Appropriate nutrition is vital to maintaining health and recovering from disease and injury. Research in this field has offered the practitioner many choices in nutritional formulation and delivery. Yet, when patients are unable to effectively meet their needs by mouth, enteral nutrition should be considered the next best choice. It is more physiologic, less costly, and associated with fewer complications than parenteral nutrition. Some studies suggest that it is underutilized in up to 60% of cases. Practitioners should familiarize themselves with the risks and benefits of enteral and parenteral nutrition while reconsidering the contraindications to gastrointestinal feeds. The use of a validated algorithm may offer additional assistance when maximizing nutritional delivery.

Patients are regularly placed on intravenous fluids or total parenteral nutrition (TPN) at the expense of oral or enteral feeds. However, research in areas as diverse as dehydration to respiratory failure suggests that oral hydration and enteral feeds are generally the preferred route of providing nutrition. Enteral feeds maintain the gastrointestinal lining, limit the translocation of enteric bacteria, provide enhanced utilization of nutrients, are easier to administer at a lower cost, and are associated with fewer infectious, metabolic and hepatobiliary risks than TPN.

Special formulas have been developed for patients of all ages and according to disease process. Some studies suggest that enteral nutrition for critically ill children should start with hypo- or isotonic lactose-free or elemental formulas advancing to a standard formula over 3 to 4 days. Additionally, rates in critically ill children can begin a 1 mL/kg/hr with stepwise increases every 4 to 6 hours to the goal calories. Alternative formulas or additives can be provided for children with fat malabsorption or azotemia/hyperammonemia. Practitioners should acquaint themselves with these formulations or regularly enlist the help of a nutritionist when offering the best substrate for the patient. The clinician should also consider the optimal route of enteral feeds, as each may carry their own set of risks and benefits. For example,
flexible polyurethane or Silastic oral or nasogastric tubing may be the easiest access and promote gastric pH balance while limiting the risks of sinus disease or mucosal irritation from the larger tubing of the past. But they may place a patient with slow gastric empty or other risk factors associated with aspiration at greater risk for pneumonia than a fluoroscopic, endoscopic, or surgical transpyloric placement of the same tube. In patients who require prolonged enteral nutrition, tube enterostomies may minimize the risk of tube displacement and resolve concerns related to the physical appearance of the tube on the face.