When can a 22-calorie (cal) formula be discontinued?

When to Discontinue 22-Calorie Formula

A 22-calorie per ounce formula should be discontinued when the patient's clinical condition improves sufficiently to meet nutritional needs with standard formula (typically 20 cal/oz) or oral intake, which generally occurs when growth parameters normalize, medical complications resolve, or the underlying indication for calorie-dense feeding no longer exists.

Clinical Decision Framework

Primary Indications for Transitioning Away from 22-Cal Formula

The decision to discontinue concentrated formula depends on reassessing the original indication:

• Growth normalization: When catch-up growth is achieved and weight-for-length or BMI percentiles stabilize within target range 1
• Resolution of fluid restriction needs: When cardiac, renal, or pulmonary conditions improve and fluid tolerance increases 2
• Adequate oral intake capacity: When the patient can consume sufficient volume of standard formula or food to meet caloric requirements (25-30 kcal/kg/day for most adults) 3, 1
• Improved nutritional status: When malnutrition markers resolve and protein-calorie balance is restored 1

Monitoring Parameters for Transition Readiness

The continued medical justification for specialized nutritional formulations must be reviewed at regular intervals determined by the patient's condition 3:

• Weekly assessment of weight trends and tolerance in acute settings 3
• Monthly evaluation of growth parameters in chronic conditions 1
• Ongoing monitoring of fluid balance, electrolytes, and metabolic markers 3

Transition Protocol

When discontinuing 22-cal formula, follow a stepwise approach:

• Step 1: Verify that caloric needs can be met with standard concentration—calculate current requirements using 25-30 kcal/kg/day for adults or age-appropriate equations for children 3, 1
• Step 2: Ensure adequate volume tolerance—confirm patient can consume the increased volume needed with standard formula (approximately 10% more volume for equivalent calories) 2
• Step 3: Gradual transition over 3-5 days—mix ratios of 22-cal and 20-cal formula to assess tolerance before complete switch 2
• Step 4: Monitor for 1-2 weeks post-transition—track weight, intake adequacy, and tolerance markers 3, 1

Special Populations

Critical Care Patients

For critically ill patients initially requiring concentrated formulas:

• Energy requirements often decrease as acute phase resolves—measured REE typically drops from hypermetabolic to normal or hypometabolic state 3, 4
• Transition timing: When hemodynamic stability achieved, inflammatory markers normalizing, and moving from acute to recovery phase (typically after day 3-7) 3
• Indirect calorimetry is the gold standard for determining actual needs during transition 3, 4

Patients with Obesity

The 2016 ASPEN/SCCM guidelines recommend specific calorie targets that may not require concentrated formulas 3:

• BMI 30-50: 11-14 kcal/kg actual body weight/day 3
• BMI >50: 22-25 kcal/kg ideal body weight/day 3
• These lower targets often achievable with standard formulas, making 22-cal formula unnecessary 3

Long-Term Enteral Nutrition

For patients on chronic tube feeding:

• Reassess every 3-6 months whether concentrated formula remains necessary 3
• Standard formulas preferred when volume tolerance permits, as they reduce osmotic complications and cost 2, 5
• Consider that 58.2% of long-term care patients are inadvertently overfed when caloric needs not measured 6

Common Pitfalls to Avoid

Do not continue 22-cal formula indefinitely without reassessment—the medical justification must be reviewed regularly, and therapy discontinued if no longer beneficial 3. Continuing unnecessary concentrated formulas increases costs and may lead to overfeeding complications including hyperglycemia, azotemia, and respiratory compromise 6.

Do not abruptly switch formulas without tolerance assessment—gradual transition prevents gastrointestinal intolerance and allows monitoring for adequacy 2, 5.

Do not assume caloric needs remain constant—energy expenditure varies significantly with clinical status, and predictive equations are often inaccurate (only 25% of patients receive appropriate calories based on equations alone) 3, 6. Measure actual requirements when possible 3, 4.

Avoid using concentrated formulas to compensate for poor feeding technique—if volume intake is inadequate, address the underlying cause (feeding schedule, tube placement, tolerance issues) rather than indefinitely relying on calorie-dense formulas 2, 5.