Outline of Enteral nutrition and Parenteral nutrition
The special feeding methods depend on the type of disease, the patient’s conditions and his tolerance to food. The
different modes of feeding patients are
1. Enteral 2. Parenteral
Enteral
By definition enteral means “within or by the way of the gastrointestinal tract.” As for as possible, the patient should be
encouraged to ingest food through the oral route. Supplements may be added whenever necessary. The foods are
administered via a tube and hence enteral feeding in also called tube feeding.
Tube feeding
Tube feeding may be advised where the patient is unable to eatbut the digestive system is functioning normally. Full fluid
diets or commercial formulas may be administered through this route. The tube may be passed through the nose into the
stomach (nasogastric), duodenum (nasoduodenal) or jejunum (nasojejunal). When there is an obstruction in the
oesphagus, enteral feeding is done by passing a tube surgically through an incision in the abdominal wall into the stomach
(gastrostomy), duodenum (duodenostomy) or jejunum (jejunostomy).
Indications for tube feeding
i. Inability to swallow due to paralysis of muscles of v. Severe malabsorption requiring administration of
swallowing (diptheria, poliomyelites) unpalatable formula.
ii. Unwillingness to eat. vi. Short bowel syndrome.
iii. Persistent anorexia requiring forced feeding. vii. Babies of very low birth weight
iv. Semiconcious or unconscious patients.
Tubes
For enteral feeding for a short period of time locally available thin bore nasogastric tubes are usually adequate. For
prolonged use, specially prepared thin bore, soft, flexible tubes are desirable.
Enteral feeds
1. Blenderized food
2. Polymeric mixtures
3. Elemental diets
Methods of administration
The three common methods of tube feeding administration are
Continous drip
This is the most common form of administration. The drip rate is adjusted in increments to prevent cramping,
nausea, diarrhoea or distention. Feedings are started at 30 to 50 ml/hr every 8 or 12 hrs until the final rate is
attained
Intermittent drip
In this 4-6 feeds are given with regular periods of interruption example : 4 hours on and 4 hours off.
Bolus method
In this method large volumes are given in a short time. For example, 200 ml is administered in a minimum time of
ten minutes.
Types of Enteral Nutrition Feeding Tubes:
Enteral nutrition is administered through various types of feeding tubes, depending on the patient's condition, expected
duration of feeding, and anatomical considerations.
1. Nasogastric (NG) Tube:
o Placement: Inserted through the nose, down the esophagus, and into the stomach.
o Indications: Used for short-term enteral feeding (usually up to 4–6 weeks).
o Advantages: Easy to place and less invasive than other methods.
o Disadvantages: Can be uncomfortable for the patient and may cause irritation in the nose or throat.
2. Nasoduodenal (ND) or Nasojejunal (NJ) Tube:
o Placement: Similar to the NG tube, but the tip is placed beyond the stomach, in the duodenum (ND) or
jejunum (NJ).
o Indications: Typically used when there is a risk of gastric reflux or when the stomach needs to be
bypassed (e.g., gastroparesis).
o Advantages: Bypasses the stomach, which can be useful in certain gastrointestinal disorders.
o Disadvantages: More difficult to place and may require fluoroscopic or endoscopic guidance.
3. Gastric Feeding Tube (G-Tube):
o Placement: A tube inserted directly into the stomach through the abdominal wall via a procedure called
percutaneous endoscopic gastrostomy (PEG).
o Indications: Used for long-term enteral feeding (for weeks or months).
o Advantages: More comfortable for long-term use compared to NG tubes. It avoids nasal and throat
irritation.
o Disadvantages: Invasive procedure required for placement. There is also a risk of infection at the
insertion site.
4. Jejunostomy Tube (J-Tube):
o Placement: A tube inserted into the jejunum (part of the small intestine) via a surgical procedure or
percutaneously (using an endoscopic technique).
o Indications: Used when long-term feeding is required, especially in patients with gastric motility
problems or gastroesophageal reflux.
o Advantages: Avoids the stomach, which can be helpful in cases of poor gastric motility or risk of
aspiration.
o Disadvantages: Requires surgery or an invasive procedure for placement.
Parenteral Nutrition
The delivery of nutrients directly into the circulation through the peripheral or central vein is termed as parenteral
nutrition. This can be total or supplemental. The total sustenance of increased nutritional requirements through
intravenous feeding has been termed Total Parenteral Nutrition (TPN).
When parenteral nutrition provides 30-50% of the total daily nutrients it is termed partial parentral nutrition. Intravenous
feeding is best used in conditions when the patient cannot eat, will not eat, should not eat, cannot eat enough or cannot be
fed adequately by tube feeding. Conditions which necessitate parenteral feeding include
1. Cancer 3. Short-bowel syndrome 5. Gastrointestinal fistulae.
2. Inflammatory bowel disease 4. Preoperative patients
Types of Parenteral Nutrition:
Parenteral nutrition can be broadly classified into two main types based on the duration of use and how it is
administered
1. Total Parenteral Nutrition (TPN)
Definition: Total Parenteral Nutrition (TPN) provides all of a patient's nutritional requirements
intravenously. It is a complete form of nutrition therapy, supplying all the essential macronutrients
(carbohydrates, proteins, fats), micronutrients (vitamins, minerals), and electrolytes.
Indications: TPN is typically used when there is severe malnutrition or when the gastrointestinal tract
is non-functional for an extended period. It is suitable for patients who cannot eat or digest food for
various reasons, such as:
o Severe gastrointestinal disorders (e.g., Crohn's disease, short bowel syndrome).
o Severe burns, trauma, or surgery.
o Pancreatitis.
o Obstruction or fistulas of the GI tract.
o Neurological conditions affecting swallowing.
Components:
o Carbohydrates: Typically provided in the form of glucose.
o Proteins: Usually provided as amino acids.
o Fats: Given in the form of lipid emulsions.
o Vitamins & Minerals: Added to ensure complete nutritional support.
o Electrolytes: Sodium, potassium, magnesium, calcium, phosphate, etc., to maintain balance.
2. Partial Parenteral Nutrition (PPN)
Definition: Partial Parenteral Nutrition (PPN) provides only part of the nutritional needs of a patient,
and the rest is provided through oral or enteral feeding (if possible). PPN is used when the
gastrointestinal tract is partially functional but unable to meet all the nutritional requirements.
Indications: PPN is used in situations where a patient’s nutritional needs are not completely met by oral
or enteral feeding, such as:
o In patients with mild malnutrition or inadequate oral intake.
o In cases of mild-to-moderate gastrointestinal dysfunction, where the GI tract is still functional
but requires supplemental nutrients.
o Short-term nutritional support after surgery or illness.
Components:
o Like TPN, PPN provides carbohydrates, proteins, fats, and electrolytes, but the composition and
concentration of the nutrients are typically lower to avoid excessive osmolarity, which would
damage smaller veins.
Differences between TPN and PPN:
Aspect Total Parenteral Nutrition (TPN) Partial Parenteral Nutrition
(PPN)
Purpose Provides all nutritional needs Supplements oral or enteral feeding
Nutritional Complete (macronutrients, micronutrients, Partial; fewer nutrients than TPN
Composition electrolytes)
Administration Central venous catheter (CVC), PICC line Peripheral vein (small veins)
Indications Severe malnutrition, non-functional GI tract Mild malnutrition, partial GI
dysfunction
Duration Long-term (weeks to months) Short-term (up to 7–10 days)
Nutrient Higher concentration (more osmolality) Lower concentration (less
Concentration osmolality)
Comparison Table:
Feature Parenteral Nutrition (PN) Enteral Nutrition (EN)
Delivery Method Intravenous (IV) through a catheter Gastrointestinal tract (feeding tube)
Nutrient Delivery Complete nutrition via IV (carbs, proteins, Complete or supplemental nutrition via feeding
fats) tube
Indications Non-functional GI tract (e.g., bowel failure) Functional GI tract but unable to eat orally
Risk of Infection Higher (catheter-related) Lower (tube-related infections, aspiration)
GI Tract Function Bypasses GI tract Uses GI tract, preserving gut integrity
Duration of Use Long-term (weeks to months) Short-term (days to months) or long-term
Cost and Complexity Expensive, complex, requires medical More cost-effective, easier to manage at home
supervision
Impact on Quality of May limit mobility Less restrictive, more independent
Life
