4.2 Recommendations from international and internationally recognised guidelines: ETF
4.2.1. Key ETF Guidelines: Summary Tables
Table 4.20, Table 4.21, Table 4.22 and Table 4.23 include the results of efforts made to identify evidence-based international and internationally recognised guidelines referring to enteral tube feeding (ETF) as an integral part of patient and disease management across the world. Searches of websites of relevant professional organisations were conducted. Guidelines which focus on the practicalities of enteral tube feeding once the decision to initiate feeding has been made have been excluded from this section but are listed in Section 4.2.2 (Guidelines: Theory to practice for enhanced patient care), Table 4.30.
Other guidelines may exist but are not included as they were not identified using the above strategies, or we were unable to obtain information in the English language for inclusion in the dossier. We would welcome information about other international guidelines that could be included in future editions of the dossier.
Note: The tables that follow include the recommendations relating to ETF only as they appear in the guidelines or documents from various organisations. Please refer to the full documents for other information relating to nutritional management, e.g., screening, assessment, and use of other forms of nutritional support. Terminology referring to enteral nutrition (EN) is not consistent within the various guidelines; therefore, the definition used within specific guidelines has been noted and summarised in Table 4.29.
GENERAL
Table 4.20
Summary of some examples of evidence-based international and internationally recognised guidelines referring to enteral tube feeding (ETF) as an integral part of patient and disease management – General (parts of guidelines relevant to ETFⁱ presented here, standard formulas only)
| Country | Body | Patient Group | Title | Recommendation, guideline, or standard [grade of evidence, where available] |
|---|---|---|---|---|
| Australia | Dietitians Association of Australia (2019) | Adults in hospital | Nutrition and Hydration Policy Support Handbook For Acute Adult Inpatient Setting1 | Artificial nutrition support should be considered when patients cannot adequately or safely meet their nutrition requirements orally • Artificial nutrition support should be considered for patients who have had nil nutritional intake for >5 days • EN should be prescribed to patients with a functioning gastrointestinal tract. |
| England and Wales | National Insti- tute for Health and Care Excel- lence (NICE) (2006) last updated in 2017 | All patients in hospital and in the community | Nutrition support in adults Oral nutrition support, enteral tube feeding and parenteral nutrition2 | Indications for enteral tube feeding: Enteral tube feeding should not be given to people unless they are malnourished or at risk of malnutrition and have inadequate or unsafe oral intake and a functional, accessible gastrointestinal tract, or they are taking part in a clinical trial. [A] |
| US | American Society for Parenteral and Enteral Nutrition (2011) | All patients in hospital and community | Nutrition Screening, Assessment, and Intervention in Adults3 | Nutrition support intervention is recommended for patients identified by screening and assessment as at risk for malnutrition or malnourished: Grade C (intervention is described as “some intervention such as change in diet, enteral or parenteral nutrition, or further medical assessment”) |
| US | American Society for Parenteral and Enteral Nutrition (2014) | All patients in home care environments and alternate care sites* | A.S.P.E.N. Standards for Nutrition Support: Home and Alternate Site Care4 | The route selected to provide nutrition support therapy shall be appropriate to the patient’s medical problems, safety, efficacy, and patient preference. • When functional, the GI tract is the preferred route for nutrition support therapy and should be used to administer nutrition support therapy |
| US | American Society for Parenteral and Enteral Nutrition (2018) | Adults in hospital | Standards for Nutrition Support: Adult Hospitalized Patients5 | The route selected to provide nutrition support therapy shall be appropriate to the patient’s medical condition and should periodically be assessed for continued appropriateness as well as for its adequacy in meeting goals of the nutrition care plan (see Figure 2 in original guideline) |
The definition of Enteral Nutrition varies depending on the recommending body see Table 4.29 for more details. SNS Specialised nutrition support; HSNS Home specialised nutrition support. *Home care is defined as being provided in the traditional home as well as a group home, intermediate care facility, or assisted living facility. Alternate site care facilities can include skilled nursing facilities (SNF), long- term acute care hospitals (LTACHs), or rehabilitation hospitals.
OLDER PEOPLE
Table 4.21
Summary of some examples of evidence-based international and internationally recognised guidelines referring to enteral tube feeding (ETF) as an integral part of patient and disease management – Older People (parts of guidelines relevant to ETF presented here, standard formulas only)
| Country | Body | Title | Recommendation, guideline, or standard [grade of evidence] |
|---|---|---|---|
| Australia and New Zealand | Australian and New Zealand Society for Geriatric Medicine (2020) | Position Statement 12. Dysphagia and Aspiration in Older People 6 | • Tube feeding may be useful in temporarily providing nutritional support to patients with a non-progressive cause of aspiration, such as stroke. However, its place for the majority of progressive causes is questionable. • Tube feeding (nasogastric or percutaneous) cannot prevent aspiration, and neither method is entirely safe when used in patients at risk of aspiration. |
| Australia and New Zealand | Australian and New Zealand Society for Geriatric Medicine (2015) | Position Statement No. 6. Undernutrition and the Older Person 7 | • Percutaneous Endoscopic Gastrostomy (PEG) feeding in advanced dementia has not been shown to prolong survival, improve nutrition, maintain skin integrity, prevent aspiration, or improve quality of life. |
| England and Wales | National Institute for Health and Care Excellence (NICE) (updated 2006, updated 2016) | Dementia: supporting people with dementia and their carers in health and social care. Clinical Guideline 42 8 | • Nutritional support, including artificial (tube) feeding, should be considered if dysphagia is thought to be a transient phenomenon, but artificial feeding should not generally be used in people with severe dementia for whom dysphagia or disinclination to eat is a manifestation of disease severity. Ethical and legal principles should be applied when making decisions about withholding or withdrawing nutritional support. |
| Europe | European Society for Clinical Nutrition and Metabolism (2015) | ESPEN Guidelines on Nutrition in Dementia 9 | • We suggest tube feeding for a limited period of time in patients with mild or moderate dementia, to overcome a crisis situation with markedly insufficient oral intake, if low nutritional intake is predominantly caused by a potentially reversible condition. (Grade of evidence: very low; strength of recommendation: weak) We recommend against the initiation of tube feeding in patients with severe dementia. [Grade of evidence: high; strength of recommendation: strong] |
| Europe | European Society for Clinical Nutrition and Metabolism (2024) | ESPEN guideline on nutrition and hydration in dementia – Update 2024 10 | • Each decision for or against (par)enteral nutrition and hydration for persons with dementia shall be made on an individual basis with respect to the patient’s clinical situation, general prognosis and preferences. Grade of recommendation GPP – strong consensus (100% agreement) • Enteral and parenteral nutrition and parenteral fluids shall NOT be initiated in persons with dementia in the terminal phase of life. Grade of recommendation GPP – strong consensus (96% agreement) Enteral nutrition should be used temporarily in persons with mild or moderate dementia, if significantly low nutritional intake is predominantly caused by a potentially reversible condition. Grade of recommendation GPP – strong consensus (100% agreement) • Enteral nutrition shall not be initiated in patients with severe dementia. Grade of recommendation GPP – strong consensus (100% agreement) |
| Europe | European Society for Clinical Nutrition and Metabolism (Volkert 2006) | ESPEN Guidelines on Enteral Nutrition: Geriatrics 11 | Frail elderly may benefit from TF as long as their general condition is stable (not in terminal phases of illness). [Grade B] In demented patients, ONS or tube feeding (TF) may lead to an improvement of nutritional status. In early and moderate dementia, consider ONS—and occasionally TF—to ensure adequate energy and nutrient supply and to prevent undernutrition. [Grade C] In patients with terminal dementia, tube feeding is not recommended [Grade C] In case of nutritional risk (e.g., insufficient nutritional intake, unintended weight loss >5% in 3 months or >10% in 6 months, body-mass index (BMI) <20 kg/m2), initiate oral nutritional supplementation and/or TF early. |
| Europe | European Society for Clinical Nutrition and Metabolism (Volkert 2022) | ESPEN guideline on clinical nutrition and hydration in geriatrics 12 | Older persons with reasonable prognosis shall be offered EN if oral intake is expected to be impossible for more than three days or expected to be below half of the energy requirements for more than one week, despite interventions to ensure adequate oral intake, in order to meet nutritional requirements and maintain or improve nutritional status. (Grade GPP, strong consensus 100%). If EN is indicated, it shall be started without delay. (Grade GPP, strong consensus 96%). Older patients who require EN presumably for less than four weeks should receive a nasogastric tube. (R33, Grade GPP, strong consensus 100%) Older patients expected to require EN for more than four weeks or who do not want or tolerate a nasogastric tube should receive a percutaneous gastrostomy/PEG. (Grade GPP, strong consensus 100%). The expected benefits and potential risks of EN shall be evaluated individually and reassessed regularly, and when the clinical condition changes. (Grade GPP, strong consensus 100%). For EN, fibre-containing products should be used. (Grade B, strong consensus 91%) |
| US | Academy of Nutrition and Dietetics (2009) | Unintended weight loss in older adults guideline 13 | Indications for Enteral Nutrition The Registered Dietitian (RD) should recommend consideration of enteral nutrition for older adults who are undernourished or at risk of undernutrition; it is clearly indicated in patients with severe dysphagia. Studies support enteral nutrition as a method to provide energy and nutrient intake, promote weight gain, and maintain or improve nutritional status or prevent undernutrition. [Strong Imperative] Contraindications for Enteral Nutrition Enteral nutrition may not be appropriate for terminally ill older adults with advanced disease states, such as terminal dementia, and should be in accordance with advance directives. The development of clinical and ethical criteria for the nutrition and hydration of persons throughout the life span should be established by members of the health care team, including the Registered Dietitian (RD). [Consensus, Conditional] Initiation of Enteral Nutrition To improve energy and nutrient intake in older adults at nutritional risk, enteral nutrition should be initiated as early as possible after confirming tube placement. Studies support that enteral nutrition can be initiated 3 hours after a percutaneous endoscopic gastrostomy (PEG) tube is placed, and placement is confirmed. [Strong, Imperative]. |
CHILDREN
| Country | Body | Title | Recommendation, guideline, or standard [grade of evidence] |
|---|---|---|---|
| England and Wales | National Institute for Health and Care Excellence (NICE) (2015) – Updated in 2019 | Gastro-oesophageal re- flux disease in children and young people: diagnosis and management 14 | Only consider enteral tube feeding to promote weight gain in infants and children with overt regurgitation and faltering growth if: • other explanations for poor weight gain have been explored and/or • recommended feeding and medical management of overt regurgitation is unsuccessful |
| Europe | European Society for Paediatric Gastroenterology, Hepatology and Nutrition (2010) | Practical Approach to Paediatric Enteral Nutrition: A Comment by the ESPGHAN Committee on Nutrition 15 | • EN is indicated in the patient with at least a partially functional gut and insufficient normal oral intake. To meet nutritional targets in some clinical settings, combined PN and EN are necessary, even in the presence of a functional gut. |
| Europe | European Society for Clinical Nutrition and Metabolism, European Society for Paediatric Gastroenterology, Hepatology and Nutrition and European Cystic Fibrosis Society (2016) | ESPEN-ESPGHAN-ECFS Guidelines on Nutrition Care for Infants, Children, and Adults with Cystic Fibrosis 16 | • We recommend a progressive approach to intensification of nutrition interventions as needs increase: preventive nutritional counselling, dietary modification, and/or oral nutrition supplements, and enteral tube feeding. [Grade of evidence: low] |
| Europe | European Society for Clinical Nutrition and Metabolism, European Society for Paediatric Gastroenterology, Hepatology and Nutrition and European Cystic Fibrosis Society (2024) | ESPEN-ESPGHAN-ECFS guideline on nutrition care for cystic fibrosis. Clinical Nutrition 17 | • If optimisation of oral feeding fails to maintain nutritional status, EN can be considered to increase nutrient intake in people with cystic fibrosis. Grade of recommendation GPP – Strong consensus 100 % agreement • The initiation of EN should be considered before periods of accelerated growth. Grade of recommendation GPP – Strong consensus 100 % agreement • We recommend clinicians discuss use of EN in a timely manner with the patient and family when patients do not grow according to their genetic potential. Grade of recommendation GPP – Strong consensus 100 % agreement Feeding infants with meconium ileus • As soon as deemed appropriate following resolution of occlusion of MI, EN should be started and advanced readily as tolerated. The choice of feeding for MI may be diverse (including breast milk, standard formula or specialised formula (e.g. amino acid, protein hydrolysate, and MCT)) according to clinical practice. Regardless of feed choice and even in presence of enterostomies, an appropriate pancreatic enzyme dose should be provided. Grade of recommendation GPP – Strong consensus 100 % agreement |
| International | Surviving Sepsis Campaign (2012) | Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 18 | • Enteral nutrition should be used in children who can tolerate it, parenteral feeding in those who cannot [Grade 2C]. |
| International | Surviving Sepsis Campaign (2021) | Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 19 | • For adult patients with sepsis or septic shock who can be fed enterally, we suggest early (within 72 h) initiation of enteral nutrition Weak recommendation; very low quality of evidence |
| US | American Society for Parenteral and Enteral Nutrition (2009) | Nutrition Support of Children with Human Immunodeficiency Virus Infection 20 | [….} or enteral tube feedings may improve weight and growth in children who are HIV+ with growth failure. [Grade C] |
| US | American Society for Parenteral and Enteral Nutrition (2017) | Nutrition Support of the Critically Ill Child 21 | • On the basis of observational studies, we recommend EN as the preferred mode of nutrient delivery to the critically ill child. Quality of evidence: low; GRADE recommendation: strong • On the basis of observational studies, we suggest that interruptions to EN be minimised in an effort to achieve nutrient delivery goals by the enteral route. Quality of evidence: low; GRADE recommendation: strong |
| US | American Society for Parenteral and Enteral Nutrition (2013) | Standards for Nutrition Support: Pediatric Hospitalized Patients 22 | The route selected to provide nutrition support therapy shall be appropriate to the patient’s medical condition and should be reassessed periodically for continued appropriateness, as well as its adequacy in meeting goals of the nutrition care plan. • Enteral nutrition (EN) should be used in preference to parenteral nutrition (PN) to the greatest extent possible. |
| US | North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (2006) | Nutrition Support for Neurologically Impaired Children: A Clinical Report of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition 23 | • Enteral tube feedings can be initiated early in children who are unable to feed orally or who cannot achieve sufficient oral intake to maintain adequate nutritional or hydration status. |
| US | North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (2012) | Use of Enteral Nutrition for the Control of Intestinal Inflammation in Pediatric Crohn’s Disease 24 | • EEN is an effective induction therapy in newly diagnosed [level 1a, grade A] and active CD [level 2b, grade C]. • EEN has an improved adverse-effect profile over corticosteroids [level 1a, grade A]. • EEN has been shown to promote mucosal healing [level 1b, grade A] and has beneficial effect on linear growth [level 2b, grade A] |
EEN exclusive enteral nutrition (can be administered orally or via a nasogastric tube)
SPECIFIC DISEASES
Table 4.22
Summary of some examples of evidence-based international and internationally recognised guidelines referring to enteral tube feeding (ETF) as an integral part of patient and disease management – Specific Diseases and conditions (parts of guidelines relevant to ETF presented here, standard formulas only)
| Patient Group | Country | Body | Title | Recommendation, guideline, or standard [grade of evidence] |
|---|---|---|---|---|
| Patients with pressure ulcers | US, Europe, Australia, New Zealand, Hong Kong and Singapore | National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (2014) | Prevention and treatment of pressure ulcers 25 | • Consider enteral or parenteral nutritional support when oral intake is inadequate. This must be consistent with the individual’s goals. [Strength of Evidence = C; Strength of Recommendation = 👍] • If oral intake is inadequate, enteral or parenteral nutrition may be recommended if consistent with the individual’s wishes. Enteral (tube) feeding is the preferred route if the gastrointestinal tract is functioning. |
| Patients with pressure ulcers | US, Europe, Australia, New Zealand, Hong Kong and Singapore | National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (2025) | Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline 26 | Implementation considerations • Consider options in the following priority when providing nutrition supplementation: increased and optimised oral intake, fortified foods, oral supplements, enteral tube feeding, parenteral supplementation. • Discuss the benefits and harms of implementing enteral (e.g., naso-enteric tube or PEG tube) or parenteral feeding with individuals at risk of PIs and their informal carers. Balance patient autonomy, beneficence, nonmaleficence, and justice. Enteral feeding might be implemented for individuals who cannot meet their nutritional requirements through oral intake despite nutritional interventions when it meets their care goals and priorities. • If used, enteral feeding should be administered by qualified professionals using a monitoring protocol that includes routine assessment to ensure that tube-feeding is delivered as prescribed. The regimen should be guided by clinical guidance from nutrition/dietary guidelines appropriate to the individual’s clinical, nutritional and demographic profile. Suggested nutritional guidelines are provided in the resources. • Evaluate tolerance of enteral feeding daily through physical examinations, stool and flatus regularity, and gastrointestinal signs and symptoms. |
| Critical illness | US | Society of Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (ASPEN) (2016) | Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient 27 (Specific patient populations addressed in these expanded and updated guidelines include organ failure (pulmonary, renal, and liver), acute pancreatitis, surgical subsets (trauma, traumatic brain injury [TBI], open abdomen [OA], and burns), sepsis, postoperative major surgery, chronic critically ill, and critically ill obese) | • We recommend that nutrition support therapy in the form of early EN be initiated within 24–48 hours in the critically ill patient who is unable to maintain volitional intake [Quality of evidence: very low] • We suggest the use of EN over PN in critically ill patients who require nutrition support therapy. [Quality of Evidence: Low to Very Low] • Based on expert consensus, we suggest that patients who are at low nutrition risk with normal baseline nutrition status and low disease severity [e.g., NRS 2002 ≤3 or NUTRIC score ≤5] who cannot maintain volitional intake do not require specialised nutrition therapy over the first week of hospitalisation in the ICU. |
| Critical illness | US | American Society for Parenteral and Enteral Nutrition (ASPEN) | Guidelines for the provision of nutrition support therapy in the adult critically ill patient: The American Society for Parenteral and Enteral Nutrition 28 | Guideline question 3. In adult critically ill patients who are candidates for EN, does similar energy intake by PN vs EN as the primary feeding modality in the first week of critical illness impact clinical outcomes? GRADE recommendation: There was no significant difference in clinical outcomes. Because similar energy intake provided as PN is not superior to EN and no differences in harm were identified, we recommend that either PN or EN is acceptable. Evidence GRADE: High; Strength of GRADE recommendation: Strong |
| Critical illness | Europe | European Society for Clinical Nutrition and Metabolism (2019) | ESPEN guideline on clinical nutrition in the intensive care unit 29 | • If oral intake is not possible, early EN (within 48 h) in critically ill adult patients should be performed/initiated rather than delaying EN. Grade of recommendation: B – strong consensus (100% agreement) • If oral intake is not possible, early EN (within 48 h) shall be performed/initiated in critically ill adult patients rather than early PN. Grade of recommendation: A – strong consensus (100% agreement) |
| Critical illness | Europe | European Society for Clinical Nutrition and Metabolism (2023) | ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit 30 | • If oral intake is not possible, early EN (within 48 h) in critically ill adult patients should be performed/initiated rather than delaying EN. (Grade B, strong consensus, 100%) • If oral intake is not possible, early EN (within 48 h) shall be performed/initiated in critically ill adult patients rather than early PN. (Grade A, strong consensus 100%) Early EN should be performed
Grade B, strong consensus, 96%) |
| Critical illness | International | Surviving Sepsis Campaign (2012) | Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 18 | Nutrition: • We suggest administering oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/septic shock [grade 2C]. • We suggest using intravenous glucose and enteral nutrition rather than total parenteral nutrition (TPN) alone or parenteral nutrition in conjunction with enteral feeding in the first 7 days after a diagnosis of severe sepsis/septic shock [grade 2B]. |
| Critical illness | US | Academy of Nutrition and Dietetics (2012) | Critical Illness (CI) Guideline 2012 31 | Enteral vs. Parenteral Nutrition • If enteral nutrition (EN) is not contraindicated (e.g., by hemodynamic instability, bowel obstruction, high output fistula, or severe ileus) then the Registered Dietitian (RD) should recommend EN over parenteral nutrition (PN) for the critically ill adult patient. Research shows less septic morbidity, fewer infectious complications, and significant cost savings in critically ill adult patients who received EN vs. PN. There is limited evidence that EN vs. PN affects hospital length of stay (LOS), but an impact on mortality has not been demonstrated. [Rating: Strong, Conditional] Initiation of Enteral Nutrition • If enteral nutrition (EN) is not contraindicated (e.g., by hemodynamic instability, bowel obstruction, high output fistula, or severe ileus), then the Registered Dietitian (RD) should recommend that EN be started within 24 to 48 hours following injury or admission to the intensive care unit (ICU) (early EN). Research indicates that EEN is associated with a reduction in infectious complications in critically ill adult patients. The impact of EEN on mortality and length of stay (LOS) is unclear [Rating: Strong, Conditional] |
| Patients with Renal Failure | US | American (2010) | Nutrition Support in Adult Acute and Chronic Renal Failure 32 | • Patients with renal failure who require nutrition support therapy should receive enteral nutrition if intestinal function permits. [Grade E] |
| Patients with Renal Failure | US | National Kidney Foundation (2000) | Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines for Nutrition in Chronic Renal Failure 33 | If oral nutrition (including nutritional supplements) is inadequate, tube feeding should be offered if medically appropriate. • If tube feedings are not used, intradialytic parenteral nutrition (IDPN; for haemodialysis) or intraperitoneal amino acids (IPAA; for peritoneal dialysis) should be considered if either approach, in conjunction with existing oral intake, meets the protein and energy requirements. • If the combination of oral intake and IDPN or IPAA does not meet protein and energy requirements, daily total or partial parenteral nutrition should be considered. |
| Patients with Renal Failure | Europe | European Renal Association – European Dialysis and Transplant Association (2007) | EBPG Guideline on Nutrition 34 | Enteral tube [naso-gastric or percutaneous entero-gastrostomy (PEG)] feeding using disease-specific formulas for dialysis patients should be prescribed if attempts to increase dietary intake with oral supplements fail and nutritional status does not improve [Evidence level IV]. |
| Patients with Renal Failure | Europe | European Society for Clinical Nutrition and Metabolism (2006) | ESPEN Guidelines on Enteral Nutrition: Adult Renal Failure 35 | Acute renal failure (ARF): • In uncomplicated ARF, use tube feeding (TF) if normal nutrition and oral nutritional supplements (ONS) are not sufficient to meet estimated requirements. [Grade C] • In severe ARF, the recommendations for TF are the same as for other ICU patients. If possible, initiate EN within 24h. Conservatively treated chronic renal failure (CRF): • Use TF when adequate oral intake is not possible despite nutritional counselling and ONS. [Grade C] • In CRF patients in whom adequate oral intake cannot be achieved, consider overnight TF in order to optimise nutrient intake. Patients on maintenance haemodialysis therapy (HD): |
| Patients with Renal Failure | UK | UK Renal Association (2019) | Clinical Practice Guideline Undernutrition in Chronic Kidney Disease 36 | We suggest that the use of enteral feeding is considered in selected cases if nutrient intake is suboptimal, despite ONS recognising that there are significant risks and inconvenience associated with these forms of feeding (2C). It is also important to consider the patient’s comorbidity, general condition, and likely survival prospects before initiating enteral feeding. |
| Patients with Renal Failure | Europe | European Society for Clinical Nutrition and Metabolism (2024) | ESPEN practical guideline on clinical nutrition in hospitalised patients with acute or chronic kidney disease 37 | If oral intake is not possible, early EN (within 48 h) in critically ill adult patients should be performed/initiated rather than delaying EN. (R4 [ICU Guideline (17)], grade B, strong consensus 100%). As in other clinical settings (Poly morbid hospitalised patients, ICU patients) EN is the most physiologic route of feeding in comparison to PN, and in general has been linked to lower infection rates, shorter ICU and hospital stay. (S4, strong consensus 100%). There is no evidence linking a reduced renal function with an increase of either gastrointestinal, mechanical, or metabolic complications during EN in patients with AKI/AKD and/or CKD or CKD with KF. (S5, strong consensus 100%). |
| Chronic heart failure | Europe | European Society for Clinical Nutrition and Metabolism (2006) | ESPEN Guidelines on Enteral Nutrition: Cardiology and Pulmonology 38 | • EN is recommended in cardiac cachexia to stop or reverse weight loss on the basis of physiological plausibility. [Grade C] • There is no indication for enteral nutrition (EN) in the prophylaxis of cardiac cachexia. [Grade C] See Table 4.20 for definition of EN. |
| COPD | Europe | European Society for Clinical Nutrition and Metabolism (2006) | ESPEN Guidelines on Enteral Nutrition: Cardiology and Pulmonology 38 | • There is limited evidence that COPD patients profit from EN per se. [Grade B] • EN in combination with exercise and anabolic pharmacotherapy has the potential to improve nutritional status and function [Grade B] See Table 4.20 for definition of EN |
| Patients with GI disease | Europe | European Society for Clinical Nutrition and Metabolism (2006) | ESPEN Guidelines on Enteral Nutrition: Gastroenterology 39 | Crohn’s disease: • Use tube feeding (and/or oral nutritional supplements) in addition to normal food to improve nutritional status and to eliminate consequences of undernutrition such as growth retardation. [Grade A] • Use tube feeding if a higher intake (>600kcals/day) is necessary [Grade C] Short bowel syndrome: • Adaption phase: Use continuous tube feeding-in limited amounts depending on the enteral fluid loss to improve intestinal adaptation. (Grade C) • Use oral nutritional supplements or tube feeding if normal nutritional status can not be maintained by normal food alone. [Grade C] |
| Patients with GI disease | Europe | European Society for Clinical Nutrition and Metabolism (2023) | ESPEN guideline: Clinical nutrition in inflammatory bowel disease 40 | • If oral feeding is not sufficient then EN can be considered as supportive therapy. EN using formulas or liquids usually take preference over PN unless it is completely contraindicated (Grade of recommendation 0 – Strong consensus 96% agreement). • Exclusive EN is effective and can be recommended as the first line of treatment to induce remission in children and adolescents with mild active CD (Grade of recommendation 0 – Strong consensus 100% agreement). • Tube feeding in IBD should be preferentially administered via an enteral feeding pump if EN is administered via a jejunal and not a gastric tube. (Grade of recommendation GPP – Strong consensus 100% agreement). • Standard EN (polymeric diet with moderate fat content) should be employed for primary and supportive nutritional therapy in active IBD (Grade of recommendation B – Consensus 90% agreement). |
| Patients with liver disease | Europe | European Society for Clinical Nutrition and Metabolism (2019) | ESPEN Guidelines on Enteral Nutrition: Liver Disease 41 | Acute liver failure • In malnourished ALF patients, enteral nutrition (EN) and/or parenteral nutrition (PN) should be initiated promptly, as in other critically ill patients. Grade of Recommendation GPP – Strong consensus (96% agreement) • ALF patients without malnutrition should be provided with nutritional support (preferentially EN) when they are considered unlikely to resume normal oral nutrition within the next five to seven days, as in other critical illnesses. Grade of Recommendation GPP – Strong consensus (96% agreement) Alcoholic steatohepatitis • EN should be used when patients with severe ASH cannot meet their caloric requirements through normal food and/or ONS in order to improve survival and infectious morbidity. Grade of recommendation B – Strong consensus (100% agreement) • EN can be used in severe ASH to ensure adequate energy and protein intake without increasing the risk of HE. Grade of recommendation 0 – Strong consensus (92% agreement) Non-alcoholic fatty liver disease/ Non-alcoholic steatohepatitis • EN or PN shall be administered in NAFL/NASH patients during severe intercurrent illness, when oral nutrition alone is inadequate or impossible or contraindicated. Grade of recommendation GPP- Strong consensus (96% agreement) Liver cirrhosis • In cirrhotic patients, nutritional intervention (either oral or EN or PN) should be recommended for potential clinical benefit without an increase in adverse events. Grade of recommendation GPP – Strong consensus (100% agreement) |
| Patients with liver disease | Europe | European Society for Clinical Nutrition and Metabolism (2020) | ESPEN practical guideline: Clinical nutrition in liver disease 42 | • In infants, children, and adults, specialised nutrition protocols making optimal use of EN should be implemented. (Grade B, strong consensus 92%) Acute liver failure: • ALF patients who cannot be fed orally should receive EN via nasogastric/naso-jejunal tube. (Grade GPP, strong consensus 100%) • ALF patients without malnutrition should be provided with nutritional support (preferentially EN) when they are considered unlikely to resume normal oral nutrition within the next five to seven days, as in other critical illnesses. (Grade GPP, strong consensus 96%) • In malnourished ALF patients, enteral nutrition (EN) and/ or PN should be initiated promptly, as in other critically ill patients. (Grade GPP, strong consensus 96%) Alcoholic steatohepatitis: • EN should be used when patients with severe ASH cannot meet their caloric requirements through normal food and/or ONS in order to improve survival and infectious morbidity. (Grade B, strong consensus 100%) Non-alcoholic fatty liver disease/ Non-alcoholic steatohepatitis • EN or PN shall be administered in NAFL/NASH patients during severe intercurrent illness, when oral nutrition alone is inadequate or impossible or contraindicated. (Grade GPP, strong consensus 96%) Liver cirrhosis: • In cirrhotic patients, who cannot be fed orally or who do not reach the nutritional target through the oral diet, EN should be performed. (Grade B, strong consensus 100%) |
| Patients with HIV and chronic infectious diseases | Europe | European Society for Clinical Nutrition and Metabolism (2006) | ESPEN Guidelines on Enteral Nutrition: Wasting in HIV and other chronic infectious diseases 43 | HIV: • Diarrhoea does not prevent a positive effect of TF on nutritional status [Grade A] • If oral intake is possible, nutritional intervention should be implemented according to the following scheme [Grade C]:
• In patients with dysphagia or if oral nutritional supplements are not effective: If normal food intake and optimal use of oral nutritional supplements cannot achieve sufficient energy supply, TF is indicated. [Grade C] |
| Patients with burns | Europe | European Society for Clinical Nutrition and Metabolism (2013) Note: these recommendations are ESPEN endorsed 44 | ESPEN endorsed recommendations: Nutritional therapy in major burns 44 | • Nutritional therapy should be initiated early, within 12 h of injury, preferentially by the enteral route. [Grade: B; Agreement: Strong] • We recommend giving priority to the enteral routeⁱⁱⁱ, parenteral administration being rarely indicated [Grade: C; Agreement: Strong] iii Note the term “enteral route” has been assumed to refer to tube feeding in this guideline, as no definition is given in the text. |
| Patients with acute or chronic pancreatitis | Europe | European Society for Clinical Nutrition and Metabolism | ESPEN practical guideline on clinical nutrition in acute and chronic pancreatitis (2024) 45 ESPEN guideline on clinical nutrition in acute and chronic pancreatitis (2022) 46 ESPEN Guidelines on Enteral Nutrition: Pancreas (2006)47 |
• In patients with acute pancreatitis and inability to feed orally, enteral nutrition shall be preferred to parenteral nutrition. (grade A, strong consensus, 97 %) • Enteral nutrition should be started early, within 24-72 h of admission, in case of intolerance to oral feeding (grade B, strong consensus, 92 %) • Enteral nutrition should be administered to patients with malnutrition who are not responding to oral nutritional support. (grade GPP, strong consensus, 100 %) EN should be started early, within 24–72 h of admission, in case of intolerance to oral feeding. Grade of Recommendation B – Strong consensus (92% agreement). Mild acute pancreatitis: • Give tube feeding if oral nutrition is not possible due to consistent pain for more than 5 days. [Grade C] Severe necrotising pancreatitis: Acute pancreatitis: Chronic pancreatitis: |
| Patients with acute or chronic pancreatitis | US | American College of Gastroenterology (2024) | Management of Acute Pancreatitis 48 | • Enteral nutrition in patients with moderately severe or severe AP seems to prevent infectious complications. • Using a nasogastric rather than nasojejunal route for delivery of enteral feeding is preferred because of comparable safety and efficacy. |
| Patients with cystic fibrosis | Europe | European Society for Clinical Nutrition and Metabolism, European Society for Paediatric Gastroenterology, Hepatology and Nutrition and European Cystic Fibrosis Society (2016) | ESPEN-ESPGHAN-ECFS Guidelines on Nutrition Care for Infants, Children, and Adults with Cystic Fibrosis 16 | • We recommend a progressive approach to intensification of nutrition interventions as needs increase: preventive nutritional counselling, dietary modification, and/or oral nutrition supplements, and enteral tube feeding. [Grade of evidence: low] |
| Surgical patients | Europe | European Society for Clinical Nutrition and Metabolism | 2021 ESPEN practical guideline: Clinical nutrition in surgery 49 2006 ESPEN Guidelines on Enteral Nutrition: Surgery Including Organ Transplantation 50 |
• Perioperative nutritional support therapy is indicated in patients with malnutrition and those at nutritional risk. Perioperative nutritional therapy should also be initiated if it is anticipated that the patient will be unable to eat for more than five days perioperatively. It is also indicated in patients expected to have low oral intake and who cannot maintain above 50% of the recommended intake for more than seven days. In these situations, it is recommended to initiate nutritional support therapy (preferably by the enteral route – oral nutritional supplements -tube feeding) without delay. Grade of recommendation GPP – strong consensus (92% agreement) • Early EN (within 24 h) shall be initiated in patients in whom early oral nutrition cannot be started, and in whom oral intake will be inadequate (<50%) for more than seven days:
• With special regard to malnourished patients, placement of a nasojejunal tube or NCJ should be considered for all candidates for EN undergoing major upper gastrointestinal and pancreatic surgery. Grade of recommendation B – strong consensus (95% agreement)
Initiate tube feeding for patients in need within 24 h after surgery. [Grade A] |
| Surgical patients | England and Wales | National Institute for Health and Care Excellence (NICE) (2006) -Updated in 2017 | Nutrition support in adults Oral nutrition support, enteral tube feeding and parenteral nutrition 2 | • Enteral nutrition support for surgical patients: Surgical patients who are: malnourished and have inadequate or unsafe oral intake and a functional, accessible gastrointestinal tract and are due to undergo major abdominal procedures, should be considered for pre-operative enteral tube feeding. [B] General surgical patients should not have enteral tube feeding within 48 hours post-surgery unless they are malnourished or at risk of malnutrition and have inadequate or unsafe oral intake and a functional, accessible gastrointestinal tract. [A] |
| Surgical patients | European and International | Enhanced Recovery after Surgery Society (2013) ERAS® Society, the European Society for Clinical Nutrition and Metabolism and the International Association for Surgical Nutrition and Metabolism – Updated in 2018 | Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations 51 Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018 52 |
• Postoperative early enteral feeding, safety: High |
| Patients with Intestinal Failure | Europe | European Society for Clinical Nutrition and Metabolism (2016) | Management of acute intestinal failure: A position paper from the European Society for Clinical Nutrition and Metabolism (ESPEN) Special Interest Group 53 | • Even if parenteral nutrition will be the nutritional support of choice, feeding via the enteral route should always be considered. |
| Patients with Intestinal Failure | Europe | European Society for Clinical Nutrition and Metabolism (2023) | ESPEN guideline on chronic intestinal failure in adults – Update 2023 54 | Short bowel syndrome • The EN in combination with oral feeding can be prescribed in patients with CIF in whom the expected gain with EN could allow to wean off HPN. Grade of recommendation GPP – Strong consensus 100% agreement. Chronic small intestinal dysmotility • Any decision to escalate from oral nutrition to EN or PN should involve careful multidisciplinary team consideration of the potential risks and benefits with the patient. Grade of recommendation GPP – Strong consensus 100% agreement. • EN should be considered as a first step in patients with chronic gastrointestinal dysmotility who are not able to meet their energy needs with oral nutrition alone and who continue to lose weight, before using HPN. Grade of recommendation GPP – Strong consensus, 96% agreement. • Radiation enteritis • In patients with chronic radiation enteritis, EN may be used if oral nutrition, including use of oral nutritional supplements, is inadequate. Grade of recommendation 0 – Strong consensus 100% agreement. |
| Patients with Dysphagia | England and Wales | National Institute for Health and Care Excellence (NICE) (2006) – Updated in 2017 | Nutrition support in adults Oral nutrition support, enteral tube feeding and parenteral nutrition 2 | • People with dysphagia: In the acute setting, for example, following stroke, people unable to swallow safely or take sufficient energy and nutrients orally should have an initial 2–4-week trial of nasogastric enteral tube feeding. Healthcare professionals with relevant skills and training in the diagnosis, assessment, and management of swallowing disorders should assess the prognosis and options for future nutrition support. [A] |
| Patients with Dysphagia | Europe | European Academy of Neurology (2011) | Late (complicated) Parkinson’s disease ⁱᵛ | Dysphagia: • Enteral feeding options may need to be considered (short-term nasogastric tube feeding or longer-term feeding systems [percutaneous endoscopic gastrostomy]) [GPP] |
| Patients with Stroke | England and Wales | National Institute for Health and Care Excellence (NICE) (2019) – Updated in 2022 | Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. Clinical Guideline 55 | • People with acute stroke who are unable to take adequate nutrition and fluids orally should receive tube feeding with a nasogastric tube within 24 hours of admission • Nutrition support should be initiated for people with stroke who are at risk of malnutrition. This may include oral nutritional supplements, specialist dietary advice, and/or tube feeding. |
| Patients with Stroke | Germany | German Society for Clinical Nutrition (DGEM) (2013) | Guideline clinical nutrition in patients with stroke 56 | • Patients with prolonged severe dysphagia anticipated to last for more than 7 days should receive tube feeding [CCP]. • Patients with a decreased level of consciousness and mechanical ventilation often require enteral nutrition for a longer period of time, and tube feeding can therefore start early [C]. • Severe swallowing difficulties that do not allow sufficient oral food intake and are anticipated to persist for more than 1 week require early enteral nutrition via feeding tube (at least within 72 hours) [C]. • If a sufficient oral food intake is not possible during the acute phase of stroke, enteral nutrition shall be preferably given via a nasogastric tube [A]. • If enteral feeding is likely for a longer period of time (> 28 days), a PEG should be chosen and shall be placed in a stable clinical phase (after 14 – 28 days) [A]. • Mechanically ventilated stroke patients should receive a PEG at an early stage [B]. • If a nasogastric tube is repeatedly removed accidentally by the patient and if artificial nutrition will probably be necessary for more than 14 days, early placement of a PEG should be considered [B]. A nasal loop (bridle) is an effective alternative in this situation [B]. |
Note on terminology: see Table 4.29
ⁱᵛOertel WH, Berardelli A, Bloem BR, Bonuccelli U, Burn D, Deuschl G, Dietrichs E, Fabbrini G, Ferreira JJ, Friedman A, Kanovsky P, Kostic V, Nieuwboer A, Odin P, Poewe W,Rascol O, Sampaio C , Schupbach M, Tolosa E, Trenkwalder C . Late (complicated) Parkinson’s disease. In: Gilhus NE, Barnes MP, Brainin M, editor(s). European handbook ofneurological management. 2nd ed. Vol. 1. Oxford (UK): Wiley-Blackwell; 2011. p. 237-67 (accesed via the National Guideline Clearinghouse https://www.guideline.gov30.05.17).
Abbreviations: CIF Chronic intestinal failure GPP Good practice point, CCP Clinical Consensus Point
CANCER
Table 4.23
Summary of some examples of evidence-based international and internationally recognised guidelines referring to enteral tube feeding (ETF) as an integral part of patient and disease management in Oncology (parts of guidelines relevant to ETF presented here, standard formulas only)
| Patient Group | Country | Body | Title | Recommendation, guideline, or standard [grade of evidence] |
|---|---|---|---|---|
| Patients with cancer | Europe | European Society for Clinical Nutrition and Metabolism. Officially endorsed by the European Society of Surgical Oncology (ESSO), the European Association for Palliative care (EAPC) and the Chinese Society of Clinical Oncology (CSCO) (2017) – Updated in 2021 | ESPEN guidelines on nutrition in cancer patients 57 ESPEN Practical Guidelines: Clinical Nutrition in Cancer 58 |
Modes of nutrition: when to escalate: • If a decision has been made to feed a patient, we recommend enteral nutrition if oral nutrition remains inadequate despite nutritional interventions (counselling, ONS), and parenteral nutrition if enteral nutrition is not sufficient or feasible. [Strength of recommendation STRONG; Level of evidence Moderate] Radiotherapy: • We recommend enteral feeding using naso-gastric or percutaneous tubes (e.g., PEG) in radiation-induced severe mucositis or in obstructive tumours of the head-neck or thorax. [Strength of recommendation STRONG, level of evidence: low]. Medical oncology: Curative or palliative anticancer drug treatment: • In a patient undergoing curative anticancer drug treatment, if oral food intake is inadequate despite counselling and oral nutritional supplements (ONS), we recommend supplemental enteral or, if this is not sufficient or possible, parenteral nutrition. [Strength of recommendation STRONG, level of evidence: very low] High-dose chemotherapy and hematopoietic stem cell transplantation (HCT): • During intensive chemotherapy and after stem cell transplantation, we recommend maintaining physical activity and to ensure an adequate nutritional intake. This may require enteral and/or parenteral nutrition. [Strength of recommendation STRONG, level of evidence: very low] • If oral nutrition is inadequate, we suggest preferring enteral tube feeding to parenteral nutrition, unless there is severe mucositis, intractable vomiting, ileus, severe malabsorption, protracted diarrhoea, or symptomatic gastrointestinal graft versus host disease (GvHD). [Strength of recommendation WEAK, level of evidence: low] Home artificial nutrition: • In patients with chronic insufficient dietary intake and/or uncontrollable malabsorption, we recommend home artificial nutrition (either enteral or parenteral) in suitable patients [Strength of recommendation STRONG; Level of evidence Low] |
| Patients with cancer | US | Academy of Nutrition and Dietetics (2013) – Updated in 2017 | Oncology (ONC) Guideline 59 Oncology evidence-based nutrition practice guideline for adults 60 |
• In adult oncology patients who have been identified to have pre-cachexia or cancer cachexia, prompt and aggressive intervention to address nutrition impact symptoms and preserve or prevent loss of lean body mass (LBM) and weight should be initiated by the registered dietitian nutritionist (RDN). Early rather than later intervention to prevent weight loss in this population is more likely to be effective. The metabolic derangements in cancer cachexia that promote wasting can lead to loss of weight and LBM and poor outcomes Medical Nutrition Therapy (MNT) in Adult Oncology Patients Undergoing Chemotherapy or Radiation Treatment: • If an adult oncology patient is undergoing chemotherapy or radiation treatment, the registered dietitian nutritionist (RDN) should provide medical nutrition therapy (MNT). MNT has been shown to be effective in improving multiple treatment outcomes in patients undergoing chemotherapy, radiation, or chemoradiotherapy in ambulatory or outpatient and inpatient oncology settings See Table 4.29 for definition of MNT |
| Adult cancer patients undergoing anti-cancer treatment and Hematopoietic Cell Transplantation | US | American Society for Parenteral and Enteral Nutrition (2009) ASPEN adult nutrition Support core curriculum 61 |
Nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation 62 | Anti-cancer treatment • Nutrition support therapy is appropriate in patients receiving active anticancer treatment who are malnourished and who are anticipated to be unable to ingest and/or absorb adequate nutrients for a prolonged period of time. [Grade: B] Hematopoietic cell transplantation: • Enteral nutrition should be used in patients with a functioning gastrointestinal tract in whom oral intake is inadequate to meet nutrition requirements. [Grade C] |
| Non-surgical cancer patients | Europe | European Society for Clinical Nutrition and Metabolism (2006) Comprehensive Guideline in 2017 |
ESPEN Guidelines on Enteral Nutrition: Non-surgical oncology 63 ESPEN Guidelines on Nutrition in Cancer Patients 57 |
During stem cell transplantation: • If oral intake is decreased, parenteral nutrition may be preferred to tube feeding in certain situations (i.e., increased risk of haemorrhage and infections associated with enteral tube placement in immune-compromised and thrombocytopenic patients). [Grade C] • Use tube feeding if an obstructing head or neck or oesophageal cancer interferes with swallowing or if severe local mucositis is expected. [Grade C] During radio- or radio-chemotherapy: • Tube feeding can either be delivered via trans nasal or percutaneous routes. If a decision has been made to feed a patient, we recommend enteral nutrition if oral nutrition remains inadequate despite nutritional interventions (counselling, ONS), and parenteral nutrition if enteral nutrition is not sufficient or feasible. Strength of recommendation: Strong; Level of evidence: Moderate |
| Patients with cancer of the aerodigestive tract | England and Wales | National Institute for Health and Care Excellence (NICE) (2016) | Cancer of the upper aerodigestive tract: assessment and management in people aged 16 and over 64 | • Assess people’s need for enteral nutrition at diagnosis, including prophylactic tube placement |
| Patients with cancer of the aerodigestive tract | Europe | ESMO (European Society for medical oncology) | Oesophageal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up 65 | • Nutritional support according to the ESPEN guidelines is an integral part of the medical care for patients with oesophageal cancer in the curative and in the palliative setting [II, A] Management of local/locoregional disease: • Nutritional status matters and should be corrected. Endoscopic stenting should not be used in locoregional disease in operable patients and alternative routes of feeding, e.g. with needle catheter jejunostomy, should be preferred [II, A] |
| Patients with head and neck cancers | Australia and New Zealand | Clinical Oncology Society of Australia | Evidence-based practice guidelines for the nutritional management of adult patients with head and neck cancer (2014) 66 | Quality nutrition care – Nutrition intervention: • Tube feeding using standard formula can be used to minimise weight loss in the acute post-operative period [Grade C] • Nutrition intervention (dietary counselling and/or supplements and/or tube feeding) improves/maintains nutritional status [Grade A] • Nutrition intervention (dietary counselling and/or supplements and/or tube feeding) improves patient-centred outcomes (quality of life, physical function, and patient satisfaction) [Grade B] • Tube feeding can improve protein and energy intake when oral intake is inadequate [Grade B] • Tube feeding may reduce unplanned hospital admissions and disruptions to treatment compared to oral intake alone [Grade C] Nutrition implementation – Pre-treatment: • Prophylactic enteral feeding should be considered to improve nutritional status, cost, and patient outcomes for patients who have T4 or hypopharyngeal tumours undergoing concurrent chemoradiotherapy [Grade C] Nutrition implementation – Surgery • Post-operative tube feeding should commence within 24 hours in patients in whom oral feeding cannot be established, with individual consideration to patients depending on surgical procedures in collaboration with the multidisciplinary team [Grade A]. Nutrition implementation – Radiotherapy and chemotherapy • Prophylactic tube feeding compared to oral intake alone or intervention tube feeding may reduce unplanned hospital admissions [Grade C] • For patients not tolerating adequate intake orally, tube feeding should be used to help minimise weight loss [Grade B] • Prophylactic tube feeding compared to oral intake alone or intervention tube feeding demonstrates improved nutrition outcomes with less weight loss [Grade B] • Prophylactic tube feeding compared to oral intake alone or intervention tube feeding may improve quality of life during and post-treatment [Grade B]. |
Table 4.24
NICE Guidelines: Grading of recommendations (adapted from NICE 2006)2
| Grade | Evidence |
|---|---|
| A | • At least one meta-analysis, systematic review, or RCT rated as 1++ (i.e., high-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias), and directly applicable to the target population, or • A systematic review of RCTs or a body of evidence consisting principally of studies rated as 1+ (i.e., well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias), directly applicable to the target population, and demonstrating overall consistency of results • Evidence drawn from a NICE technology appraisal |
| B | • A body of evidence including studies rated as 2++ (i.e., high quality systematic reviews of case-control or cohort studies, high-quality case- control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal) directly applicable to the target population, and demonstrating overall consistency of results, or • Extrapolated evidence from studies rated as 1++ or 1+ |
| C | • A body of evidence including studies rated as 2+ (i.e., well-conducted case-control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal), directly applicable to the target population and demonstrating overall consistency of results, or • Extrapolated evidence from studies rated as 2++ |
| D | • Evidence level 3 (i.e., non-analytic studies, e.g., case reports, case series) or 4 (i.e., expert opinion), or • Extrapolated evidence from studies rated as 2+, or • Formal consensus |
| D (GPP) | • A good practice point (GPP) is a recommendation for best practice based on the experience of the Guideline Development Group |
Criteria for Recommendation Ratings
Table 4.25
Academy of Nutrition and Dietetics recommendation ratings
Academy Evidence-Based Nutrition Practice Guidelines published on the Evidence Analysis
Library (EAL) are assigned a rating of: strong, fair, weak, consensus, or insufficient evidence based on the following criteria.
| Statement Rating | Definition | Implication for Practice |
|---|---|---|
| Strong | A Strong recommendation means that the workgroup believes that the benefits of the recommended approach clearly exceed the harms (or that the harms clearly exceed the benefits in the case of a strong negative recommendation), and that the quality of the supporting evidence is excellent/good (grade I or II).* In some clearly identified circumstances, strong recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. | Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present. |
| Fair | A Fair recommendation means that the workgroup believes that the benefits exceed the harms (or that the harms clearly exceed the benefits in the case of a negative recommendation), but the quality of evidence is not as strong (grade II or III).* In some clearly identified circumstances, recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits outweigh the harms. | Practitioners should generally follow a Fair recommendation but remain alert to new information and be sensitive to patient preferences. |
| Weak | A Weak recommendation means that the quality of evidence that exists is suspect or that well-done studies (grade I, II, or III)* show little clear advantage to one approach versus another. | Practitioners should be cautious in deciding whether to follow a recommendation classified as Weak and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role. |
| Consensus | A Consensus recommendation means that Expert opinion (grade IV) supports the guideline recommendation even though the available scientific evidence did not present consistent results, or controlled trials were lacking. | Practitioners should be flexible in deciding whether to follow a recommendation classified as Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role. |
| Insufficient Evidence | An Insufficient Evidence recommendation means that there is both a lack of pertinent evidence (grade V)* and/or an unclear balance between benefits and harms. | Practitioners should feel little constraint in deciding whether to follow a recommendation labelled as Insufficient Evidence and should exercise judgment and be alert to emerging publications that report evidence that clarifies the balance of benefit versus harm. Patient preference should have a substantial influencing role. |
Recommendations are categorised in terms of either imperative or conditional statements.
Fulfilment of the condition triggers one or more guideline-specified actions. |
||
Adapted by the Academy of Nutrition and Dietetics from the American Academy of Pediatrics, Classifying Recommendations for Clinical Practice Guidelines, Pediatrics.2004;114;874-877s
Table 4.26
ESPEN Guidelines: Grading of recommendations (adapted from Shultz 2006)67
| Grade | Level of evidence | Requirement |
|---|---|---|
| A | Ia Ib |
• Meta-analysis of randomised controlled trials • At least one randomised controlled trial |
| B | IIa IIb III |
• At least one well-designed controlled trial without randomisation • At least one other type of well-designed, quasi-experimental study • Well-designed non-experimental descriptive studies such as comparative studies, correlation studies, case-control studies |
| C | IV | • Expert opinions and/or clinical experience of respected authorities |
Adapted from Schutz T, Herbst B, Koller M. Methodology for the Development of the ESPEN Guidelines on Enteral Nutrition. Clinical Nutrition. 2006;25:203–209.
Table 4.27
ASPEN Grading of Guidelines and Levels of Evidenceᵛ
| Grading of Guidelines | |
|---|---|
| A | Supported by at least two level I investigations |
| B | Supported by one level I investigation |
| C | Supported by at least one level II investigation |
| D | Supported by at least one level III investigation |
| E | Supported by level IV or V evidence |
| Levels of Evidence | |
| I | Large randomised trials with clear-cut results; low risk of false-positive (alpha) and/ or false-negative (beta) error |
| II | Small, randomised trials with uncertain results; moderate-to-high risk of false-positive (alpha) and/or false-negative (beta) error |
| III | Nonrandomised cohort with contemporaneous controls |
| IV | Nonrandomised cohort with historical controls |
| V | Case series, uncontrolled studies, and expert opinion |
From 2012 ASPEN have adopted a revised method of evidence grading based on the GRADE methodology (Druyan 2012) see Table 4.28
Table 4.28
Signposts for evidence grading of other international organisations
| Recommending body | Signpost for evidence grading |
|---|---|
| National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance | https://npiap.com/page/InternationalGuidelines https://pppia.org/pi-guideline https://epuap.org/pu-guidelines/ |
| Academy of Nutrition and Dietetics | https://www.andeal.org/recommendation-ratings |
| ASPEN | https://nutritioncare.org/ |
| ~~Clinical Oncology Society of Australia~~ | https://www.cosa.org.au/ |
| NASPGHAN | http://www.cebm.net/ |
| Surviving Sepsis Campaign | http://www.sccm.org/Documents/SSC-Guidelines.pdf |
| ESPGHAN | http://www.espghan.org/fileadmin/user_upload/ guidelines_pdf/Guidelines_2404/Management_of_ Pediatric_Ulcerative_Colitis Joint.24.pdf |
| ESPEN | http://www.espen.org/files/ESPEN-Guidelines/0 Standard_operating_procedures_for_ESPEN_guide- lines_and_consensus_papers_2.pdf |
Table 4.29
Definitions of Enteral Nutrition according to recommending body
| Organisation | Term | Definition |
|---|---|---|
| Academy of Nutrition and Dietetics | Medical Nutrition Therapy (MNT) | Medical nutrition therapy (MNT) is an evidence‐based application of the Nutrition Care Process. The provision of MNT (to a patient/ client) may include one or more of the following: nutrition assessment/re -re-assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation that typically results in the prevention, delay, or management of diseases and/ or conditions. |
| ASPEN69 | Enteral Nutrition | “Nutrition provided through the gastrointestinal tract via a tube, catheter, or stoma that delivers nutrients distal to the oral cavity.” |
| ESPEN70 | Enteral Nutrition | “The term EN is used to comprise all forms of nutritional support that imply the use of ‘dietary foods for special medical purposes’ as defined in the European legal regulation of the Commission Directive 1999/21/EC of 25 March 1991ᵛⁱ, independent of the route of application. It includes oral nutritional supplements (ONS) as well as tube feeding via nasogastric, nasoenteral, or percutaneous tubes.” |
| ESPEN71 | Enteral Nutrition | “As oral intake is almost always impossible in these patients, in this chapter the term ‘‘EN’ is confined to tube feeding exclusively without regard to any kind of oral nutritional supplement”. |
| ESPEN58 | Artificial Nutrition | Artificial nutrition is the non-volitional application of nutrients via enteral tubes (enteral nutrition) or parenteral infusions (parenteral nutrition). |
| NASPGHAN24 | Exclusive Enteral Nutrition (EEN) | EEN can be administered orally or via a nasogastric tube |
| ESPGHAN15 | Enteral Nutrition | “EN encompasses the use of dietary foods for special medical purposes as defined in the European legal regulation of the Commission Directive 1999/21/EC, irrespective of the route of delivery.” |
ᵛⁱNote that the legislation for FSMPs has been updated since publication of these guidelines. See Defintions of Terms at the beginning of this dossier for up to date details of relevant legislation.