Enteral Tube Feeding Nutrition Intervention
Table 12.5 Food safety practices
a
Food shopping 1. Check expiration dates on food and do not buy or use if the food is out of date.
2. Do not purchase ready-to-eat food from bulk food bins i.e., breads, nuts, dried fruit, candies. 3. Avoid all food in cans that are swollen, dented or damaged.
4. Avoid produce that is bruised or damaged. 5. Bag fresh fruits and vegetables separately from meat, poultry and seafood products.
Food storage 1. Store perishable fresh fruits and vegetables i.e. cucumbers, tomatoes in a clean refrigerator at a temperature
of 40 °F or below. 2. Refrigerate all produce that is purchased pre-cut or peeled.
3. Beef should be refrigerated at 40 °F and used within two days. Beef can be frozen at 0 °F and used within 6 months of the purchase date.
Food preparation 1. Wash hands with water and soap for 20 s before and after any food preparation.
2. Wash fruits or vegetables under running water even if you are going to peel them. Do not use soap, bleach or commercial produce washes to clean fruit.
3. Dry produce with a clean cloth towel or paper towel. This will reduce the spread of bacteria. Do not wash meat, poultry or eggs.
4. Defrost all meats in the refrigerator. Do not defrost at room temperature. 5. Food-preparation surfaces must be cleaned fi rst. Wash surfaces thoroughly with soap and water and thoroughly
dry. As an extra precaution, you can use a solution of one tablespoon unscented, liquid chlorine bleach in one gallon of water to sanitize washed surfaces and utensils.
6. Wash cutting boards, dishes, utensils and counter tops with hot, soapy water after preparing each food item and before you go on to the next item.
Cooking 1. Cook foods immediately after thawing.
2. All raw foods such as meats, poultry and entrees should be cooked until they are well-done. Beef should be cooked to 160 °F, depending on the cut. Chicken should be cooked to an internal temperature of 165 °F. Cold
foods should be stored 40 °F, hot foods kept 140 °F. A home thermometer may help. Storage of cooked foods
1. Store leftovers within 2 h. By dividing leftovers into several clean, shallow containers, you’ll allow them to chill faster. Discard leftovers that were kept at room temperature for greater than 2 h.
2. Perishable foods fruits, vegetables, meat, dairy should be put into the fridge or freezer within 2 h. In the summer months, cut this time down to 1 h.
3. Do not use leftovers prior to reheating to 165 °F before serving. Baby foodinfant formula
1. Never put baby food in the refrigerator if the baby doesn’t fi nish it. Do not feed your baby directly from the jar of baby food. Instead, put a small serving of food on a clean dish and refrigerate the remaining food in the jar.
If the baby needs more food, use a clean spoon to serve another portion. Throw away any food in the dish that’s not eaten. If you do feed a baby from a jar, always discard any remaining food.
2. Prepare safe water for preparing formula. Bring tap water to a roiling boil and boil it for 1 min. If you use bottled water, follow this same process. Cool the water to body temperature before mixing formula.
3. Sterilize bottles and nipples before fi rst use. After that, wash them by hand or in a dishwasher. 4. Formula can become contaminated during preparation, and bacteria can multiply quickly if formula is
improperly stored. Prepare formula in smaller quantities on an as-needed basis to greatly reduce the possibility of contamination. Always follow the label instructions for mixing formula.
Additional information may be found at www.foodsafety.gov.
a
Select recommendations from the United States Federal Drug Adminis tration’s Clean, Separate, Cook and Chill. 12 Nutrition
Considerations in determining the type of for- mula, volume of feeds, and schedule should
include the patient’s oral intake, sleep patterns, lifestyle, food allergiesintolerances, and GI con-
ditions that affect dietary intake. Continuous feed- ing schedules are generally better tolerated than
intermittent bolus feeds. Nocturnal continuous feeds allow the patient to attempt normal feeding
during the day while ensuring the necessary pro- portion of nutrients are being delivered via
TF. Daytime continuous feeds may be initiated on days when children are unable to consume signifi -
cant oral intake. TF allows the family fl exibility with the child’s feeding schedule while continu-
ing to support oromotor developmental skills and a more normal lifestyle. Continuous feeds are the
preferred schedule in patients at high risk for nau- sea and vomiting, constipation, or diarrhea. If fre-
quent vomiting continues to occur with continuous TF, post-pyloric feedings may help improve toler-
ance Sacks et al.
2004 ; Ladas et al.
2005 .
The choice of formula will depend on the clini- cal condition of the patient. In most cases, a stan-
dard milk-based formula with or without fi ber may be used to initiate TF Table
12.4 . Unfl avored for-
mulas have a lower osmolarity than fl avored prod- ucts, are better tolerated and should preferentially
be used for TF. In patients with lactose intolerance, a soy-based or lactose- free formula should be used.
Elemental formulas are ideal for patients with GI infl ammation or malabsorption. Modifi cation of
the chosen formula may be necessary in patients with underlying GI problems if with intolerance to
the current formula, persistent constipation or diar- rhea, or stomach pain. Continuous TF should be
initiated with a full-strength formula at 1–2 mL kgh and increased by 1–2 mLkgh as tolerated
until the goal rate is achieved Sacks et al.
2004 ;
Ladas et al. 2005
. Elevating the head of the bed to 30° during and after TF and using prokinetic
medications such as metoclopramide, erythromy- cin or cisapride not available in the United States
may assist with reducing high gastric residuals caused by delayed gastric emptying and therefore
promote digestion Sacks et al.
2004 . Feeding
tubes should be fl ushed before and after feeds or the administration of any medication. A solution
composed of a Viokase
TM
enzyme tablet, a 325 mg sodium bicarbonate tablet, and 5 mL of warm water
can be utilized to help unclog the tube by inserting the 5 mL solution, clamping the tube for 15–30 min
and then fl ushing with 20–30 mL of warm water Sacks et al.
2004 . Utilization of acidic beverages
such as Coca-Cola or cranberry juice has been uti- lized but may precipitate the caseinate in formula
and should not be used. Reevaluation of nutritional status and feeding methods for the individual
patient should be undertaken if feeding problems persist and growth is not observed.
Side effects associated with TF include diarrhea, constipation, abdominal pain and aspiration.
Although empirically thought to increase the risk of infection or mucosal bleeding, feeding tube inser-
tion has been shown safe during periods of mucosi- tis Deswarte-Wallace et al.
2001 . Whether TF is
tolerated with severe mucositis involving much of the GI tract is unclear. Vomiting may occur but is not
a contraindication to tube reinsertion; passing the tube beyond the pyloric valve into the duodenum
may prevent recurrence. Diarrhea can develop sec- ondary to hyperosmolar feeds, lactose intolerance or
refeeding syndrome. Refeeding syndrome can occur in the severely malnourished patient who is started
on feeds at too rapid a rate and consists of diarrhea, vomiting and a variety of metabolic disturbances.
Criteria for placement of a percutaneous endo- scopic gastrostomy PEG include dysphagia, risk
of aspiration, intractable vomiting, esophageal strictures, cancer of the head and neck, radiation
to the head, neck or chest, or anticipated long-term need for nutritional support. Adequate GI function
is necessary for PEG insertion Sacks et al.
2004 ;
Ladas et al. 2005
. Infection at the local insertion site can occur and careful hygiene is required.