Myth-busting in enteral nutrition: Supporting evidence-based care

[Music] Welcome to the Dietitian Connection podcast, a show about nutrition, dietitians and their success stories. Through our conversations with nutrition leaders we aim to inspire you, to connect you with like-minded colleagues, to innovate and push you out of your comfort zone, to create robust debate, to encourage lifelong learning, and to empower you to create more impact as a dietitian. Welcome to the Dietitian Connection podcast. I'm Kristen Houts from Dietitian Connection and I'm a registered dietitian from Chicago. This episode is supported by Nestle Health Science. We know that for many dietitians, addressing misinformation and busting nutrition myths has become part of everyday practice. And while we work hard to educate others, we also recognize that within our own profession, busy schedules, reliance on familiar routines, and limited access to the latest evidence can sometimes create gaps in knowledge and understanding. Recently, we ran a survey on dietitians' recommendations and practices around tube feeding. We asked directly about the most common misconceptions you encounter, but surprisingly even more surfaced through the answers to the other questions. That's why in today's episode, we're setting the record straight on some of the biggest myths and misconceptions in tube feeding. To help us do that, we're joined by registered dietitian and certified nutrition support clinician, Leslie Mary. With more than 20 years of experience in acute and critical care, Leslie is passionate about advancing evidence-based nutrition therapy, and educating both providers and colleagues to strengthen practice across the profession. She is currently part of the nutrition support team at Duke University Hospital, practicing in the surgical trauma ICU. Leslie, welcome to the dietitian connection podcast. Thank you for having me. So let's start with timing and the initiation of entral nutrition. What is the biggest misconception around starting tube feeds? All right. Well, per our critical care guidelines, we want to start early intral support within the first 24 to 48 hours of admission to the ICU. And what that means is anyone that is critically ill, we don't anticipate they're going to be transitioning to an old diet start early. And the reason is patients that are started early on, they have lower risk of infection, lower rates of mortality, and lower lengths of stay. But certainly when it comes to starting these patients within that first 24 to 48 hours, sometimes they run into some roadblocks or maybe misconceptions about the critical ill population and starting to intral feed them. And in my experience, it's really fall into two categories. The first is clinical stability, and that would be feeding on presser support, and the second is GI function. So presser support, you may have providers say, "Oh, the patient's on, basal pressers, we really don't want to start intral support." But really the data tells us that we can safely feed on intral support. Now it's important to look at clinical stability, meaning are they resuscitated? Are they hemodynamically stable? And looking at the rate of pressers, so you want the patients to be on a low stable dose of pressers. And then you start those trickle feeds or trophic feeds and watch the tolerance. Second is bowel function or bowel sounds. And whoa, we should wait for a bowel movement to start intral support. And that also is a big misconception. So bowel sounds, they're not a sensitive marker of GI function, just because someone hasn't passed playtis or had a bowel movement. Doesn't mean that they don't have contractility in the small bowel. So it doesn't mean that we can't start intral support. So being knowledgeable and encouraging that early intral support really provides benefit to your patient. So are there times when you would delay or hold under only nutrition? Yeah, absolutely. Certainly the patient that is experiencing septic shock, maybe they are on high dose pressers or maybe you've started them on intral support, but yet their clinical status changes and those pressers increasing numbers or mouths. That's when you would want to push pause on that intral support. And then maybe from a GI standpoint of someone if there's a concern for an obstruction, then obviously not starting intral support in that case. Yeah, got it. Okay. We also heard from our audience that others on the medical team may place a large emphasis on gastric residuals. Can you provide some context to this issue and tell us what the current research says about folding feeds due to gastric residuals? Absolutely. I really think this is a very controversial and complex issue. The Aspen critical care guidelines, curses multiple guidelines within that huge document. And one of them says that they recommend against routine monitoring of gastric residuals. And why is that? Well, because when they looked at what does gastric residuals tell us, they really are not a reliable marker to predict who's going to aspirate, who's going to sub-aracheration pneumonia. They looked at data, looking at what if you check gastric residuals, what if you don't, and major outcome differences like linked to staying mortality really was not different between the two. However, reason I say this is controversial and complex is as I was just talking about the misconception of feeding on pressers while it's safe, you do want to monitor tolerance. And in those same guidelines, gastric residuals are one of those monitoring points. So looking at the data behind, do I check, do I not? Well, the studies did not include patients on pressers, did not include patients with GI surgery. They also administered prophylactic progenetic agents, which we don't do. So, you know, as clinicians, we have to look at all of our patients as individuals. And in my case, I work with patients on pressers, I work with GI surgery patients. So we still do monitor gastric residuals. But I think the important part in why it can be confusing for clinicians is, you know, it's just a piece of the puzzle. I agree, we shouldn't automatically stop feeding for a gastric residual greater than 500. My next question is always, is there abdomen distended? Is it firm? When was the last bowel movement? You know, it's one piece of the puzzle, ask other questions. But certainly, there are patient populations. We don't need to check gastric residuals on or we can stop gastric residual monitoring. So that may be someone who you have established tolerance to control support. Someone who's stable on the floor, someone who can tell you if they're nauseous. So like I said, it's complex. It's not cut and dry. But, you know, they're just guidelines. So we need to use our clinical judgment and think of our patients, meet them where they are and their clinical journey. Absolutely. Now, I think that the clinical judgment piece is always there, right? We have great recommendations and guidelines, but we do have to look at everyone as an individual, too, well said. So you mentioned GI intolerance. So let's talk a little bit more about that. Can you explain some of the non-formula factors that contribute to GI intolerance into fed patients and how do you address these concerns? Yeah, absolutely. Probably one of my favorite topics, one of the things I deal with almost on a daily basis. So, I want to first make sure we know what we're talking about when we say "entral feeding intolerance." So in the literature, you see it as EFI or "entral feeding intolerance." And generally, that's described as things like nausea, vomiting, diarrhea, bloating, distinction, gastroposituals. When I'm consulted to see a patient or I run across a patient with one of these signs or symptoms, I kind of run through a checklist. Step one, what's wrong with the patient? Why are they here? So, acute problems, but also chronic medical conditions that could be contributing to their GI intolerance. And then step two on that non-formula related things. Medications, liquid medications contain large amounts of sorbitol. Up to 55% of the diarrhea in hospitalized patients could be related to sorbitol containing medications. So when you can change those medications to a pill or a tablet, looking for, do they have bowel regimens that are scheduled? Can we put those on pause? Now, they're not infrequent, is they've given a suppository or in a much promote bowel movements, and they worked. Look for infectious etiology like C-Diff. Me epivitting to, let's say, they're complaining of nausea, vomiting, diarrhea, gastroposituals. Then I think about motility issues. Again, looking at past medical history, do they have diabetes, and they have some gastroparesis, or they critically ill-related gastroparesis. And then Ilya's obstruction looking for a double X-rays to rule those out as reasons for intolerance. You know, lastly, you can consider the feeding method, bolus continuous, and where you're feeding, is that a possibility causing an issue. And then, you know, you make the changes you can and monitor. Yeah, so those are all great things to keep in mind, kind of first. And then when you start to think about, kind of, formula really, factors that might be contributing to GI intolerance, how do you determine when it's time to switch formulas or try something now? Well, certainly when we've rolled out the non-formula, the meds, the ilius, and the patient's still exhibiting intral feeding intolerance, it's time to make a change. It's time to think about, "Do they have food allergies or intolerances even? Do we make a change to the protein content of the formula?" "Formulas can be milk-based or they can be plant-based like soy or pea protein, so maybe you're going to make a change there." Or have you identified things within their past medical history, such as maybe inflammatory bowel disease or something that's impacting their ability to digest and absorb, and then you pivot to more of a hydrolyzed formula? Right. Since you've brought up hydrolyzed formulas, we actually heard from our audience that there are a lot of misconceptions around the use of peptide-based formulas. So can you explain what a peptide-based formula is and then when it would be used? Absolutely. So multiple categories of formulas, but we have what we know is like our standard or intact protein or polymeric. Think of that as a train. All the train cars are connected, so that's your protein, and your body's got to break that train into pieces, right? So a hydrolyzed formula or a peptide formula is where that train those cars are broken into pieces. So the formula is pre-digested if you will, so it's taken a step out of the digestive process that might be missing or insufficient in your patient. And so some of these peptide formulas some are broken into individual peptides and some are longer. Some formulas are actually a mix of hydrolyzed and intact. And the significance of a 100% hydrolyzed way protein is that it's easily digested, it's quickly absorbed, and it leaves the stomach quickly. So that's where we promote that improved tolerance in a patient. And are there specific patients that you would automatically go to a peptide-based formula with? I mean, certainly, you maybe have thought about transitioning the patient from an intact to a hydrolyzed. We don't need to reserve that for someone with severe malabsorption. Some good patient examples. Maybe your patient has had a recent surgery. They've had bowel resections, and now they're malabsorbing, and they're losing their pancreatic secretions. Maybe they have tubes and drains where these things are being lost. These are your normal digestive enzymes. Maybe they've had bowel resection where they've lost absorbed capacity. Other examples might be oncology patients that have radiation and do stiorea. Even patients that are receiving pancreatic enzymes say someone with cystic fibrosis or chronic pachyretitis, but yet they're still exhibiting a malabsorption. They would benefit from a peptide-based formula. And then damaged bowel situation. So, irritable bowel syndrome, radiation to the bowel, even someone like a critically ill patient that has had an ischemic event. You know, these patients, we don't know the quality of their bowel. So, even though they haven't had bowel resected, it may not be fully functional. And so, again, that's where those hydrolyzed proteins can be so beneficial. Yeah. Have you had any patients that you've seen move to a peptide-based formula and have a really improved outcome? Certainly when I was early on in my career, you know, again, I think in stiaticians were taught that intact formula, everyone can tolerate, but you know, I can remember thinking, oh, I don't know if I should be changing this formula to this peptide-based formula. They don't have the normal short, bowel short gut, but yet the patient just, no matter what we did, they weren't tolerating it. They haven't severe diarrhea. And I didn't recall, it was a learning lesson for me is when all else fails and they're still having diarrhea, they're still having bloating, then absolutely make that change. It can make a difference for your patient. Great. We've also heard from our audience that people think that peptide formulas are only for jajunal seating. Can you clarify a little bit about that? Well, that's an interesting one. We should think about formulas and the indication for them not necessarily where they're feeding. So we can successfully feed someone, whether it's gastric, postpiloric, abdominal, or dejunal with an intact formula. Certainly someone that's being dejunally fed, they may benefit from a peptide-based formula, but it's probably more about what's going on, maybe pancreatic biliary losses or resections or other issues causing feeding intolerance that we talked about, but it's not an absolute indication. Okay. So as we know, not all tube feeding formulas are created equal. I'm sure this also applies to peptide-based formulas. So can you discuss some of the differences across this category? Perhaps maybe differences in protein sources, peptide profile, MCT levels, and what options does this present for patients? Yeah. So when we think about the hydrolyzed formulas or the peptide-based formulas, they fall into either 100% hydrolyzed, partially hydrolyzed, a combination of hydrolyzed and intact. And so certainly taking a look when you're making a decision and determining that your patient needs a peptide formula, look to see which one is going to best meet their needs. As I said, the 100% hydrolyzed way, it's really readily absorbed and leaves it so much faster. So if you're having someone with gastroparesis, that may be a real benefit. Other things to think about when we talk about peptide-based formulas is that another characteristic that's so important is the lipid or the fat content. So peptide-based formulas generally are higher in medium chain triglycerides as opposed to long chain triglycerides. And why that's so important is because MCT oil, they don't require bile or pancreatic enzymes to be absorbed and converted to energy. And so again, in your patients with pancreatitis or cystic fibrosis or those bilio-pancreatic secretion losses, they really may benefit from the MCT high percent MCT oil containing formulas. And then you know protein sources, whether you're talking about an intact or hydrolyzed, they can be milk-based, they can be plant-based, soy-p, there's even hydrolyzed, plant-based formulas. So many options these days. Yes, it's great. I think we have to take all of these things into consideration as you said before, all of our patients are individuals. So having those sorts of options to meet patients needs exactly where they are is really, it's really great. Do you find that there are misconceptions or maybe misunderstandings around cost and insurance coverage of enteral formulas and maybe specifically for peptide-based formulas? Certainly any specialized formula is going to be more costly, but it's important that we don't limit ourselves to changing formulas based on cost alone. You know, there's actually been studies and data out there looking at the cost of an intact or standard formula versus a peptide-based. In some instances, both in patient and outpatient, they've seen a reduction in cost when patients who had the indication and had an interval feeding in times when they are switched from an intact to a peptide, they've shown a reduction in cost. And when we think about that, you're thinking about healthcare utilization, so frequency of visits or length of stay, but also think about your patients that diarrhea puts them at risk for wound break, or skin breakdown and wounds. All that adds up into cost. Certainly an inpatient setting, if we do transition someone from an intact to a peptide-based formula, it's important that we're documenting why we changed and the benefit that improves their interval feeding in tolerance. And that's important when patients are going to then transition to home on this formula because we've seen that it works for them. And we want that documentation so that they can gain insurance approval and coverage for their formula. Certainly, you know, also working with case managers are working with the home care company and providing that documentation for medical necessity. Another great resource is the formula companies. You know, they have claim support, they help patients if they've been denied or with appraisals, they have documentation that helps to really outline medical necessity and form. So there's a lot of resources out there when it comes to getting approval for any specialized formula, peptide-based or even whole-food formulas. Yeah, that's really all great information because I do feel like many times the dietician is kind of the link between the hospital and home. And so it's great that dieticians kind of help more of their patients stay on the formulas that are really benefiting them. Absolutely. Let's see, are there any major takeaways we've discussed a lot of kind of general misconceptions and. I'm too feeding out. Is there one big take home point that you would want our listeners to take from today's episode? - I think that sometimes it can be easy when you're in the impatient setting to think, "Oh, you know, well, who hasn't heard a nurse or a doctor say, oh, it's tube feed diarrhea, right? Oh my goodness. If I could have a button that says it's not tube feeds, right? (laughs) But recognizing that we can't see what's happening inside the patient, we can't see how functional the GI tract is. And sometimes, you know, critical illness itself for past medical history, all these things can contribute and not discount when patients are having gas and bloating or discounting when they're having diarrhea because they're on antibiotics. You know, there's still some malabsorption, they're still not properly digesting the nutrition and that's when, you know, really making that change and doesn't mean making one formula change, doesn't mean you can't make another one when that doesn't work, you know? Maybe you do the pathway of changing the protein source, changing to peptide, looking at the percent of medium chain triglycerides. Like I said, there's so many options, but doing the best we can with the formula is to help those intral feeding intolerances. - Thank you so much, Leslie. You are a wealth of information. You've really helped me and I'm sure our listeners understand that tube feeding intolerance is rarely a one size fits all issue. As you mentioned, as dieticians, we really need to use our best clinical judgment, carefully assessing the root causes of symptoms and leveraging all available formula options and documentation strategies for insurance approval to get the best option for each individual patient. I personally learned a lot about peptide-based formulas during today's discussion and I love the analogy you use to describe this type of formula. Thinking of peptides like train cars, already broken into pieces for easier digestion. I also learned a lot about all the instances where this type of formula would be indicated as a first line approach, including for those with malabsorbsions or borpoly syndrome, chronic diarrhea, including radiation, duesteria, GI surgery, IBD, and critically all patients. Thank you so much for joining us on the dietician connection podcast. And of course, a big thank you to Nestle Health Science for supporting today's podcast. Until next time, the content, products, and/or services referred to in this episode are intended for healthcare professionals only and are not intended to be medical advice, which should be tailored to your individual circumstances. The content is for your information only and we advise that you exercise your own judgment before deciding to use the information provided. Professional medical advice should be obtained before taking action. The reference to British ill products and/or services in this episode does not constitute any form of endorsement. Please see our website for terms and conditions. To get all of the links and resources we discussed in this episode, you can go to dieticianconnection.com/podcasts. And if you'd like to support the dietician connection podcast, please leave a review and a rating on the Apple Podcast app. Tell us what you thought of this episode, what you learnt, and share your guest requests for us to consider for future episodes. We value hearing from you and we really appreciate your feedback, so please, please hit that review button.