Enteral Tube Feeding Clinical Care Guidelines

Enteral tube feedings are an important treatment option in cystic fibrosis when oral intake is not adequate to meet nutritional goals. A multidisciplinary Cystic Fibrosis Foundation panel developed consensus evidence-based guidelines on all aspects of care regarding enteral feeding.

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Enteral Tube Feeding Clinical Care Guidelines

Schwarzenberg SJ, Hempstead SE, McDonald CM, et al. Enteral Tube Feeding for Individuals With Cystic Fibrosis: Cystic Fibrosis Foundation Evidence-Informed Guidelines. J Cyst Fibros. 2016. Nov;15(6):724-735.PMID: 27599607

Recommendations focus on care delivery by a multidisciplinary team including when to consider a tube and what to include in the pre-, peri- and post-operative assessment. Further research is needed in a variety of areas including the impact of enteral feeds on pulmonary status, optimal enzyme delivery, and formula composition.

Purpose and Background

Nutrition is an important component of CF care. Better nutrition is associated with improved pulmonary outcomes. Ensuring adequate nutrition requires a multidisciplinary team including, but not limited to, the patient and family, a registered dietitian/nutritionist, gastroenterologist, nurse, and primary CF physician. This multidisciplinary strategy allows for frequent and comprehensive assessments of barriers to nutrition and interventions as appropriate, including optimizing oral intake as well as bowel function. When strategies involving oral nutrition are insufficient to meet growth/weight goals, enteral tube feeding is the preferred route to optimize nutritional status. Evidence for this guideline is somewhat limited, and prospective, multicenter trials are needed to shape and strengthen further recommendations for nutritional assessment and intervention.

Methodology

A multidisciplinary expert panel developed recommendations for enteral tube feeding. The panel included pediatric and adult dietitians, gastroenterologists, pulmonologists, a psychologist, a social worker, a nurse, the parent of a child with CF, and an individual with CF. Structured questions were developed utilizing the Population, Intervention, Control, Outcome (PICO) method. This was followed by a guided literature search and review. All consensus statements were discussed and voted on by the committee, which reached 100 percent agreement on each recommendation.

Recommendations

Preparation for Enteral Tube Feeding
Recommendations	Evaluation of the Evidence
1. Enteral tube feeding as a means to improve age-dependent anthropometrics in individuals with CF that are unable to consume adequate calories and protein to meet growth/weight maintenance goals, despite appropriate evaluation and intervention by a multidisciplinary team.	Consensus
1. Evaluation by a multidisciplinary CF team prior to enteral feeding tube placement in individuals with CF to identify and treat conditions that might be contributing to nutritional decline.	Consensus
3. The use of supplemental enteral nutrition for pregnant or lactating women with CF who are unable to consume adequate calories and protein to meet nutritional goals despite appropriate evaluation and intervention by a multidisciplinary team.	Consensus
4. Patient and family education about nutritional care including the role of enteral tube feeding be done throughout the lifetime of the individual with CF.	Consensus
5. That the risks of certain conditions be considered and discussed with individuals with CF prior to the placement of an enteral feeding tube including but not limited to: coagulopathy, severe obstructive lung disease, ascites, portal hypertension, history of abdominal surgery, peritoneal dialysis, or alcohol and/or substance abuse.	Consensus
6. Nasoenteral tube feeding in individuals with CF who require short-term (less than three months) nutritional repletion.	Consensus
7. Discussion of third party/individual coverage of supplies and formula with individuals with CF prior to placement of an enteral feeding tube.	Consensus
8. A comprehensive history and physical exam with specific attention to factors that represent potential complications be performed in advance of scheduling the placement of the percutaneous or surgical enteral feeding tube by the medical team performing the procedure in individuals with CF.	Consensus
9. Clinical assessment of gastroesophageal reflux be performed prior to enteral feeding tube placement in individuals with CF.	Consensus
Placement of Enteral Feeding Tube
Recommendations	Evaluation of the Evidence
11. Platelet count and international normalized ratio (INR) be measured in individuals with CF prior to percutaneous enteral feeding tube placement.	Consensus
12. Consultation with an anesthesiologist and the consideration of more intensive pulmonary therapy prior to placement of a percutaneous or surgical enteral feeding tube in individuals with CF and moderate to severe lung disease.	Consensus
13. Enteral feeding tubes be placed by percutaneous endoscopic, laparoscopic, or radiologic technique when possible as opposed to open surgical techniques in individuals with CF.	Consensus
14. That individuals with CF who are intolerant of gastric feeding receive jejunal feeding.	Consensus
Post-enteral Tube Feeding
Recommendations	Evaluation of the Evidence
15. Airway clearance be re-initiated within 24 hours of percutaneous or surgical enteral feeding tube placement in children and adults with CF.	Consensus
16. Optimal post-operative pain management to facilitate re-initiation of airway clearance in adults and children with CF who receive an enteral feeding tube.	Consensus
17. Initiation of a bowel regimen to prevent post-operative constipation or distal intestinal obstruction syndrome in individuals with CF, especially those receiving narcotic pain management.	Consensus
18. Adherence to the 2010 Clinical Care Guidelines for Cystic Fibrosis-Related Diabetes in individuals with CF who are using enteral feeding tubes.	Consensus
19. The use of Cystic Fibrosis Foundation evidence-based guidelines for management of infants with cystic fibrosis to choose the best feeding type, breastmilk or formula, for enteral tube feeding in children with CF under 2 years of age.	Consensus
20. Continuous nocturnal infusion for individuals with CF who are receiving supplemental enteral tube feeding.	Consensus
21. A comprehensive planning approach with a multidisciplinary CF care team including the managing gastroenterologist, case manager, and home care agency prior to discharge.	Consensus
22. That individuals with CF who have had enteral feeding tube placement be monitored at least annually by a gastroenterologist, preferably with enteral device experience, in addition to their quarterly CF care center visit.	Consensus
Recommendations Against
Recommendations	Evaluation of the Evidence
23. Using FEV₁ as an absolute contraindication to percutaneous or surgical enteral tube placement in individuals with CF.	Consensus
24. Routine pH/impedance or radiographic procedures to assess gastroesophageal reflux in individuals with CF prior to percutaneous or surgical enteral feeding tube placement.	Consensus
25. Placement of a percutaneous or surgical enteral feeding tube during acute illness.	Consensus

Unanswered Questions

What patient characteristics are predictive of improved clinical outcomes with enteral tube feeds?
When should enteral tube feeds be initiated?
Which enteral tube feed formula should be used and why?
What is the optimal way to deliver pancreatic enzymes with tube feeds?
When should tube feeds be stopped, and when should the enteral tube be pulled?
Does enteral nutrition improve pulmonary outcomes, such as FEV₁, and exacerbation frequency?