Enteral Tube Feeding Clinical Care Guidelines
Schwarzenberg SJ, Hempstead SE, McDonald CM, Powers SW, Wooldridge J, Blair S, Freedman S, Harrington E, Murphy PJ, Palmer L, Schroeder AE, Shiel K, Sullivan J, Wallentine M, Marshall BC, Leonard AR. 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.
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.
Preparation for Enteral Tube Feeding
|Recommendations||Evaluations 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|
|2. 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|
|10. To mitigate perioperative risk, the CF provider managing the pulmonary care of individuals with CF determine timing, based on pulmonary status, for percutaneous or surgical enteral feeding tube placement.||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|
|15. 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||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|
- 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?
Relevant manuscripts published after the original guidelines are listed below. These manuscripts have not been reviewed or endorsed by the guidelines committee.
- Freedman S, Orenstein D, Black P, et al. Increased Fat Absorption From Enteral Formula Through an In-line Digestive Cartridge in Patients With Cystic Fibrosis. J Pediatr Gastroenterol Nutr. 2017 Jul;65(1):97-101. doi: 10.1097/MPG.0000000000001617. PMID: 28471913
- Giguere-Rich C, Mathew A, Reid E, Autore K, Guill MF. Use of an In-line Digestive Cartridge With Enteral Nutrition Improves the Weight Trajectory of 2 Children With Cystic Fibrosis Complicated by Another Medical Diagnosis. Nutr Clin Pract. 2018 Apr;33(2):286-294. doi: 10.1002/ncp.10080. PMID: 29658186
- Stevens J, Wyatt C, Brown P, Patel D, Grujic D, Freedman SD. Absorption and Safety With Sustained Use of RELiZORB Evaluation (ASSURE) Study in Patients With Cystic Fibrosis Receiving Enteral Feeding. J Pediatr Gastroenterol Nutr. 2018 Oct;67(4):527-532. doi: 10.1097/MPG.0000000000002110. PMID: 30074573
Use of These Guidelines
The CF Foundation intends for this executive summary of its guideline to summarize the published guideline. The published guideline summarizes evidence, and provides reasonable clinical recommendations based on that evidence, to clinicians, patients, and other stakeholders. Care decisions regarding individual patients should be made using a combination of these recommendations, the associated benefit-risk assessment of treatment options from the clinical team, the patient's individual and unique circumstances, as well as the goals and preferences of the patients and families that the team serves, as a part of shared decision-making between the patient and clinician.
This executive summary was prepared by:
Adam C. Stein, MD (Northwestern University), and Amanda Leonard, MPH, RD, CDE (Johns Hopkins University)
The guidelines were published in November 2016, they were reviewed in July 2021 and it was determined that no update is needed at this time.