Nutrition: Feeding hospitalized patients for best clinical outcome

Nutrition: Feeding hospitalized patients for best clinical outcome

A guide to oral, tube feeding and estimating caloric requirements
Jan 01, 2009

Developing a feeding plan early for your hospitalized patients can significantly increase the likelihood for recovery.

Nutrients can be supplied to the body either enterally or parenterally. Enteral (using the gastrointestinal tract) feeding provides adequate nutrition simply and cost effectively, whether done orally or by feeding tube.

Enteral feeding usually is preferred to parenteral feeding because it is less expensive, stimulates the immune system and avoids most metabolic complications. However, nutrients must be administered parenterally when the small intestine is inaccessible or not functioning adequately enough to meet the patient's nutrient requirements enterally. The two methods are not mutually exclusive. In fact, supplementing what the patient consumes voluntarily with a parenteral caloric and protein infusion is possible in most veterinary practices.

Therefore, overall patient assessment, including evaluating a patient's ability to eat and assimilate food, is the first step in developing a feeding plan because it dictates the route of administration. The route for providing nutritional support then determines which type of foods may be fed.

Oral feeding

Several routes exist for enteral feeding, but the first attempt should be oral feeding unless there is a clear complicating factor, such as facial trauma. Placing a bolus of food in the proximal portion of the mouth may stimulate the swallowing reflex and, if the patient offers no resistance, is a good method as long as the patient receives enough food to meet its resting energy requirement (RER).

Simple syringe feeding of a liquid product also is a good method, if tolerated. For dogs, the syringe tip is placed outside the molar teeth and food is deposited in the cheek pouch with the head held in a normal or lowered position. For cats, the syringe tip is placed between the four canine teeth. The patient may choose to swallow the liquid or allow it to flow out of the mouth by gravity. Some patients refuse to swallow boluses of food, but force-feeding is not advisable because of the increased risk of food aspiration.

Oral feeding should be discontinued if the patient does not swallow food voluntarily. Appetite stimulants may be used to induce food consumption. However, voluntary food intake using stimulants is rarely sufficient to meet the patient's minimum caloric intake.

  • OROGASTRIC TUBES require placement at each feeding but may provide a useful option for one or two days of feeding. They can be used as long as there is no nasal, pharyngeal or esophageal trauma or disease. Anesthesia or sedation is not required. Neonates tolerate multiple daily oral-tube feedings better than adults. A red rubber or polyvinyl chloride tube (8 to 24 Fr.) may be used with the tip inserted to the caudal esophagus or stomach.

An indwelling feeding tube is the method of choice if assisted feeding is necessary for more than two days. It is easier and less stressful on the patient. Nasoesophageal, pharyngostomy, esophagostomy, gastrostomy and enterostomy are potential sites. Tubes should be placed in the most proximal functioning portion of the GI tract by the least invasive method. The stomach, acting as a reservoir of a meal, should be used whenever possible.

  • NASOESOPHAGEAL (NE) TUBES are generally used for three to seven days, but are occasionally used longer (weeks). Polyurethane tubes (6 to 8 Fr., 90 to 100 cm), with or without weighted tip or silicone feeding tubes (3.5 to 10 Fr., 20 to 105 cm), may be passed through the nasal cavity to the caudal esophagus or stomach.

The preferred placement of all indwelling feeding tubes originating cranial to the stomach is for the tip to be in the caudal esophagus to minimize gastric reflux and subsequent esophagitis. An 8-Fr. tube will pass through the nasal cavity of most dogs. A 5-Fr. tube is more comfortable for cats. NE feedings may be used in anorectic patients that do not have nasal, oral or pharyngeal disease or trauma.

Anesthesia or tranquilization is not necessary to place an NE tube, so this route provides a feeding option for patients considered an anesthetic risk. These tubes are most often used in the hospital, although conscientious owners can use NE tubes at home.