Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022 Sep;46(7):1470-1496.
doi: 10.1002/jpen.2364. Epub 2022 Jul 15.

When is enteral nutrition indicated?

Matthew L Bechtold  1 , Patricia M Brown  2 , Arlene Escuro  3 , Brandee Grenda  4 , Theresa Johnston  5 , Michelle Kozeniecki  6 , Berkeley N Limketkai  7 , Krystie K Nelson  8 , Jan Powers  9 , Andrea Ronan  10 , Nathan Schober  11 , Brian J Strang  12 , Cristina Swartz  13 , Justine Turner  14 , Lauren Tweel  15 , Renee Walker  16 , Lisa Epp  17 , Ainsley Malone  18 ; ASPEN Enteral Nutrition Committee
Affiliations

When is enteral nutrition indicated?

Matthew L Bechtold et al. JPEN J Parenter Enteral Nutr. 2022 Sep.

Abstract

Enteral nutrition (EN) is a vital component of nutrition around the world. EN allows for delivery of nutrients to those who cannot maintain adequate nutrition by oral intake alone. Common questions regarding EN are when to initiate and in what scenarios it is safe. The answers to these questions are often complex and require an evidence-based approach. The Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) established an Enteral Nutrition Committtee to address the important questions surrounding the indications for EN. Consensus recommendations were established based on eight extremely clinically relevant questions regarding EN indications as deemed by the Enteral Nutrition Committee. These consensus recommendations may act as a guide for clinicians and stakeholders on difficult questions pertaining to indications for EN. This paper was approved by the ASPEN Board of Directors.

Keywords: enteral nutrition; indications; recommendations.

PubMed Disclaimer

Similar articles

See all similar articles

Cited by

See all "Cited by" articles

References

REFERENCES

    1. Bankhead R, Boullata J, Brantley S, et al. A.S.P.E.N. Board of Directors. Enteral nutrition practice recommendations. JPEN J Parenter Enteral Nutr. 2009;33(2):122-167.
    1. McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2009;33(3):277-316.
    1. Song J, Zhong Y, Lu X, et al. Enteral nutrition provided within 48 hours after admission in severe acute pancreatitis: a systematic review and meta-analysis. Medicine (Baltimore). 2018;97(34):e11871.
    1. Quan H, Wang X, Guo C. A meta-analysis of enteral nutrition and total parenteral nutrition in patients with acute pancreatitis. Gastroenterol Res Pract. 2011;2011:698248.
    1. Brennan GT, Ha I, Hogan C, et al. Does preoperative enteral or parenteral nutrition reduce postoperative complications in Crohn's disease patients: a meta-analysis. Eur J Gastroenterol Hepatol. 2018;30(9):997-1002.

REFERENCES

    1. Tian F, Heighes PT, Allingstrup MJ, Doig G. Early enteral nutrition provided within 24 hours of ICU admission: a meta-analysis of randomized controlled trials. Crit Care Medicine. 2018;46(7):1049-1056.
    1. Bally M, Yildirim PZ, Bounoure L, et al. Nutritional support and outcomes in malnourished medical inpatients: a systematic review and meta-analysis. JAMA Intern Med. 2016;176(1):43-53.
    1. Arabi, YM, Al-Dorzi HM. Trophic or full nutritional support? Curr Opin Crit Care. 2018;24(4):262-268.
    1. McClave S, DiBaise JK, Mullin GE, Martindale RG. ACG Clinical Guideline: nutrition therapy in the adult hospitalized patient. Am J Gastroenterol. 2016;111(3):315-334.
    1. Heyland DK, Dhaliwal R, Jiang X, Day AG. Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Crit Care. 2011;15(6):R628.

REFERENCES

    1. World Health Organization. Cancer Fact sheet [online]. eq 2017. Accessed February 16, 2022. https://www.who.int/news-room/fact-sheets/detail/cancer
    1. White JV, Guenter P, Jensen GL, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (under-nutrition). JPEN J Parent Ent Nutr. 2012;36(3):275-283.
    1. Cotognil P. Enteral versus parenteral nutrition in cancer patients: evidences and controversies. Ann Palliat Med. 2016;5(1):42-49.
    1. Thompson K, Elliott L, Fuchs-Tarlovsky V, Levin RM, Voss AC, Piemonte T. Oncology evidence-based nutrition practice guideline for adults. J Acad Nutr Diet. 2017;117(2):297-310.
    1. Heburerne X, Lemarie E, Michallet M, Beauvillain de Montreuil C, Schneider SM, Goldwasser F. Prevalence of malnutrition and current use of nutrition support in patients with cancer. JPEN J Parent Ent Nutr. 2014;38(2):169-204.

REFERENCES

    1. Fuji S, Mori T, Khattry N, et al. Nutritional Support Working Group of the Asian Pacific Bone Marrow Transplantation. Severe weight loss in 3 months after allogeneic hematopoietic SCT was associated with an increased risk of subsequent non-relapse mortality. Bone Marrow Transplant. 2014;50(1):100-105.
    1. Fuji S, Einsele H, Savani BN, Kapp M. Systematic nutritional support in allogeneic hematopoietic stem cell transplant recipients. Biol Blood Marrow Transplant. 2015;21(10):1707-1713.
    1. Bumgartner A, Bargetzi M, Bargetzi A, et al. Nutritional support practices in hematopoietic stem cell transplantation centers: a nationwide comparison. Nutrition. 2017;35:43-50.
    1. August DA, Huhmann MB. American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. clinical guidelines: nutrition support therapy during adult anticancer treatment in hematopoietic cell transplantation. JPEN J Parenter Enteral Nutr. 2009;33(5):472-500.
    1. Bozzetti F, Arends J, Lundholm K, Micklewright A, Zurcher G, Muscaritoli M. ESPEN guidelines on parenteral nutrition: non-surgical oncology. Clin Nutr. 2009;28(4):445-454.

REFERENCES

    1. Sanderson IR, Boulton P, Menzies I, Walker-Smith JA. Improvement of abnormal lactulose/rhamnose permeability in active Crohn's disease of the small bowel by an elemental diet. Gut. 1987;28(9):1073-1076.
    1. Sanderson IR, Croft NM. The anti-inflammatory effects of enteral nutrition. JPEN J Parenter Enteral Nutr. 2005;29(4 suppl):S134-S138.
    1. Narula N, Dhillon A, Zhang D, Sherlock ME, Tondeur M, Zachos M. Enteral nutritional therapy for induction of remission in Crohn's disease. Cochrane Database Syst Rev. 2018;4(4):CD000542.
    1. Akobeng AK, Zhang D, Gordon M, MacDonald JK. Enteral nutrition for maintenance of remission in Crohn's disease. Cochrane Database Syst Rev. 2018;8(8):CD005984.
    1. Critch J, Day AS, Otley A, et al. Use of enteral nutrition for the control of intestinal inflammation in pediatric Crohn disease. J Pediatr Gastroenterol Nutr. 2012;54(2):298-305.

REFERENCES

    1. Cheung K, Lee SS, Raman M. Prevalence and mechanisms of malnutrition in patients with advanced liver disease, and nutrition management strategies. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2012;10(2):117-125.
    1. Plauth M, Cabre E, Riggio O, et al. ESPEN guidelines on enteral nutrition: liver disease. Clin Nutr. 2006;25(2):285-294.
    1. James JH, Ziparo V, Jeppsson B, Fischer JE. Hyperammonaemia, plasma aminoacid imbalance, and blood-brain aminoacid transport: a unified theory of portal-systemic encephalopathy. Lancet. 1979;2(8146):772-775.
    1. Marchesini G, Bianchi G, Merli M, et al. Nutritional supplementation with branched-chain amino acids in advanced cirrhosis: a double-blind, randomized trial. Gastroenterology. 2003;124(7):1792-1801.
    1. Muto Y, Sato S, Watanabe A, et al. Effects of oral branched-chain amino acid granules on event-free survival in patients with liver cirrhosis. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2005;3(7):705-713.

REFERENCES

    1. Lowenfels AB, Maisonneuve P, Sullivan T. The changing character of acute pancreatitis: epidemiology, etiology, and prognosis. Curr Gastroenterol Rep. 2009;11(2):97-103.
    1. Mirtallo JM, Forbes A, McClave SA, Jensen GL, Waitzberg DL, Davies AR; International Consensus Guideline Committee Pancreatitis Task Force. International consensus guidelines for nutrition therapy in pancreatitis. JPEN J Parenter Enteral Nutr. 2012;36(3):284-291.
    1. Crockett SD, Wani S, Gardner TB, Falck-Ytter Y, Barkun AN. American Gastroenterological Association Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on initial management of acute pancreatitis. Gastroenterology. 2018;154(4):1096-1101.
    1. Petrov MS, Whelan K. Comparison of complications attributable to enteral and parenteral nutrition in predicted severe acute pancreatitis: a systematic review and meta-analysis. Br J Nutr. 2010;103(9):1287-1295.
    1. Bakker OJ, Besselink MG, Gooszen HG. Early versus on-demand tube feeding in pancreatitis. N Engl J Med. 2015;372(7):684-685.

REFERENCES

    1. Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke. 2005;36(12):2756-2763.
    1. Kirby DF, DeLegge MH, Fleming CR. American gastroenterological association technical review on tube feeding for enteral nutrition. Gastroenterology. 1995;108(4):1282-1301.
    1. Mann G, Hankey GJ, Cameron D. Swallowing function after stroke: prognosis and prognostic factors at 6 months. Stroke. 1999;30(4):744-748.
    1. Geeganage C, Beavan J, Ellender S, Bath PM. Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database Syst Rev. 2012;10:CD000323.
    1. Davalos A, Ricart W, Gonzalez-Huix F, et al. Effect of malnutrition after acute stroke on clinical outcome. Stroke. 1996;27(6):1028-1032.

REFERENCES

    1. Schindler T, Michel S, Wilson AWM. Nutrition management of cystic fibrosis in the 21st century. Nutr Clin Pract. 2015;30(4):488-500.
    1. Hollander FM, de Roos NM, van Meerkerk GB, van Berkhout FT, Heijerman HGM, van de Graaf EA. Body weight and body mass index in patients with end-stage cystic fibrosis stabilize after the start of enteral tube feeding. J Acad Nutr Diet. 2017;117(11):1808-1815.
    1. Erskine JM, Lingard C, Sontag M. Update on enteral nutrition support for cystic fibrosis. Nutr Clin Pract. 2007;22(2):223-232.
    1. Turck D, Braegger CP, Colombo C, et al. ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with cystic fibrosis. Clin Nutr. 2016;35(3):557-577.
    1. Shimmin D, Lowdon J, Remmington T. Enteral tube feeding for cystic fibrosis (review). Cochrane DB Syst Rev. 2019;7(7):CD001198.

REFERENCES

    1. Global Initiative for Chronic Obstructive Lung Disease. 2021. Accessed December 6, 2021. www.goldcopd.org
    1. GBD 2015 Chronic Respiratory Disease Collaborators. Global, regionals and national deaths, prevalence, disability-adjusted life years, and years lived with disability for chronic obstructive pulmonary disease and asthma, 1990-2015; a systematic analysis for the global burden of disease study 2015. Lancet Respir Med. 2017;5(9);691-706.
    1. Araújo BE, Kowalski V, Leites GM, da Silva Fink J, Silva FM. AND-ASPEN and ESPEN consensus, and GLIM criteria for malnutrition identification in AECOPD patients: a longitudinal study comparing concurrent and predictive validity. Eur J Clin Nutr. Accepted manuscript. Published online October 26, 2021. doi:10.1038/s41430-021-01025-x
    1. Rawal G, Yadav S. Nutrition in chronic obstructive pulmonary disease: a review. J Transl Int Med. 2015;3(4):151-154.
    1. Wilson DO, Donahoe M, Rogers, RM, Pennock BE. Metabolic rate and weight loss in chronic obstructive lung disease. JPEN J Parenter Enter Nutr. 1990;14(1):7-11.

REFERENCES

    1. Brown RO, Compher C. American Society for Parenteral and Enteral Nutrition Board of Directors. A.S.P.E.N. clinical guidelines: nutrition support in adult acute and chronic renal failure. JPEN J Parenter Enteral Nutr. 2010;34(4):366-377.
    1. Kalantar-Zadeh K, Cano NJ, Budde K, et al. Diets and enteral supplements for improving outcomes in chronic kidney disease. Nat Rev Nephrol. 2011;7(7):369-384.
    1. Sabatino A, Regolisti G, Gandolfini I, et al. Diet and enteral nutrition in patients with chronic kidney disease not on dialysis: a review focusing on fat, fiber and protein intake. J Nephrol. 2017;30(6):743-754.
    1. Cano N, Fiaccadori E, Tesinsky P, et al. ESPEN guidelines on enteral nutrition: adult renal failure. Clin Nutr. 2006;25(2):295-310.
    1. Caglar K, Fedje L, Dimmitt R, Hakim RM, Shyr Y, Ikizler TA. Therapeutic effects of oral nutritional supplementation during hemodialysis. Kidney Int. 2002;62(3):1054-1059.

REFERENCES

    1. Mancl EE, Muzevich KM. Tolerability and safety of enteral nutrition in critically ill patients receiving intravenous vasopressor therapy. JPEN J Parenter Enteral Nutr. 2013;37(5):641-651.
    1. Wells DL. Provision of enteral nutrition during vasopressor therapy for hemodynamic instability: an evidence-based review. Nutr Clin Pract. 2012;27(4):521-526.
    1. Yang S, Wu X, Yu W, Li J. Early enteral nutrition in critically ill patients with hemodynamic instability: an evidence-based review and practical advice. Nutr Clin Pract. 2014;29(1):90-96.
    1. Schunn CD, Daly JM. Small bowel necrosis associated with postoperative jejunal tube feeding. J Am Coll Surg. 1995;180(4):410-416.
    1. Spalding DRC, Behrannwala KA, Straker P, et al. Non-occlusive small bowel necrosis in association with feeding jejunostomy after elective upper gastrointestinal surgery. Ann R Coll Surg Engl. 2009;91(6):477-482.

REFERENCES

    1. Revelly JP, Tappy L, Berger MM, Gersbach P, Cayeux C, Chioléro R. Early metabolic and splanchnic responses to enteral nutrition in postoperative cardiac surgery patients with circulatory compromise. Intensive Care Med. 2001;27(3):540-547.
    1. Berger M, Revelly JP, Cayeux MC, Chiolero RL. Enteral nutrition in critically ill patients with severe hemodynamic failure after cardiopulmonary bypass. Clin Nutr. 2005;24(1):124-132.
    1. Patel JJ, Kozeniecki M, Biesboer A, et al. Early trophic enteral nutrition is associated with improved outcomes in mechanically ventilated patients with septic shock: a retrospective review. J Intensive Care Med. 2016;31(7):471-477.
    1. Mancl EE, Muzevich KM. Tolerability and safety of enteral nutrition in critically ill patients receiving intravenous vasopressor therapy. JPEN J Parenter Enteral Nutr. 2013;37(5):641-651.
    1. TARGET Investigators, for the ANZICS Clinical Trials Group; Chapman M, Peake SL, Bellomo R, et al. Energy-dense versus routine enteral nutrition in the critically ill. N Engl J Med. 2018;379(19):1823-1834.

REFERENCES

    1. Blaser, AR, Starkopf J, Alhazzani W, et al. ESICM Working Group on Gastrointestinal Function. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Intensive Care Med. 2017;43(3):380-398.
    1. Lu MC, Yang MD, Li PC, et al. Effects of nutritional intrvention on the survival of patients with cardiopulmonary failure undergoing extracorporeal membrane oxygenation therapy. In Vivo. 2018;32(4):829-834.
    1. Ferrie S, Herkes R, Forrest P. Nutrition support during extracorporeal membrane oxygenation (ECMO) in adults: a retrospective audit of 86 patients. Intensive Care Med. 2013;39(11):1989-1994.
    1. MacGowan L, Smith E, Elliott-Hammond C, et al. Adequacy of nutrition support during extracorporeal membrane oxygenation. Clin Nutr. 2019;38(1):324-331.
    1. Scott L, Boudreaux K, Thaljeh F, Grier LR, Conrad SA. Early enteral feedings in adults receiving venovenous extracorporeal membrane oxygenation. JPEN J Parenter Enteral Nutr. 2004;28(5):295-300.

REFERENCES

    1. Ohbe H, Jo T, Matsui H, Fushimi K, Yasunaga H. Early enteral nutrition in patients undergoing sustained neuromuscular blockade: a propensity-matched analysis using a nationwide inpatient database. Crit Care Med. 2019;47(8):1072-1080.
    1. Tamion F, Hamelin K, Duflo A, Girault C, Richard J-C, Bonmarchand G. Gastric emptying in mechanically ventilated critically ill patients: effect of neuromuscular blocking agent. Intensive Care Med. 2003;29(10):1717-1722.
    1. Reintam Blaser A, Starkopf J, Alhazzani W, et al. ESICM Working Group on Gastrointestinal Function. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Intensive Care Med. 2017;43(3):380-398.
    1. Kochanek PM, Tasker RC, Carney N, et al. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: update of the brain trauma foundation guidelines, executive summary. Neurosurgery. 2019;84(6):1169-1178.
    1. Carney N, Totten AM, O'Reilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017;80(1):6-15.

REFERENCES

    1. Reeves A, White H, Sosnowski K, Tran K, Jones M, Palmer M. Energy and protein intakes of hospitalised patients with acute respiratory failure receiving non-invasive ventilation. Clin Nutr. 2014;33(6):1068-1073.
    1. McClave SA, Taylor BE, Martindale RG, et al. Society of Critical Care Medicine; American Society for Parenteral and Enteral Nutrition. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159-211.
    1. McClave SA, Martindale RG, Rice TW, Heyland DK. Feeding the critically ill patient. Crit Care Med. 2014;42(12):2600-2610.
    1. Carron M, Freo U, BaHammam AS, Dellweg D, et al. Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials. Br J Anaesth. 2013;110(6):896-914.
    1. Singer P, Rattanachaiwong S. To eat or to breathe? The answer is both! Nutritional management during noninvasive ventilation. Crit Care. 2018;22(1):27.

REFERENCES

    1. Cahill NE, Murch L, Cook D, Heyland DK, Canadian Critical Care Trials Group. Improving the provision of enteral nutrition in the intensive care unit: a description of a multifaceted intervention tailored to overcome local barriers. Nutr Clin Pract. 2014;29(1):110-117.
    1. Kozeniecki M, Pitts H, Patel JJ. Barriers and solutions to delivery of intensive care unit nutrition therapy. Nutr Clin Pract. 2018;33(1):8-15.
    1. Lichtenberg K, Guay-Berry P, Pipitone A, Bondy A, Rotello L. Compensatory increased enteral feeding goal rates: a way to achieve optimal nutrition. Nutr Clin Pract. 2010;25(6):653-657.
    1. McClave SA, Taylor BE, Martindale RG, et al. Society of Critical Care Medicine; American Society for Parenteral and Enteral Nutrition. Guidelines for the provision and assessment of nutrition support therapy for the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JEPN J Parenter Enteral Nutr. 2016;40(2):159-211.
    1. Yeh D, Cropano C, Quraishi S, et al. Implementation of an aggressive enteral nutrition protocol and the effect on clinical outcomes. Nutr Clin Pract. 2017;32(2):175-181.

LinkOut - more resources