What is the recommended initial rate and frequency of increase for tube feeds?

From the Guidelines

The recommended initial rate for tube feeds is 10 mL/h, with gradual increases of 10-20 mL/h every 8-12 hours as tolerated until the goal rate is reached, as supported by the most recent and highest quality study 1. When starting tube feeds, it is essential to begin with a low flow rate and increase the feeding rate carefully and individually due to limited intestinal tolerance, as recommended by the ESPEN practical guideline 1. The time to reach the target intake can be very different and may take five to seven days, as stated in the ESPEN guideline 1. Key considerations for tube feeding include:

• Starting with a low flow rate (e.g., 10 mL/h) and gradually increasing as tolerated
• Monitoring for signs of feeding intolerance, such as abdominal distension, increased gastric residual volumes, nausea, vomiting, or diarrhea
• Regular assessment of fluid status, electrolytes, and blood glucose, particularly in patients at risk for refeeding syndrome
• Continuous feeding is generally preferred over bolus feeding in the acute care setting to improve tolerance and reduce complications, as noted in the example answer. It is crucial to reassess nutritional status regularly during the hospital stay and continue nutritional support after discharge if necessary, as recommended by the ESPEN guidelines 1. The most recent study 1 provides a graduated program for commencement of jejunal home enteral nutrition (HEN) feeds, which can be applied to tube feeding in general. Overall, the goal is to provide adequate nutrition while minimizing the risk of complications and promoting optimal outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Initial Rate and Frequency of Increase for Tube Feeds

• The initial rate for tube feeds can start at 30 mL/hr, as seen in a study comparing gastric versus small-bowel tube feeding in the intensive care unit 2.
• The rate can be advanced to the patient's specific goal rate, with one study achieving goal rate sooner (28.8 hrs vs. 43.0 hrs) with gastric feeding compared with small-bowel feeding 2.
• Another study started enteral feeding at half the amount of previous enteral feeds after clamping the nasogastric tube (NGT) for 2 hours, and increased the erythromycin dose every 24 hours if the patient did not tolerate the feeds 3.

Increasing Tube Feeds

• If the patient does not tolerate the feeds, the erythromycin dose can be increased every 24 hours in increments of 250,500, and 1000 mg 3.
• The frequency of increasing tube feeds should be based on the patient's tolerance and response to the feeds, with the goal of achieving the desired nutritional support.
• It is essential to monitor the patient's clinical status, including residual volume, flush volume, and presence of blue food coloring in the oropharynx, to ensure adequate delivery of enteral tube feeding 4.

Adverse Events and Considerations

• Adverse events such as diarrhea, vomiting, and aspiration can occur with tube feeds, and should be monitored and managed accordingly 5, 4.
• The risk of aspiration can be higher in patients with altered mental status or inability to protect their airway 5.
• Enteral feeding bags and tubes should be changed regularly, with one study suggesting that changing every 72 hours is appropriate 6.