Malnutrition and Enteral

Nutrition

Presented by Brandon Lee, B.S.

Always Apply the Nutrition Care Process!

Malnutrition

Malnutrition is

defined as any

derangement in

the normal nutrition

status.

1 in 3 patients are

malnourished upon

admission.

AND/ASPEN Etiology-Based Malnutrition

Definitions

Mini Nutritional Assessment (MNA)

A validated nutritional screening instrument designed to identify elderly persons

who are malnourished or at risk of malnutrition.

Primarily intended to evaluate older persons exhibiting some kind of functional

impairment (e.g. hearing, persons living nursing homes, >85 years old).

Approximately 10-15 minutes are needed to complete the full MNA

questionnaire.

The MNA-Short Form (SF) is an abbreviated version that can be completed in less

than 5 minutes.

The MNA is a practical, noninvasive and cost-effective tool.

Please refer to the document handed out.

Malnutrition Universal Screening Tool

(MUST)

A validated, evidence-based nutrition screening instrument designed to identify

adults who are malnourished, at risk of malnutrition, underweight, as well as

obese.

Approximately 3-5 minutes to complete.

Uses a five step process to evaluate (1) BMI, (2) history of unintentional weight loss

during the previous three to six months, and (3) the presence of decreased food

intake due to acute illness that patient is experiencing.

Effective in predicting clinical outcomes such as length of hospitalization and mortality in older persons, and for providing guidance in the discharge goal of

orthopedic patients and other patients.

Please refer to the document handed out.

Malnutrition Screening Tool (MST)

A validated tool to screen patients for risk of malnutrition.

The instrument is appropriate for a residential aged care facility or for adults in the

inpatient/outpatient hospital setting.

Nutrition screen parameters include weight loss and appetite.

Please refer to the document handed out.

Validated Malnutrition Screening and

Assessment Tools: Comparison Guide

Please see the document handed out.

ASPEN Malnutrition Criteria

Inadequate energy intake

Interpretation of weight loss

Body fat loss

Muscle loss

Fluid accumulation

Reduced grip strength

*Two criteria must be met to nutritionally diagnosis malnutrition.

Risk factors/Possible Causes of

Malnutrition In Older Adults

Poor dentition

Loss of taste and smell

Lack of knowledge about foods and cooking

Isolation/loneliness

Needs assistance with eating

Unpleasant sights, sounds, and smells

Confusion

Dementia

Inadequate Energy Intake

Malnutrition is the result of inadequate food and nutrient intake or assimilation.

Intake compared with estimated requirements is a primary criterion defining

malnutrition

Methods to assess:

Review the food and nutrition history

Estimate optimum energy needs and then compare with estimates of energy

consumed

Report inadequate intake as a percentage of estimated energy requirements over

time

Interpretation of Weight Loss

Assess weight change over time reported as a percentage of weight loss from

baseline

Percent weight change

1. Usual body weight – current body weight= weight loss #

2. Weight loss #/ usual body weight= % weight change

Evaluate weight in light of other clinical findings (e.g. under- or overhydration)

Nutrition Focused Physical Findings

The purpose of this physical exam is to assess the patient for signs and symptoms

consistent with malnutrition or specific nutrient deficiencies.

Often assessing for loss of subcutaneous fat, muscle wasting and/or generalized

accumulation of fluid.

See video for more information.

Subcutaneous Fat Loss

Orbitals

Triceps

Fat overlying the ribs (see photo)

Muscle Loss

Temples

Clavicles (see photo)

Shoulders (see photo)

Interosseous muscles

Scapula

Thigh

Calf

Fluid Accumulation

Evaluate generalized or localized fluid accumulation evident on exam.

Weight loss is often masked by generalized fluid retention (edema) and weight

gain may be observed.

Assessment should include examination of extremities, vulvar/scrotal edema or

ascites.

Reduced Grip Strength

Dynamometry assesses muscular strength. The

patient is asked to grip the dynamometer device as

tight as possible.

Handgrip standards are ≥35kg for males and ≥23kg

for females but may vary depending on the

instrument manufacturer’s guidelines.

Useful for long-term follow-up in outpatient or

rehabilitation settings.

Not valid in the presence of neuromuscular junction,

muscle, or joint disease.

Example PES statements

Acute Disease or Injury Related Malnutrition

Malnutrition related to physiological causes resulting in anorexia as evidenced by mild

loss of subcutaneous fat and estimated energy intake < 75% of estimated energy

requirement for > 7 days.

Chronic Disease or Condition Related Malnutrition

Malnutrition related to alteration in gastrointestinal tract structure function as

evidenced by severe muscle loss and measurably reduced changes in grip strength.

Example PES statements (cont.)

Starvation Related Malnutrition

Malnutrition related to behavioral/psychological causes as evidenced by

unintentional weight loss of 21% usual body weight x 1 year, severe muscle loss and

diagnosis of anorexia nervosa.

Enteral Nutrition

Enteral nutrition (EN) is defined as the provision of nutrients into the gastrointestinal

tract through a tube or catheter.

Conditions that warrant EN:

Inability to eat (e.g. dysphagia, oral or esophageal trauma, traumatic brain injury)

Inability to eat enough (e.g. burns, heart failure, anorexia nervosa)

Impaired digestion, absorption, metabolism (e.g. severe gastroparesis, Crohn disease,

pancreatitis)

If the gut works, use it.

Indications for EN

Dysphagia

Malnourished patients unable to consume adequate oral intake

Mechanical ventilation

Chronic history of poor oral intake

Critically ill patients as well as those with major trauma and burns

Surgeries (e.g. head and neck)

Contraindications for EN

Nonfunctional or inaccessible gastrointestinal tract

Severe short bowel syndrome (less than 100 cm of remaining small bowel)

Intractable vomiting and/or diarrhea

Gastrointestinal ischemia

Intestinal obstruction

Peritonitis

Paralytic ileus

High output fistula (unable to be fed distal to fistula)

New pressor support, increasing pressors, or multiple pressors

Indications for PN

Severe short bowel syndrome

Paralytic ileus

Mesenteric ischemia

Small bowel obstruction

Gastrointestinal fistula and not able to tube feed distal to the fistula

Unable to meet estimated energy needs after 7 to 10 days of EN

*Only an option when EN is insufficient or physiologically not appropriate.

Malnutrition treated with EN

Many scientific articles have shown that well-nourished patients have fewer

complications, shorter lengths of hospital stay, and lower costs associated with their care

than patients who are malnourished.

Enteral Access Selection

Depends on…

1. Anticipated length of time enteral feeding will be required

2. Degree of risk for aspiration or tube displacement

3. Patient’s clinical status

4. Presence or absence of normal digestion and absorption

5. Patient’s anatomy (tube feeding (TF) may not be feasible in obese patients)

6. Whether a surgical intervention is planned

Short-Term Enteral Access

Nasogastric Route

Nasogastric Tube (<3-4 weeks)

Tube is passed through the nose and into

the stomach

Patients with normal gastrointestinal

function can tolerate this route

Nasoduodenal or Nasojejunal Tube (3-4

weeks)

The tip of the tube passes through the

pylorus and into the duodenum or into the

jejunum.

Long-Term Enteral Access

Gastrostomy or Jejunostomy

Percutaneous Endoscopic Gastrostomy (PEG) (>3-4weeks)

A nonsurgical technique for placing a tube

directly into the stomach through the

abdominal wall.

Performed using a endoscope, with the

patient under local anesthesia.

Percutaneous Endoscopic Gastrojejunostomy (>3-4 weeks)

Threading of a small-bore tube through the

PEG tube into the jejunum using either

fluoroscopy or endoscopy.

Formula Content and Selection

Classifications:

1. Standard polymeric formulas (e.g. Osmolite, Jevity)

1. Provide essentially the same nutrients as those consumed in a regular diet.

2. Elemental, predigested or chemically defined (e.g. Vital AF 1.2 CAL)

1. For patients with a dysfunction GI tract, including malabsorption, pancreatic

dysfunction or prolonged bowel rest following major abdominal surgery.

3. Specialized (e.g. Nepro with Carb Steady, TwoCAL HN)

1. Disease specific

Macronutrients of Enteral Formulas

Carbohydrates:

Represent the primary macronutrient in most formulas and range from 28%-82% of

total calories.

Polymeric formulas provide carbohydrate mainly in the form of corn syrup solids.

Hydrolyzed formulas offer hydrolyzed cornstarch or maltodextrin.

All enteral formulas manufactured for TF do not contain lactose and are gluten-

free.

Macronutrients of Enteral Formulas (cont.)

Proteins

The content of protein in enteral formulas range from 6%-37%.

The forms of protein available can include intact proteins, hydrolyzed proteins or

crystalline amino acids.

When high protein formulas are used, it is vital to consider increasing free-water

delivery to minimize dehydration related to the excretion of nitrogenous wastes.

Macronutrients of Enteral Formulas (cont.)

Lipids

The percentage of total calories provided by fat in enteral formulas range from

1%-55%.

Essential fatty acids (linoleic and linolenic acids) should make up a minimum of

4% of total calories to avoid Essential Fatty Acid Deficiency (EFAD).

Fat in formulas are included as triglycerides with constituent long-chain or

medium-chain fatty acids.

Administration

Bolus

Intermittent

Continuous

Bolus Feedings

A 60mL-syringe is used to administer enteral formula.

More convenient and less expensive than pump or gravity bolus feedings. Ideal

method for home enteral nutrition (HEN).

Infusion time of 5-20 minutes.

Three to four- 500mL of formula can meet nutritional needs.

Intermittent Feedings

Allow patients more free time and autonomy compared to continuous drip

infusions.

Can be administered via pump or gravity drip.

A schedule is based on four to six feedings per day administered for 20-60 minutes.

Start rate of 100-150mL per feeding and increased as tolerated.

Continuous Feedings

Enteral formula provided over a ~24 hour hang time.

Appropriate for patients who do not tolerate large-volume infusions during a

given feeding.

Most common method used in inpatient, acute hospital settings.

Recommended option for patients being fed into the small intestines.

Initiation and Advancement

Bolus feedings

Schedule 3-8 feedings per day. Begin at 60-120mL, infused over 5-20 minutes

Increase volume by 60-120mL every 8-12 hours until goal is reached

Intermittent feedings

Administer 4-6 times daily

Start at volumes of 240 to 720 mL, infused over 20-60 minutes

Continuous feedings

Begin at 10-40mL/hr

Increase by 10-20mL/hr every 8-12 hours until goal is reached

Trophic EN Feeding

Feedings given in small volumes to stimulate gastrointestinal (GI) tract.

Often given to preterm infants or adults with severe malnutrition.

Commonly started at 20kcal/hr for adults and 10-20 mL/hr for preterm infants.

These feedings are not meant to be nutritive; they are meant to prepare the GI

tract for later nutritional feedings.

Calculating EN Provisions

1. Calculate the patients energy, protein and fluid needs.

2. Calculate the volume needed- take the starting rate (e.g. 20mL) and multiple against the hang time (e.g. 24 hours). This gives you the total formula that will be

provided in 24 hours.

3. Calculate the kcal provided- total formula volume (e.g. 480mL) multiplied by the

amount of kcal provided the formula per L.

4. Calculate the protein provided- same method #3

5. Calculate the fluid provided- move the percent of water two decimals to the left

and multiple against total formula amount (e.g. 480mL). Don’t forget free water flushes to meet fluid needs.

If these are starting rate calculations, it will not meet your patients needs.

Example EN Calculation

Vital 1.5

Provides 1500 kcal/L, 63.8g of protein/L and is composed of 76% water.

1. Volume

a. 45 mL/hr x 24 hrs = 1080mls

2. Kcals

a. 1080mL x 1.5 kcal/mL = 1620 kcal

3. Protein

a. 1080mL x 0.0638 g pro/mL = 68.9 Pro

4. Free fluid

a. 1080 mL x 0.76% H2O = 821 mLs of H20

NOTE: YOU MUST CALCULATE THE PATIENTS NEEDS BEFORE CALCULATING EN PROVISIONS.

Practice #1

Patient X- Wt: 68.1kg

Energy needs: 1,703-2,043 kcal

Protein needs: 54-68g

Fluid needs: 1,703- 2,043 mL

Administration Method: Continuous

Formula: Jevity 1 Cal

Hang time: 24 hours

Calculate the starting rate, advancements and goal rate to meet nutrition needs.

Practice #1 Answers

Patient XX- Wt: 68.1kg

Energy needs: 1,703-2,043 kcal

Protein needs: 54-68g

Fluid needs: 1,703- 2,043 mL

Administration Method: Continuous

Formula: Jevity 1 Cal

Hang time: 24 hours

Calculate the starting rate, advancements and goal rate to meet nutrition needs.

Answers: Starting rate 10-40mL/hr, advancement 10-20mL/hr, goal rate of 70mL/hr

and free water flushes of 292mL/day.

Practice #2

Patient XY- Wt: 95.4kg

Energy Needs: 2,862-3,339 kcal

Protein Needs: 114-143g

Fluids Needs: 1,500 mL

Administration Method: Continuous

Formula: Nepro with Carb Steady

Hang time: 24 hours

Calculate the starting rate, advancements and goal rate to meet nutrition needs.

Practice #2 Answers

Patient XY- Wt: 95.4kg

Energy Needs: 2,862-3,339 kcal

Protein Needs: 114-124g

Fluids Needs: 1,500 mL

Administration Method: Continuous

Formula: Nepro with Carb Steady

Hang time: 24 hours

Calculate the starting rate, advancements and goal rate to meet nutrition needs.

Answers: Starting rate 10-40mL/hr, advancement 10-20mL/hr, goal rate of 65mL/hrand free water flushes of 361mL/day.

Common Complications with EN

Diarrhea (most common)/ constipation

Nausea/vomiting

Elevated gastric residual volume

Maldigestion/malabsorption

Abdominal distention, bloating, cramping

Aspiration/pneumonia

Dehydration/Overhydration

Common Complications of EN (cont.)

Hypo/hyper-kalemia

Hypo/hyper-natremia

Hypo/hyper-phosphatemia

Hypercapnia

Thiamin deficiency

Hypo/hyper-glycemia

Refeeding Syndrome (RFS)

Defined as the biochemical changes, clinical manifestations and complications

that happen as a result of rapidly feeding a malnourished patient.

Primary cause: Change from using stored fat as energy to carbohydrates.

The typical patient that experiences refeeding syndrome has been malnourished

for days to weeks.

Hypophosphatemia, hypokalemia and hypomagnesemia are common

occurrences in RFS. Hypophosphatemia is the most common among the three.

Potential complications: Hemolytic anemia, respiratory distress, tetany and

cardiac arrhythmias.

RFS Nutrition Intervention

Energy:15-20kcal/kg for first 3 days, reach goal kcal/kg by day 7.

Protein: 1.2g/kg to start and progressively increase to 1.5g/kg.

Carbohydrates: 150-200g/day to start

Fluids: 30mL/kg (approx. 1.5 L per day)

Phosphorus: 20-25mg/kg

Potassium: 80-120mEq/day

Thiamin: 100mg bolus daily for 3 days when patient is at risk for developing RFS

Supplement with additional B-complex and vitamins as well

Monitoring & Evaluating EN Patients

Abdominal distention and discomfort (indicates TF intolerance)

Fluid intake and output (daily)

Gastric residuals (every 4 hours) if appropriate

Edema or dehydration (daily)

Weight (3x’s a week)

Nutritional intake adequacy (2x’s a week)

Serum electrolytes, BUN, Creatinine (2-3x’s a week)

Serum glucose calcium, magnesium, phosphorus

(weekly or as ordered)

Questions or Concerns?

References

Academy of Nutrition and Dietetics. Nutrition Care Manual.

http://www.nutritioncaremanual.org. Accessed [November 16th, 2017].

Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual

(eNCPT): Dietetics Language for Nutrition Care. http://ncpt.webauthor.com.

Accessed [November 15th, 2017].

Escott-Stump, S. (2015). Nutrition and Diagnosis-Related Care (8th ed.).

Philadelphia: Wolters Kluwer.

Charney, P., & Malone, A. (2013). Pocket Guide to Enteral Nutrition (2nd ed.).

Chicago, IL: Academy of Nutrition and Dietetics.

References (cont.)

Lee, R. D., & Nieman, D. C. (2013). Nutritional Assessment (6th ed.). New York, NY:

McGraw-Hill.

Lunde, D. (n.d.). Extrauterine Growth Restriction: What Is the Evidence for Better

Nutritional Practices in the Neonatal Intensive Care Unit? Retrieved November 18,

2017, from https://www.medscape.com/viewarticle/831961_5

Mahan, L. K., Escott-Stump, S., & Raymond, J. L. (2012). Krauses Food & the Nutrition Care Process (13th ed.). St. Louis, MO: Elsevier.

Malnutrition Screening and Assessment Tools. (n.d.). Retrieved November 18,

2017, from https://www.ncoa.org/center-for-healthy-

aging/resourcehub/assesssments-tools/malnutrition-screening-assessment-tools/

References (cont.)

Mesenteric Ischemia. (n.d.). Retrieved November 18, 2017, from

https://vascular.org/patient-resources/vascular-conditions/mesenteric-ischemia

Nahikian-Nelms, M. N., Sucher, K. P., & Lacey, K. (2016). Nutrition Therapy and

Pathophysiology (3rd ed.). Boston, MA: Cengage Learning.