Tube feeding formulas can be made of intact proteins, protein hydrolysates, carbohydrates like starch or sugars, and fats from vegetable oils or butter. They aim to provide nutrients and be isotonic to match body fluids. Carbohydrates most influence osmolality as they are rapidly digested. Formulas are tailored to specific conditions, using different macronutrient balances. Tube feeding can be given through nasogastric tubes short-term or gastrostomy tubes for long-term use. Total parenteral nutrition provides nutrients intravenously and includes crystalline amino acids, dextrose, lipid emulsions, vitamins and minerals. It is reserved for when enteral nutrition is not possible.

1. Tube feeding Composition
& Osmolality
Composition
The form of proteins in the formula can be
intact proteins (milk, egg ) or protein
hydrolysates
containing peptides and amino acids.
Starch or disaccharides (sucrose or lactose0 may
also be used. Lactose is avoided in many ready-made
formulas because in some problems of absorption,
lactose is not tolerated.
Fats used in the
formulas are
vegetable oils, butter,
lecithin, mono- and
diglycerides and
medium
chain triglycerides
(MCT).
Formulas normally
provide 1kcal/ml.

2. Tube feeding Composition
& Osmolality
Osmolality The number and size of particles per kg of water
is called Osmolality
Isotonic formulas as the word indicates, have the
same osmolality as
body fluids and are well tolerated. Hyper-osmoler
formulas (with higher osmolality) may cause rapid
movement of fluid and electrolytes across the cell wall, if
these are introduced in the intestine.
Any formula which
has a high level of
electrolytes has high
osmolality. Thus
glucose and sucrose
have higher
osmolality than
complex
carbohydrates;
It is good to
remember that
carbohydrates have
the greatest influence
on osmolality,
because they are
digested very rapidly.

3. Tube feeding Composition
& Osmolality
Types of
Formulas
Thus Balanced
Complete Formulas are made from ordinary
foods or baby foods by blending these.
A milk-based formula is prepared from cow’s, toned or skim milk
with addition of pasteurised
eggs, a source of carbohydrate and supplements of vitamins.
Lactose-free formulas are made for lactose-sensitive patients.
Speciality formulas are made for specific conditions, with the
needed adjustments in nutrient content. For example, high fat and
low carbohydrate formulas are made for pulmonary conditions; for
phenylketonuria, a formula low or devoid of phenylalanine is
given. In trauma or liver disease, a formula
low in aromatic amino acids and high in branched chain amino
acids is given.

4. Tube feeding Composition
& Osmolality
Types of
Formulas
The mode of administration of formula is decided taking
patient’s condition and the period for which tube feed is to be
given. For short term feeding nasogastric tube is used.
When there is injury to the esophagus or for long term tube
feeding, a gastrostomy tube may be
surgically inserted into the stomach. This route is not suitable for
patients with unchecked vomiting or
where gastric emptying is disturbed. A jejunostomy tube may be
used when the stomach must be
bypassed.

5. Tube feeding Composition
& Osmolality
Types of
Formulas
Home Tube Feeding
Long term tube feeding can be given at home, with guidance from
the health care team. The careprovider
needs to be given instructions about how to maintain sanitation
and hygiene in handling feeds
and the equipment used.

6. Tube feeding Composition
& Osmolality
Types of
Formulas
Parenteral Nutrition
In parenteral feeding, the nutrient preparations are given directly
into a vein. When a patient is
likely to be dehydrated and needs quick reversal of the condition,
a 5% dextrose solution in water
(DSW) is usually given by a peripheral vein (also known as IV
drip) to provide fluids and some energy
(calories). Electrolyte solutions can also be given by this mode. In
some conditions the higher dextrose
concentrations with amino acids and lipids are given.

7. Tube feeding Composition
& Osmolality
Types of
Formulas
Total Parenteral Nutrition (TPN)
TPN is used only when it is not possible to use enteral route and
the patient is hypermetabolic or
debilitated. Before giving TPN, a thorough nutritional and
metabolic assessment of the patient is done.
The blood levels of various nutrients are monitored frequently
during TPN and the solution adjusted, if
needed.

8. Tube feeding Composition
& Osmolality
Total Parenteral
Nutrition (TPN)
Composition of Solutions: Crystalline amino acids
are used to meet protein needs, so that the
composition can be controlled to meet patient’s
needs. Dextrose solutions (hypertonic) provide
carbohydrates as energy source and ensure amino
acid sparing action. For patients with lung problems,
high dextrose load causes difficulty in breathing. For
such patients part of the carbohydrate is replaced
with fat, to prevent this problem.
Emulsions of safflower or soy oil are given
separately, to meet part of the energy needs and to
provide essential fatty acids.. As lipid emulsions are
isotonic, these are given by central or peripheral
vein. Other nutrients (vitamins, minerals and other
electrolytes) are given in solution or by injection.
TPN solutions being hypertonic are introduced into
a large central vein where the solution gets
diluted quickly in the high rate of blood flow.

9. Tube feeding Composition
& Osmolality
Total Parenteral
Nutrition (TPN)
Home Care of Patients
The family could be guided to take care of the
patient’s nutrition at home. Thus over 25 per cent
of nursing home residents could be taken care of at
home. There is a need to set up home health care
services to reduce the need for institutional care.

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