the blenderised ENF compared with the commercial ENF and the difference in the expected nutritional values may be due to the fact blenderised ENF is produced from common foods. Thus, the type of foodstuffs, cooking, and processing methods may lead to loss of nutrients and energy density. The deficits in the energy content and some of the macro- and micro-nutrients in the blenderised ENF compared with commercial ENF may have implications for patients’ health and clinical outcomes. The clinical implications of the underdelivering of nutrients may include increased risk of undernutrition, including energy malnutrition, which could have a negative effect on body composition and anthropometric parameters, morbidity, mortality, length of hospital stay, and costs. For outpatient care, this could increase the risk of hospital re-admission and homecare costs. Additionally, the higher viscosity and osmolality of the blenderised ENF compared with the commercial ENF can increase the risk of complications, including tube blockage, and impaired delivery of feed, water, and medications, with significant implications for patients’ nutritional status and health outcomes. Conclusion: The results of this systematic review and meta-analysis identified significant variability in the nutritional value of blenderised ENF compared with commercial ENF. Furthermore, the nutritional values of the blenderised ENF do not meet the expected recommended levels compared with commercial ENF and these may have implications for patients’ nutritional status and health outcomes, including the effect on body composition, morbidity, mortality, hospital re-admission, and costs. Further studies are needed to elucidate the nutritional value of blenderised ENF on patients’ clinical outcomes.

Clinical Outcomes Associated With Commercial and Homemade Blenderized Tube Feedings: A Literature Review

There is emerging evidence in the pediatric population that blenderized tube feeding (BTF) may improve gastrointestinal intolerance; however, not much is known about the impact of BTF on clinical outcomes in adults. This article presents a review of the literature published in the past 10 years that explored the impact of BTF on nutrition status (ie, weight status, body mass index, and upper-arm circumference) and nutrition adequacy in adults. The results indicate that BTF, compared with commercial enteral formula (CEF), may be inadequate in calories, macronutrients, and some micronutrients, given variability in BTF formula composition. As a result, BTF may result in significantly more weight loss than CEF. Thus, BTF may not be appropriate for adult patients who are malnourished or are at risk for malnutrition due to the potential worsening of clinical outcomes.