enteral nutrition syringe

Formulas For Tube Fed Children

When foods can be eaten safely, tube feedings may merely supplement the child's own nutrition. The caregivers can continue to feed the child actively. This dual feeding method (by mouth and when needed, by tube) provides the child, parents and caregivers great satisfaction. Mealtimes improve because there is no longer any worry about what's consumed. The need to force down medication or nourishment is now replaced by using the tube. However, the child may eat less, because he or she feels full for a considerable time after a very filling tube-fed liquid bolus or a night of drip feeding.

Gastric Feedings

Because children don't taste the formulas, flavoring and sweetness are not needed. The formulas are designed to meet the nutritional needs of the child with less sugar added and better balance. They contain a balance of protein and the vitamins and minerals the child needs (generally, as you'll soon see).

They now come in several concentrations. The standard is known as 1.0 which means that 1 milliliter (ml) of fluid contains 1 calorie, so an 8 ounce can of formula (240 ml) contains approximately 240 calories. That's the same strength as Pediasure, Boost, Ensure and similar products that you'll find on grocery shelves, but without the extra sugar and flavors. These formulas are used routinely for most patients, because they are easily processed by the stomach and do not cause an extra work load for the kidneys.

But some children need more calories. They are unable to take that much fluid, so these formulas are also available in a more concentrated form, with some available as 1.2, 1.5 or 2.0. These have 20%, 50% or 100% more calories in the same 8 ounces. Perfect for the child with heart problems who can't take as much fluid or for the teenager that needs more calories to maintain his weight. They do have the increased risk of causing vomiting, diarrhea, excess fullness or kidney and liver problems, so children receiving them should be monitored closely. And they can be used along with the standard formulas -- letting a child receive 2 cans or the 1.0 and 2 of the 1.5 each day, for example.

I have been lobbying the formula companies for years to also make a low calorie formula for the children who are gaining too much weight on the standard formulas because of their inactivity. These children are often sitting quietly in their wheelchairs all day not using their calories, but they still need the same amounts of protein and some of the minerals so we can't just run their formula at a slower rate and get the same nutritional benefit. Fortunately, a few products are now available as 0.6 feedings, giving a calorie concentration close to whole milk.

Gastric emptying may be delayed in children with cerebral palsy. This can contribute to reflux and vomiting. Most of the formulas are milk based containing a mixture of casein and whey (Remember Little Miss Muffett eating her curds, from the casein, and whey). Those that are whey-based seem to decrease gastric emptying time and reduce the frequency of vomiting in gastric tube-fed children with severe cerebral palsy.

Intestinal Feedings

Modifications are need for the child whose formula goes straight to the intestine. Because the stomach acid and enzymes are unable to break down the formula before it enters the intestine and because the stomach is unable to regulate the gradual release of the fluid into the intestine, the formula must be predigested and delivered slowly by drip feedings. The predigestion means that the protein, fats and sugars are all tailored to be better absorbed. The proteins are broken into amino acids, more readily absorbed fats are substituted and the carbohydrates are reduced to those that easily pass into the intestine. This lessens the potential for diarrhea and the chance of the calories and nutrients being wasted.

Amount to Feed

For wheelchair or bed-bound children with assistive feeding, the choice of formula is often less an issue than the volume delivered. The amount given can't be defined by the child's hunger or appetite. It's determined by caregivers and medical providers. Long term over-nutrition presents as much risk as under-nutrition. High blood pressure and obesity can increase lung, liver and cardiac concerns.

Therefore, calculations must approximate a child's need for calories and nutrients. Since the volume and calorie recommendations may over or under estimate actual requirements, re-evaluation at regular intervals with the calculations revisited is perhaps more important than any prescription.

The nutrient requirements for vitamins and minerals generally parallel energy or calorie needs. So the focus is usually given to caloric requirements. But those too are hard to estimate.

Most estimates of calorie needs for children are based on age, which reflects their size and activity. But these children are sedentary and their proportions are not necessarily the same as the children who are sitting at the table eating then rushing outside to play. So the initial calculations are usually based on their height or on their leg length. These estimates can be modified for activity level (or lack thereof), and the amount of weight they are gaining or losing. Those who are aren't walking require an average of 75% of the calories needed by those of comparable height.

Initially at least, the primary physician or practitioner can calculate caloric needs based on centimeters of height for certain conditions. An additional amount can be added for those who need to gain more weight.

Caloric requirements for specific disabilities
Conditionkcal/cm height
Cerebral palsy (5–11 years)13.9 if mild–moderate activity
11.1 if severely restricted
Down's syndrome (5-12 years)16.1 males
14.3 females
Myelomeningocele (over 8 years)7 to achieve weight loss
9-11 for maintenance
Prader–Willi syndrome10–11 for maintenance
8.5 for weight loss

Adapted from Cohen SA, Navathe A, Piazza CC: Feeding and Nutrition, in Rubin IL, Crocker AC, Medical Care for Children and Adults with Developmental Disabilities, Second edition, Baltimore: Brookes, 2005.

The Formulas and Nutrient Needs

The formulas are available with or without fiber to help regulate bowel movements. T hey are designed so that all the child's vitamin and mineral needs are met if they consume 6 cans of 8 ounces of the 1.0 concentration each day. There's a problem with that, of course, which is why I said earlier that these formulas generally meet the individual child's needs.

The formulas these have fixed nutrient / energy ratios, so that reducing the calories prescribed proportionate to a debilitated patient's needs based on height may also significantly reduce that patient's intake of all other nutrients below recommended daily allowance for age. A potential reduction in calcium, phosphorus, and vitamin D risks bone disease in these patients. Other vitamin and mineral deficiencies possible as well.

So it is best to have the physician or dietitian start by determining a child's calorie and protein needs. The closest formula to meet those can be modified and extra nutrients added. Or a homebrew can be designed for the child. However, it is important that the physician and dietitian be able to follow up and adjust the components of the formula as needed.

Dr. Stan Cohen13 May 2015

Dr. Stan Cohen is one of our founders and our CEO as well as the Chairman of our Medical Advisory Board. Dr. Stan is an internationally recognized expert in Read more

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