Vitamin K deficiency under enteral feeding: real or imagined threat

Patients receiving enteral feeding may develop vitamin K deficiency if the nutrition formula does not meet their daily vitamin K requirement. Vitamin K is essential for clotting factors II, VII, IX and X to be released in their functional form. Under vitamin K deficiency a coagulopathy may develop which is marked by prolongation of the prothrombin time (PT). There might be a need, unrecognized to-day, for monitoring the PT in patients receiving enteral feeding to unmask a latent coagulopathy. We assessed the prevalence of a prolonged PT in patients receiving enteral feeding for 3 months of more with one or a combination of the enteral formulas Osmolite®, Jevity®, Easymilk®. Twenty-three residents in long-term hospital care received solely enteral feeding for an average of 37 months, SD 21 months. The median daily vitamin K supplied by enteral feeding was 96.8 mcg (average 103.3 mcg, SD 28.8); this does not satisfy the 150 mcg of vitamin K required by the Food and Drug Administration. In 21 patients the PT-INR was 1-1.2 (normal). The PT was prolonged in two patients. In one of the latter, prolongation of PT-INR was not confirmed two days later. In the second case, the patient having repeatedly a PT-INR 1.4 (and a normal APTT), administration of vitamin K did not correct the PT. In conclusion, long-term vitamin K-deficient nutrition did not affect the vitamin K-dependent coagulation. This data may argue against the supposed need to monitor the PT in patients receiving long-term enteral nutrition.

Medium-Chain Triglyceride (MCT) Content of Adult Enteral Tube Feeding Formulas and Clinical Outcomes. A Systematic Review

Available data on the effect of lipid composition of enteral formulas on clinical outcomes are controversial. The present systematic review was performed in order to verify whether the presence of specific lipidic substrates, namely medium-chain triglycerides (MCT), in enteral tube feeding formulas is associated to measurable clinical benefits in patients receiving enteral nutrition in different clinical settings, including home enteral nutrition (HEN). The results of this systematic review highlight a lack of robust evidence supporting the use of specific types of lipids in standard or disease-specific formulas. Evidence exists, however, that MCT-containing formulas are safe and well-tolerated. Further, well-designed, adequately powered, randomized controlled trials would be needed in order to assess the superiority of MCT- containing enteral formulas over other standard or disease-specific commercially available enteral products.

Amino acids in enteral formula based on local fermented food for children with protein energy malnutrition

Protein-energy malnutrition still becomes a problem in the world and Indonesia. The enteral formula is needed in the process of fulfilling overall nutrition in the form of a liquid diet in malnourished patients to digest and absorb nutrients without any difficulties. Amino acid lysine, methionine, cysteine, threonine, and tryptophan are often deficits in children's food; even, malnourished children (stunting, wasting, or protein-energy malnutrition) have decreased amino acids. Tempeh gembus, fermented local food, is used as the main ingredient for the enteral formula, and the hydrolysate process is carried out and made into flour, resulting in more amino acids due to the process of protein breakdown. The making of enteral formula from local food fermentation aims to enable the community to optimize local food into more nutritious food so that it can be produced at the household scale. Other supplementary ingredients are isolated soy protein, pumpkin flour, maltodextrin, sugar, and soybean oil. The enteral formula is isocaloric and isoprotein; it is divided into two with different compositions of the hydrolysate of Tempeh gembus flour. This study aims to determine the content of protein, amino acids, and limiting amino acids in the enteral formula. The amino acid analysis was performed using the HPLC method. Amino acid glutamate has the highest content in enteral formulas A and B (2,080 mg.100g-1and 1,950 mg.100g-1). The total amino acid content of enteral formula A is higher than that of enteral formula B with a difference of 210 mg.100g-1. Enteral formula A has a higher average amino acid content (1,400 mg.100g-1) than enteral formula B (1,378 mg.100g-1), and there is no significant difference (p = 0.812) between them. The enteral formula A has a higher amino acid content, but the highest protein content is in enteral formula B. The limiting amino acids in enteral formulas A and B are the methionine amino acids. Enteral formulas A and B can fulfill the needs of amino acids and be an alternative formula for Children with PEM.

Necessidade de módulo proteico para pacientes em estado grave: estudo das fórmulas enterais em sistema fechado disponíveis no mercado

Introduction: The nutritional support of critically ill patients must be individualized and meet the daily energy and protein needs. Despite the fact that health entities publish their respective nutritional therapy recommendations for these patients, guidelines on the use of protein modules are still scarce and controversial. This study aimed to evaluate the protein / energy adequacy of the industrialized enteral formulas existing in the Brazilian market used in the nutritional therapy of adult patients, as well as the need to use protein modules. Methods: 46 enteral formulas found in the Brazilian market were evaluated, by means of mathematical simulations, in relation to the adequacy against protein recommendations, without extrapolating the energy supply (limit of 110% of the daily requirement). For the simulations, comprising the protein module, the energy supply of the module was included in the analysis. Results: The protein / calorie ratio varied between 3.1 and 9.2. For patients without obesity, only the Peptamen Intense - Nestlé formula [protein ratio (g)/100 kcal = 9.2] reaches at least 100% of the protein requirement (1.5 to 2g protein/kg/day), with a volume calculated to 20 to 25 kcal/kg. For patients with BMI between 30 and 36 kg/m2, there is no formula that achieves the recommendation in isolation. The Peptamen Intense - Nestlé formula meets the recommendations for patients with a BMI between 36 and 40 and a BMI> 44 kg/m2. The comparison of the Peptamen Intense - Nestlé formula with the rest of the formulas available on the market plus protein module shows that Fresubin 2 kcal HP - Fresenius needs the lowest volume of the set (enteral formula + protein module) to reach 1000 kcal and 92 g of protein (25.5% less than Peptamen Intense - Nestlé). Conclusion: Most of the enteral formulas available in the Brazilian market are not able to offer, in isolation, an adequate protein supply, without generating excess energy supply (overfeeding). The use of protein modules can bring benefits to the recovery of patients, including those infected by COVID-19.

Microbiology quality and shelf life analysis of enteral formulas based on tempeh flour and yam flour

Background: Critically ill patients have an increased risk of developing infection. Enteral formula that given to patients must meet food safety which includes microbiology quality. In powder form, powder formula is a solution to suppress microbial growth, although it is still susceptible to oxidation. Shelf life is useful to determine the oxidation status. Objectives: This study aimed to analyze the value of TPC, Salmonella, E. coli and shelf life of enteral formula.Methods: This study was a completely randomized experimental design of one factor, namely the length of storage for values of TPC, Salmonella and E. coli with variations in storage for 0, 1, 2, and 3 hours at room temperature. Data on the TPC test was analyzed using Kruskal-Wallis. The temperature used for shelf life with TBA based-Arrhenius equation is 250C, 350C, and 450C for 28 days.Results: There was a difference in the length of storage of 0, 1, 2, and 3 hours on the value of TPC. The TPC value at 0 and 1 hour did not exceed the normal limit. The value of Salmonella was negative/25 g and < 3/g for E. coli. The shelf life of enteral formulas was respectively 250C, 350C and 450C for 44.89, 28.26 and 18.32 days.Conclusion: The longer the length of storage, the higher the TPC value. In accordance with the Indonesian standard (SNI), there is no contamination of Salmonella and E. coli in the enteral formula. The longest shelf life is at 250C.

Analysis of glycemic index, glycemic load and acceptability of enteral formulas based on tempeh flour and jicama flour as innovations for hyperglycemia patients

Low glycemic index formula are recommended for patients with hyperglycemia. Although tempeh and jicama flour contains fiber, arginine, glycine, inulin and alpha-linolenic acid that can be used as ingredients for enteral formulas of hyperglycemic patients, the evidence in reducing the glycemic index has not been proven. This study analyzed the differences of glycemic index (GI), glycemic load (GL) and acceptability of enteral formula based on tempeh flour and jicama flour for hyperglycemic patients. An experimental study with a completely randomized single factor design, by using the three ratios of tempeh flour to jicama flour A (2:3), B (1:1) and C (5:3). The glycemic index test used a one-shot case study model on 30 women selected. Acceptability test (hedonic test) was held on 30 semi-trained panelists. Data was analyzed using the Kruskal Wallis test, Mann Whitney, and independent t-test. The GI of formulas A, B and C were 101.15, 96.21 and 41.06. The GL of three formulas were 114, 86, and 41. Panelists like the color, flavor, and texture of formulas A, B and C, while the taste of the formula was considered to be neutral. The results showed there were significant differences between the GI and the flavor of formulas A and C (p = 0.002), (p = 0.011) and B and C (p = 0.013), (p = 0.036). There were no differences between color, flavor and texture of the formulas (p > 0.005). There are significant differences of the GI and the acceptability in taste attributes between formulas A, B and C. Formula C has the lowest GI and GL but requires improvement of taste attribute.