Review: Enteral Nutrition in Hospitalized Adults

Introduction:
This is a summary of a new review published in the New England Journal of Medicine discussing the rationale, evidence, and practical considerations for administering enteral nutrition to hospitalized adults. The main objective is to provide guidance on identifying patients with disease-related malnutrition, initiating enteral feeding, and differentiating strategies for critically ill versus non–critically ill patients who require nutritional support.

Key Recommendations:

1. Identify Malnutrition Early:

   • Screen all hospitalized patients for malnutrition (e.g., using the Malnutrition Screening Tool) on admission.

   • Confirm high-risk cases with a comprehensive nutrition assessment (e.g., GLIM or AAIM criteria).

2. Optimize Oral Intake First:

   • Whenever possible, use strategies such as dietary modifications and oral nutritional supplements before initiating enteral nutrition.

   • Implement medical nutrition therapy with the goal of meeting at least 75% of estimated energy and protein requirements orally; consider EN/PN if this goal is not reached within approximately 5 days.

3. Initiate Enteral Nutrition if Oral Intake Is Inadequate:

   • Consider enteral feeding for patients who fail to meet energy and protein goals and do not have contraindications (e.g., intestinal obstruction, severe shock, intestinal ischemia, or active gastrointestinal hemorrhage).

   • Dosing considerations differ significantly by patient population and clinical phase:

     • In critical illness (acute phase, first week), evidence suggests potential harm from early full caloric feeding or high protein doses (e.g., ≥2.2 g/kg/day), particularly in patients with shock or organ failure. A more “trophic” or hypocaloric approach (<70% of estimated energy needs) is often appropriate, especially if there is acute kidney injury or multiorgan dysfunction.

     • In contrast, for non–critically ill medical or surgical patients at risk of malnutrition, studies show that underfeeding is associated with worse outcomes, making it important to achieve closer to full nutritional requirements sooner.

4. Select the Appropriate Route and Timing:

   • For short-term use (up to 6 weeks), place a nasoenteric tube.

   • For anticipated long-term support, consider a gastrostomy or jejunostomy tube.

   • Postpyloric feeding (duodenal or jejunal) may reduce aspiration risk in certain patients.

5. Adjust Dose According to Clinical Phase:

   • In the ICU acute phase, avoid early full feeding; consider “trophic” or hypocaloric regimens.

   • As the patient recovers from critical illness, gradually increase caloric and protein delivery to meet estimated needs if tolerated, though exact targets remain under investigation.

   • In non–critically ill patients, aim to meet estimated requirements unless specific clinical issues necessitate lower delivery.

6. Mitigate Complications:

   • Use continuous pump-assisted infusion, though volume-based feeding can improve goal attainment.

   • Monitor regularly for refeeding syndrome (e.g., hypophosphatemia, hypokalemia, hypomagnesemia) and correct electrolyte abnormalities.

   • Employ glucose management strategies to avoid hyperglycemia.

7. Coordinate Interdisciplinary Care:

   • Engage dietitians, nursing staff, pharmacists, and other professionals to tailor therapy and optimize patient acceptance.

   • Involve patients in shared decision-making, particularly regarding personal values and treatment goals.

Conclusion:
These recommendations underscore enteral nutrition’s essential role in preventing and treating disease-related malnutrition. However, the direct impact on major outcomes (e.g., mortality, complications) varies by patient population, feeding strategy, and timing. In critically ill patients, especially during the first week of ICU care, lower-dose or “trophic” enteral feeding may be safer, whereas non–critically ill patients generally benefit from achieving nutritional targets more fully. Our understanding of optimal feeding approaches continues to evolve, particularly with regard to feeding dose during different phases of illness and recovery.

Reference:
Gramlich L, Guenter P. Enteral Nutrition in Hospitalized Adults. New England Journal of Medicine. 2025;392:1518-1530. DOI: https://doi.org/10.1056/NEJMra2406030