Can a healthcare provider order enteral formula?

Can Healthcare Providers Order Enteral Formula?

Yes, healthcare providers can and should order enteral formula when patients cannot meet their nutritional requirements through oral intake alone, provided the patient has a functional gastrointestinal tract. 1

Who Can Order Enteral Nutrition

Healthcare providers with prescriptive authority can order enteral formulas, including:

• Physicians (primary care and specialists) can initiate both hospital-based and home enteral nutrition 1
• General practitioners can refer patients for elective home enteral nutrition with outpatient feeding tube placement 1
• Treatment is typically initiated in secondary care settings but can be managed in the community with appropriate support 1

When to Order Enteral Formula

Primary indications for ordering enteral nutrition include: 1

• Prevention and treatment of undernutrition when oral intake is inadequate 1
• Patients unable to maintain adequate oral intake from normal food 1
• Improvement of nutritional status in patients with weight loss and protein deficiency 1
• Specific disease states including liver disease, inflammatory bowel disease, short bowel syndrome, and cancer 1

What Type of Formula to Order

Standard whole protein formulas are recommended for most patients as first-line therapy: 1, 2

• No clinical advantage has been demonstrated for peptide-based formulas over whole-protein formulas in most situations 1, 2
• Standard formulas are nutrient-complete and appropriate for the majority of patients requiring enteral support 1
• High-calorie density formulas (≥1.5 kcal/mL) should be ordered for patients with fluid restriction or ascites 1, 2

Disease-specific formulas should be ordered only in select circumstances: 1

• BCAA-enriched formulas for hepatic encephalopathy during enteral nutrition 1
• Specialized formulas for specific metabolic conditions when standard formulas are not tolerated 1

Nutritional Targets When Ordering

Energy requirements: 1, 3

• Ambulant patients: 30-35 kcal/kg/day 1
• Bedridden patients: 20-25 kcal/kg/day 1
• Calculate based on actual body weight for non-obese patients 1

Protein requirements: 1, 3

• Standard recommendation: 1.2-1.5 g/kg/day 1
• Malnourished or catabolic patients: up to 1.5-2.0 g/kg/day 1, 3

Route of Administration to Specify

Order oral nutritional supplements when: 1

• Supplemental intake up to 600 kcal/day is needed in addition to normal food 1
• Patient can tolerate oral route but needs additional nutrition 1

Order tube feeding when: 1, 3

• Higher intake than 600 kcal/day is necessary 1
• Patient cannot maintain adequate oral intake 1
• Nasogastric tube or PEG can be safely used (even with esophageal varices) 1
• Small bowel (jejunal) feeding for severe gastroparesis 3

Essential Components of the Order

The prescription must include: 1, 3

• Specific formula type and caloric density 3, 2
• Total daily volume or rate of administration 3
• Route of administration (oral supplements vs. tube feeding) 1
• Feeding schedule (continuous vs. bolus) - continuous preferred initially for tube feeding 3
• Starting rate for tube feeding: 10-20 ml/hour, advancing by 10-20 ml/hour every 12-24 hours based on tolerance 3

Required Support Structure

Before ordering home enteral nutrition, ensure: 1

• Access to a nutrition support team (physician, dietician, nutrition support nurse minimum) 1
• Patient and caregiver education on tube care, feeding schedule, and complications 1, 3
• Arrangements for continuing prescription of feed and equipment 1, 3
• Coordination with home care providers for formula delivery and supplies 1
• Written information provided including emergency contact information 1

Common Pitfalls to Avoid

Do not order enteral nutrition when: 4

• Kitchen-made or blenderized diets in hospital settings due to infection risk and tube clogging 4
• Overfeeding during acute illness (>25 kcal/kg/day may worsen outcomes) 4

Monitor for complications: 1, 3

• Refeeding syndrome in severely malnourished patients 3
• Aspiration (maintain 30° elevation during and 30 minutes after feeding) 3
• Feeding intolerance (check gastric residuals every 4 hours initially; review if >200 ml) 3
• Tube displacement and gastrointestinal complications 1

Ensure reimbursement: 1

• Discuss coverage with insurance companies or government programs before initiating home enteral nutrition 1