Enteral feeding: Gastric versus post-pyloric
- Robert Heuschkel, MBBS, MRCPCH
Robert Heuschkel, MBBS, MRCPCH
- Consultant, Department of Pediatric Gastroenterology
- Addenbrooke's Hospital, Cambridge, UK
- Christopher Duggan, MD, MPH
Christopher Duggan, MD, MPH
- Professor of Pediatrics, Harvard Medical School
- Division of Gastroenterology, Hepatology, and Nutrition
- Boston Children’s Hospital, Boston, MA
The maintenance of appropriate nutrition in patients with acute and chronic illness is well recognized as a fundamental part of standard medical and surgical care. Malnourished patients have poorer clinical outcomes, more complications and infections, and use more resources than well-nourished patients [1-3]. Because of lower energy reserves and proportionately higher energy and nutrient needs, children are more susceptible than adults to malnutrition and its multiple complications; as a result, nutritional interventions are even more important in pediatric patients. Thus, in both adult and pediatric patients, every effort should be made to support normal nutritional status throughout illness.
Enteral nutrition is generally preferred to parenteral nutrition because of its relative simplicity, safety, and lower cost, as well as its ability to maintain mucosal barrier function. There are several ways to deliver enteral nutrition (figure 1). This topic review will focus on the theoretical and practical aspects of pre- and post-pyloric enteral nutrition in children and adults. The advantages and disadvantages of each approach will be discussed, with particular reference to the decisions that lead to a choice of feeding method (algorithm 1). The American Gastroenterological Association (AGA) guideline for enteral nutrition , as well as other AGA guidelines, can be accessed through the AGA website.
ISSUES FOR DECIDING UPON THE TYPE OF ENTERAL NUTRITION
Nasoenteric tubes are the first means of gaining enteral access in the vast majority of patients. Orogastric feeds are often used in neonatal practice, since infants are predominantly obligate nasal breathers. A more permanent feeding tube should be considered if enteral support will be needed for more than four to five weeks . (See "Nasogastric and nasoenteric tubes" and "Gastrostomy tubes: Uses, patient selection, and efficacy in adults".)
However, the transnasal approach may not always be possible. Anatomic anomalies, tumors, and trauma may impede the passage of a tube from the nose into the stomach and can lead to complications (table 1). Furthermore, placing a nasoenteric tube may be hazardous in patients with altered consciousness who may not be able to cooperate adequately with swallowing or indicate inadvertent misplacement of the tube into the trachea. Special precautions should be taken particularly in intubated patients, since cuffed endotracheal tubes do not sufficiently protect against pulmonary intubation during passage of a feeding tube. Nasoenteric tubes have also been associated with an increased risk of bacterial sinusitis .
In addition to the above considerations, the following must be established prior to deciding upon the type of access and site of administration:
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- ISSUES FOR DECIDING UPON THE TYPE OF ENTERAL NUTRITION
- GASTRIC FEEDING
- Advantages of gastric feeding
- - More physiological
- - Ease of placement
- - Convenience
- Disadvantages of gastric feeds
- - Delayed gastric emptying
- - Gastroesophageal reflux and aspiration
- POST-PYLORIC FEEDING
- Advantages of post-pyloric feeding
- - Minimize aspiration risk
- - Role in critically ill patients
- - Benefits in acute pancreatitis
- Disadvantages of post-pyloric feeding
- - Difficulty with placement and ease of displacement
- - Feeding intolerance
- LONG-TERM PRE- AND POST-PYLORIC FEEDING
- SUMMARY AND RECOMMENDATIONS