Enteral and parenteral nutrition are two methods of feeding patients who cannot consume food orally. Enteral nutrition involves feeding through the digestive tract using oral feeding, tube feeding through the nose or surgically placed tubes. Parenteral nutrition involves intravenous feeding bypassing the digestive system. Tube feeding is used for patients who can tolerate it while parenteral nutrition is for those who cannot use enteral methods. The type of formula used depends on a patient's ability to digest nutrients and may include polymeric, elemental, semi-elemental or specialized formulas. Tube feeding can be given continuously, intermittently or through bolus feeding methods. The document provides details on the different enteral and parenteral nutrition methods, formulas and considerations for

1. Enteral and Parenteral Nutrition
Enteral Nutrition
Enteral nutrition (EN) is the form of feeding that brings nutrients directly into the digestive tract.
It includes three types:
1. Oral Feeding + Tube Feeding
Oral feeding is when the food is given to patients through their mouths. It can be in the form of a
clear liquid diet, full liquid diet, or soft semi-solid diet. This is supplemented by tube feeding.
2. Tube Feeding (TF)
Tube feeding is when a nasogastric (NG) tube is inserted through the patient’s nose, down the
esophagus, and into the stomach. It is used for patients with difficulties in chewing and
swallowing. The tube can be form nose to stomache (nasogastric), nose to first part of the
intestine (nasoduodenal) or nose to second part of intestine (nasojejunal).

2. 3. Ostomy
If the tube feedings is required for more than six weeks, an opening called ostomy is surgically
created into the esophagus (esophagostomy), the stomach (gastrostomy) or second part of the
intestine (jejunostomy).
 Total Enteral Nutrition (TEN) is when the complete nutrition of the patient comes
through tube feedings inserted through the vein.
ParenteralNutrition
Parenteral nutrition (PN) is the feeding of a person intravenously, bypassing the usual process of
eating and digestion. The person receives nutritional formula that contain nutrients such as
glucose, salts, amino acids, lipids and added vitamins and dietary minerals.

3. Short term
Short-term TPN may be used if a person's digestive system has shut down (for example
by peritonitis), and they are at a low enough weight to cause concerns about nutrition during an
extended hospital stay.
Long Term
Long-term TPN is occasionally used to treat people suffering from an accident, surgery, or
digestive disorder. PN has extended the life of children born with nonexistent or deformed
organs. Small, frequent, low-fat, low-fiber formulas are usually used.
Other Names
 Total Parenteral Nutrition (TPN) is when the complete diet of the patient comes through
parenteral nutrition.
 Peripheral parenteral nutrition (PPN) when feeding is given through vein access in a
limb rather than through a central vein as central venous nutrition (CVN).
 Partial parenteral nutrition (PPN) is when nutrition comes form part enteric nutrition and
part parenteral.

4. Difference of Parenteraland Enteral Nutrition
TEN is used for patients who
- Can easily have a tube inserted.
- Require tube feeding as supplement to oral feeding (they can still eat by mouth)
- Who require tube feeding for less than 30 days
- Have uncontrolled diabetes or blood pressure
- Are at risk for aspiration (due to delayed gastric emptying, high gastric residue, head
back position)
TPN is used for patients who
- TEN is not possible for (maybe due to a medical problem that does not allow safe
passage of tube)
- Cannot eat by mouth at all.
- Require longer than 30 days of tube feeding
- Have no serious metabolic diseases
When is TEN or TPN Ordered?
Nutrition support is started when a patient is unable to take adequate oral diet for longer than 10
days. Two factors are taken into account, the nutrition status of the patient and the severity of the
disease.
Nutritional Status:
Patients who score an A or B on a malnutrition assessment test are allowed 10 – 14 days before
starting TEN or TPN. This is because the medical problem that is stopping adequate intake of
food might be corrected in that time.
Patients with severe malnutrition (score C) are usually started on TEN or TPN in within 2 days
of hospitalization.
Severity of the Disease:
A patient with severe pancreatitis might need 14 days to recover the ability to eat properly. Even
if the patient gets an A or B on the nutritional assessment, it would be appropriate to start TEN or
TPN earlier than 14 days.
However, if the patient has a mild form of a disease that might take only 5 days to recover, the
patient will not be put on TEN or TPN.

5. Important Requirements of Tube Feeding:
 The tubes have to be soft and flexible.
 They also should be narrow and thin enough to pass easily without harming the insides of
the patient.
 Tubes should be places by a professional health care worker.
 An X-ray is done to make sure the tube is inserted correctly and there is no danger of
aspiration.
 Tubes can be inserted under anesthesia to prevent pain.
 The health care worker has to make sure the tube is inserted securely so that it does not
get pulled out.
 If pulled out, the tube is inserted back immediately to reduce chance of infection.
 When giving tube feeding, the bed of the patient should be raised so that formula doesn’t
enter the lungs and cause pneumonia (aspiration).
 If the feeding is continuous, the head of the bed should always be raised.
 Before giving a tube feeding, a flush solution should be poured through the tube to make
sure there is no clogging.
 When inserting the tube through a vein, the area of the skin should first be wiped with
disinfectant. This prevents blood infections (sepsis).
 Tube formulas should be kept refrigerated at all times to prevent bacterial and fungal
infections.
 The tube feeding formula should be checked for proper dilution. Too concentrated
formula can cause inflammation of a vein (phlebitis) or blockage by a blood clot
(thrombosis) which can even be deadly.
Formulas for Tube Feeding

6. 1) Polymeric Formulas
 Patients who can digest all nutrients are given polymeric formulas.
 These have 1 – 2 kcal per milliliter as well as whole complex proteins, carbohydrates and
long chain triglycerides that require further digestion in the body.
 They are nutritionally complete and may be taken orally or via tube.
 These are available as blenderized whole food formulations
 Polymeric formulas are often used for longer periods of time (6+ weeks) a
 They less expensive than elemental or semi-elemental formulas. Boost® and Ensure® are
examples of high calorie polymeric formulas.
2) Elemental/ Hydrolyzed Formulas
 Patients who have difficulty digesting all nutrients are given these formulas.
 These have 1.0 kcal per milliliter and only contain simple proteins carbohydrates and fats
(the products of digestion).
 They are also lactose- free and do not require any digestion in the body.
 They are nutritionally complete.
 Patients on an elemental formula rely on it as the only source of nutrition for 2-3 weeks
 Physicians’ Elemental Diet is an orally administered elemental formula. Other examples
include Vivonex® T.E.N., and Vivonex® PLUS .

7. 3) Semi Elemental Formulas
 Semi-elemental formulas contain amino acids of varying length, simple carbohydrates,
and medium chain fatty acids.
 They are partially pre-digested but not fully pre-digested. They are used for patients with
mild digestion problems.
 Some types are nutritionally complete while other need to be supplenmented.
 An example is Peptamen AF®.
4) SpecializedFormulas
 These are designed to meet the needs of individuals with specific health conditions.
 The availability varies widely.
 These are nutritionally complete and can be given with oral feeding or in place of it.
 One such example is Magnacal Renal , which is formulated specifically for renal support.
 Another example is hypoallergenic formula, containing no intact protein, corn or soy
derived micronutrients or macronutrients )

8. 5) Modular Formulas
 Patients who require a specific nutrient are given modular formulas.
 These have 3.8 – 4.0 kcal per milliliter.
 They are also used as supplements to other formulas, or for creating a customized tube
formula for a specific patient.
 They are not nutritionally complete by themselves.
Methods of Tube Feeding
1) Continuous:
This is also known as continuous infusion method. The patient is continuously fed through the
tube in a 16 – 24 hour period. In the beginning, the formula is given at half strength of 30 to 50
ml per hour. Once the patient tolerates half- strength, the rate is increased by 25 ml every four

9. hours until tolerance for the complete strength is made. When the patient can tolerate oral
feedings, a slow transfer is done.
2) Intermittent:
Intermittent tube feeding is given in intervals, and is sometimes given alongside oral feeding. For
example, tube feeding can be given only at night and solid foods during the day. If the patients
takes oral medication, tube feeding is stopped one hour before the medication and resumes one
hour later.
3) Bolus Feeding
Bolus is a small rounded mass of a substance, especially of chewed food at the moment of
swallowing. Bolus feeding is done by dividing the daily kcal needs of the patient into six
servings. Each serving should not exceed 400 cc and is given over 15 minutes time span
followed by 25 to 60 ml water. This is more common in parenteral nutrition.

10. ASSIGNMENT
DIETETICS
SUBMITTED TO :- MISS SHAKEELA
SUBMITTED BY:- GROUP 1
B.S III SEMESTER V
DEPARTMENT OF HOME ECONOMICS
LAHORE COLLEGE FOR WOMEN UNIVERSITY, LAHORE

11. SUBMITTED BY
HUDA USAMA 21155150
MANAHIL NADEEM 21155147
RUQIAYA SIDDIQUE 21155156
AROOJ ATTIQUE 21155140
FIZA SAFDAR 21155138