Recommendations Summary

UWL: Enteral Nutrition 2009

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    UWL: Indications for Enteral Nutrition

     

    The Registered Dietitian (RD) should recommend consideration of enteral nutrition for older adults who are undernourished or at risk of undernutrition; it is clearly indicated in patients with severe dysphagia.  Studies support enteral nutrition as a method to provide energy and nutrient intake, promote weight gain and maintain or improve nutritional status or prevent undernutrition.

    Rating: Strong
    Imperative

    UWL: Contraindications for Enteral Nutrition

    Enteral nutrition may not be appropriate for terminally ill older adults with advanced disease states, such as terminal dementia, and should be in accordance with advance directives.  The development of clinical and ethical criteria for the nutrition and hydration of persons through the life span should be established by members of the health care team, including the Registered Dietitian (RD).

    Rating: Consensus
    Conditional

    UWL: Initiation of Enteral Nutrition

    To improve energy and nutrient intake in older adults at nutritional risk, enteral nutrition should be initiated as early as possible after confirming tube placement.  Studies support that enteral nutrition can be initiated 3 hours after a percutaneous endoscopic gastrostomy (PEG) tube is placed, and placement is confirmed.  

    Rating: Strong
    Imperative

    UWL: Route of Enteral Nutrition

    For older adults with neurological dysphagia and/or if enteral nutrition is anticipated for longer than 4 weeks,  the use of a percutaneous endoscopic gastrostomy (PEG) tube is preferable to nasogastric tubes.  Studies report that PEG tube use is associated with fewer treatment failures and improved nutritional status.

    Rating: Strong
    Conditional

    • Risks/Harms of Implementing This Recommendation

      • Inadvertent misplacement of the enteral feeding tube
      • Overfeeding, underfeeding and social isolation may contribute to greater risks of complications over time.

    • Conditions of Application

      • The UWL:  Contraindications for Enteral Nutrition recommendation applies to terminally ill older adults with advanced disease states, such as terminal dementia 
      • The UWL:  Route of Enteral Nutrition recommendation applies to older adults with neurological dysphagia and/or if enteral nutrition is anticipated for longer than 4 weeks
      • It is the position of the American Dietetic Association that the development of clinical and ethical criteria for the nutrition and hydration of persons through the life span should be established by members of the health care team.  Registered dietitians should work collaboratively to make nutrition, hydration, and feeding recommendations in individual cases.

    • Potential Costs Associated with Application

      • Enteral nutrition may be more expensive than oral nutritional supplementation.
      • The impact of feeding tube placement on cost of medical care has not been adequately evaluated.

    • Recommendation Narrative

      • ESPEN Recommendation 2.1:  "In case of nutritional risk (e.g. insufficient nutritional intake, unintended weight loss >5% in 3 months or >10% in 6 months, body-mass index (BMI) < 20 kg/m2) initiate oral nutritional supplementation and/or tube feeding early" (Grade B).
      • ESPEN Recommendation 2.2:  "Frail elderly may benefit from tube feeding as long as their general condition is stable (not in terminal phases of illness)" (Grade B).
      • ESPEN Recommendation 2.3:  "In geriatric patients with severe neurological dysphagia use enteral nutrition to ensure energy and nutrient supply and, thus, to maintain or improve nutritional status"  (Grade A).
      • ESPEN Recommendation 2.3:  "in geriatric patients with severe neurological dysphagia enteral nutrition has to be initiated as soon as possible.  In geriatric patients with neurological dysphagia accompany enteral nutrition by intensive swallowing therapy until safe and sufficient oral intake is possible" (Grade C).
      • ESPEN Recommendation 2.3:  "In geriatric patients with neurological dysphagia prefer percutaneous endoscopic gastrostomy (PEG) to nasogastric tubes (NGT) for long-term nutritional support, since it is associated with less treatment failures and better nutritional status" (Grade A).
      • ESPEN Recommendation 2.6:  "In depression use enteral nutrition to overcome the phase of severe anorexia and loss of motivation" (Grade C). 
      • ESPEN Recommendation 2.7:  "In demented patients oral nutritional supplements or tube feeding may lead to an improvement of nutritional status.  In early to moderate dementia consider oral nutritional supplements -- and occasionally tube feeding -- to ensure adequate energy and nutrient supply and to prevent undernutrition.  In patients with terminal dementia, tube feeding is not recommended" (Grade C).
      • ESPEN Recommendation 3.1:  Use a PEG tube if enteral nutrition is anticipated for longer than 4 weeks" (Grade A).
      • ESPEN Recommendation 3.2:  "Initiate enteral nutrition 3 hours after PEG placement" (Grade A). 

    • Recommendation Strength Rationale

      • ESPEN recommendations received Grades A, B and/or C.

    • Minority Opinions

      Consensus reached.

  • Supporting Evidence

    The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

    • References
    • References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process

      A.S.P.E.N. Enteral Nutrition Practice Recommendations. Bankhead R, Boullata J, Brantley S, Corkins M, Guenter P, Krenitsky J, Lyman B, Metheny NA, Mueller C, Robbins S, Wessel J, and the A.S.P.E.N. Board of Directors. J Parenter Enteral Nutr 2009;33(2) March/April:122-167. Originally published online Jan 26, 2009.  The online version of this article can be found at: http://pen.sagepub.com.

      Korner U, Bondolfi A, Buhler E, MacFie J, Meguid MM, Messing B, Oehmichen F, Valentini L, Allison SP.  Ethical and legal aspects of enteral nutrition.  Clin Nutr 2006;25:196-202.

      Maillet JO, Potter RL, Heller L.  Position of the American Dietetic Association:  ethical and legal issues in nutrition, hydration, and feeding.  J Am Diet Assoc 2002;102(5):716-26.

      President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.  Deciding to Forgo Life Sustaining Treatment.  No. 83-600503.  Washington, DC:  Government Printing Office; 1983.

      Volkert D, Berner YN, Berry E, Cederholm T, Coti Bertrand P, Milne A, Palmblad J, Schneider S, Sobotka L, Stanga Z, DGEM: Lenzen-Grossimlinghaus R, Krys U, Pirlich M, Herbst B, Schutz T, Schroer W, Weinrebe W, Ockenga J, Lochs H, ESPEN.  ESPEN Guidelines on Enteral Nutrition:  Geriatrics.  Clin Nutr 2006;25(2):330-360.

      The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel, 2009. Accessible at www.npuap.org