Issue 141 Bolus feeding

CLINICAL

BOLUS FEEDING

Bolus feeding is a method of enteral feeding, with continuous feeding via a pump being the alternative. This article aims to review the advantages and disadvantages of bolus feeding and its practical aspects.

Bolus feeding is thought to be a preferable method of feeding in certain patient groups, such as head and neck cancer. Ultimately, it is up to the patient to choose which method of feed administration they would like and for the dietitian to educate on both bolus and continuous feeding, so that an informed decision can be made by the patient.

Many of my dietetic colleagues and I are of the opinion that bolus feeding is more prevalent as a method of enteral feeding than it was 10 years ago. A 2016 survey showed that one third of patients receiving home enteral tube feeding were receiving part or all of their nutrition via bolus feeding.1 Following NICE (2006) guidance,2 patients fed into the stomach should be considered for continuous pump feeding or bolus feeding based on patient preference, convenience and drug administration.

From experience, other factors should also be considered to determine which method of feeding is best. These include social circumstances, level of dependence, mobility and dexterity and gastrointestinal tolerance.

It is the dietitian’s role to explain to the patient what each method of feeding entails, inform the patient of what is perceived to be the pros/ cons of each method of feeding and support the patient in their choice of method.

Louise Edwards Community Team Leader/Specialist Dietitian

If you were to conduct a literature search for ‘bolus feeding’ you would find very little evidence to support dietetic recommendations.

Individual dietitian’s and dietetic departments experience with bolus feeding is generally what drives the recommendations made in regards to this method of feeding.

In 2017, Nutricia Ltd launched a practical guide to ‘Bolus Feeding in Adults’3 aiming to define what bolus feeding is and to provide practical guidance to healthcare professionals involved in the enteral feeding of individuals. The guide is supported

by BAPEN, the BDA, the British Pharmaceutical Nutrition Group (BPNG) and the National Nurses Nutrition Group (NNNG).

This practical guide defines bolus feeding as: ‘The administration of feed through an enteral feeding tube as a series of smaller volume feeds given at regular intervals. A typical bolus is 200-250ml, but individual patients may tolerate more than this. This can be delivered with an enteral syringe or bolus set using a plunger, gravity, or a feeding pump.’3 Bolus feeding can involve the use of a ‘ready to hang’ feed bottle that is given at regular intervals throughout the day, but

Louise is a Specialist Dietitian working at the Central Cheshire Integrated Care Partnership (CCICP).

REFERENCES Please visit the Subscriber zone at NHDmag.com

With thanks to Kirsty Capper, Home Enteral Tube Feeding Dietitian, for sharing her dietetic experience.

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More in tune with patients’ lives A feed delivered the way you choose Bolus or Oral

Nutrison Energy Multi Fibre Vanilla 200ml Supports convenience and patient mobility when bolus feeding.

Kcal Protein

308 12 g Fibre

4.4 g PER 200ML

This information is intended for healthcare professionals only.

Nutrison Energy Multi Fibre Vanilla is a Food for Special Medical Purposes for the dietary management of disease related malnutrition and must be used under medical supervision.

Nutrison Energy Multi Fibre Vanilla 1.5 kcal/ml Right patient, right product, right outcomes

https://www.nutriciahcp.com/adult/products/Nutrison_Energy_Multi_Fibre_Vanilla/ Date of preparation: 01/19

CLINICAL Table 1: Advantages and disadvantages of bolus feeding Advantages

Disadvantages

Reduced amount of time of feeding.

A large volume bolus in a short time frame may not be well tolerated by the patient.

Flexibility regarding when feeds are given can mimic a ‘normal’ eating pattern and give patients increased opportunity to do activities/therapy sessions.

A level of dexterity and strength is required to administer the bolus feed.

Less equipment if syringe/gravity fed.

Potential for infection with the use of ‘open’ feeds.

Could be considered simpler to administer.

If bolus feeding is to be completed by a carer/family etc, length of visit needs to be for the duration of the feed and frequent for each bolus.

Timing of feed administration can be arranged around care calls, when carers/family are available (if patient dependent).

If being administered via a nasogastric tube (NGT), it’s time consuming due to the requirement to confirm NGT position for each bolus feed.

Safer method of feeding if patient is unable to maintain positioning for a significant period of time.

Required to store a large number of oral nutritional supplements (ONS).

Useful as a ‘top up’ for patients whose oral intake may be insufficient to meet nutritional requirements.

It can be difficult to meet fluid requirements for dependent patients when care is only available for feed boluses.

Regular bolus feeds may reduce hunger compared to a fixed time period on continuous pump feeding.

Fast administration of feeds is not well tolerated by everyone.

Easier to facilitate transition to oral intake (if appropriate).

Not suitable for post pyloric feeding.

more commonly it is sip feeds that are used for the bolus. Bolus feeding should not be routinely used for post pyloric feeding, since guidelines have discussed that bolus delivery into the jejunum can cause a ‘dumping’ type syndrome effect.6 Continuous pump feeding refers to nutrition being administered via an electronic pump at a specific rate, often using a larger volume of feed over a significant time frame (ie, over 10 hours). In order to assist my patients in making well informed decisions as to which method of feeding they would like, I highlight what could be perceived to be the advantages and disadvantages of each method. Table 1 lists these for bolus feeding, but it is by no means exhaustive. However, you may find certain points in the Table that your patient would view as important to their quality of life.

PATIENT GROUPS

You may consider patient groups for which bolus feeding is seen to be preferable to continuous

pump feeding, such as for head and neck cancer patients. Around one quarter of adults receiving home enteral tube feeding (HETF) registered with the British Artificial Nutrition Survey (BANS) had a diagnosis of cancer, with over 80% having head and neck cancer.4 The BANS report 2018 highlighted that this patient group is generally relatively independent and active, therefore, a feeding regime that fits in with an active lifestyle is required. Bolus feeding is often used more frequently in this patient group, particularly in those receiving outpatient treatments, those who work during oncological treatment, and for those who wish to have more flexibility with feeding.7 As oral dietary intake may decline as a side effect of oncology treatment, bolus feeding can be highly appropriate, by administering ONS via a feeding tube that can be increased in frequency to support nutritional requirements. There is also flexibility in finding the time to administer bolus feeds around outpatient appointments. www.NHDmag.com February 2019 - Issue 141

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CLINICAL Table 2: The methods of bolus feeding - considerations Syringe plunger

Gravity

Pump

More control over flow rate.

Useful if not tolerating ‘syringe plunger’ method as slower flow.

Useful when a large volume bolus is indicated.

Requires a level of dexterity.

Requires a level of dexterity.

Dexterity required for setting up, giving set and feeding pump.

Requires a level of strength.

Requires a level of strength.

Useful when a specific feeding rate is indicated.

Can be rather messy.

Bolus feeding may also be a preferable feeding option for post stroke patients undergoing rehabilitation therapy. This is due to the flexibility of administering boluses pre and post therapy sessions.

From experience, bolus feeding is also desirable over continuous pump feeding in individuals who struggle to maintain a safe feeding position (torso at >30 degree angle) for a significant period of time.

Bolus feeding of a high calorie, small volume ONS via a feeding tube enables a substantial amount of calories to be administered over a short time frame.

As long as a safe feeding position is maintained during this bolus and at least 30 minutes after significant nutrition can be administered safely.

This repeated several times over the day (as per dietetic recommendations) ensures that the patient’s nutritional requirements are met and the patient’s safety has been considered in regards to feeding with poor positioning.

A randomised control trial (RCT) looking at whether continuous pump feeding over bolus feeding reduced the incidence of pneumonia in nasogastric fed patients found no statistical difference.5 From my experience in the acute setting, continuous pump feeding is more commonly initiated as the method of enteral tube feeding since nursing staff may find it easier to set up and administer. With a bolus feeding regime there is the possibility that a feed bolus may be missed by a nurse if they are busy, resulting in the patient being under fed. If the patient is dependent on nursing staff administering the feed via their enteral feeding tube, bolus feeding could be interpreted to require more nursing time and, therefore, be more labour intensive.

Bolus feeding can be conducted using three different methods: 30

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1 Bolus by syringe plunger - when the syringe is filled with feed and the syringe plunger is pushed to administer the feed.

2 Bolus by gravity - when the syringe is filled with feed with the plunger removed, the syringe is held upwards with gravity promoting the feed down the tube.

3 Bolus by pump - when a giving set and pump is used to administer feed at a specific rate.

Table 2 summarises some considerations of each method.

CONCLUSION

Whether a patient decides to bolus feed or be fed continuously using a pump, your role as a dietitian is to support them in making the right decision for them, assuming they have the capacity to do so. Discussing the advantages and disadvantages is paramount to ensure that the patient and their family/carers can make an informed decision.

For the majority of patients who are being enterally tube fed, the aim is to try and improve their quality of life to whatever that means for the patient. Regular reviews of the patient and their method of feeding is recommended to ensure that it is not impacting on their quality of life, for example, it may be taking up too much time and the patient may be unable to leave the house.

The products we use to bolus feed a patient vary from ready-to-hang formulas to ONS. In the current market, this may begin to shift as companies focus more on providing a suitable bolus feed product more nutritionally complete than using ONS. This in turn may impact the decision-making process when considering bolus feeding.