In Carson’s case, he will be receiving long-term enteral feeds at home with low likelihood of resuming an oral diet while undergoing cancer treatment. He will benefit from a bolus feeding schedule for increased comfort, improved QOL & to make nutrition optimization feasible with his daily cancer treatment schedule.

Consider finances and coverage of enteral supplies and formulas when choosing an enteral regime for patients being discharged home. Also consider what supports patients may require to administer their enteral feeds if they are not able to be independent with the task.

Carson’s current enteral feeding regime is Isosource 1.2 @ 75 mL/hr × 20 hours for a total of 1500 mL enteral formula. 1 carton of Isosource 1.2 is 250 mL. Therefore, Carson would need 6 cartons/day to meet his needs. This will provide 1800 kcal/day (31 kcal/kg), 81 g protein/day (1.4 g/kg), and 1215 mL free water. Therefore, Carson will require 550 mL of water flushes per day through his G-tube to meet his hydration requirement.

• Current Enteral Regime: Isosource 1.2 @ 75 mL/hr × 20 hours = 1500 mL enteral volume.
• Bolus feeds: 1 carton Isosource 1.2 = 250 mL; 1500 mL⁄250 mL = 6 cartons/day.
• 6 cartons/day = 1500 mL = 1800 kcal/day (31 kcal/kg), 81 g protein/day (1.4 g/kg), 1215 mL free water
• Water flushes: 2065 mL (requirement) − 300 mL (medications) − 1215 mL (free water) = 550 mL

General Plan

Here is a general plan for Carson to transition to bolus feeding while he is in hospital. To be conservative, it is important to estimate that a longer hang time via gravity drip of 1 hour per carton would be required for tolerance. This can be adjusted after assessing for tolerance.

• Proposed Schedule: 2 cartons (breakfast), 1 carton (lunch),  2 cartons (dinner),  1 carton (evening snack)
• Implementation:
  • 2 cartons (500 mL) Isosource 1.2 via gravity drip over 2 hrs at 0600 & 1800 hrs
  • 1 carton (250 mL) Isosource 1.2 via gravity drip over 1 hr at 1200 & 2200 hrs
  • Flush G-tube with 60 mL water pre and post feeds (480 mL)
  • HOB >45 degrees while feeding
• Considerations:
  • This regime does not avoid drug-nutrient interaction with levothyroxine at 0800 hrs; consider changing the administration time of levothyroxine (for example to 1000 hrs).
  • This bolus feeding plan works in the hospital, but Carson will be receiving chemotherapy and radiation therapy from 1200 h to 1430 h daily on discharge. You will need to adjust the proposed regime (i.e. more concentrated formula to decrease volume & changing feeding times) so he can meet his treatment goals.

Adjusted Plan

Here is an example of how you may change the feeding plan to meet Carson’s daily needs/ treatment plan. This new plan would likely work much better for Carson and still meets his estimated requirements. The updated plan should be implemented in hospital to make sure Carson can tolerate it before being discharged home.

• Isosource 1.5 × 5 cartons/day (more concentrated formula = less enteral volume and number of cartons) to provide:
  • 1875 kcal/day (32 kcal/kg)
  • 85 g protein/day (1.4 g/kg)
  • 950 mL free water
• Flushes: 135 mL pre & post feeds × 6 (810 mL) + 300 mL meds + 950 mL free water = 2060 mL/day (35 mL/kg)
• Administration:
  • Levothyroxine at 0600 hrs
  • 2 cartons (500 mL) via gravity drip over 2 hrs + 135 mL water pre/post feeds at 0800 – 1000 hrs
  • Chemotherapy/radiation therapy: 1200 -1430 hrs
  • 1 carton (250 mL) via gravity drip over 1 hr + 135 mL water pre/post feeds at 1500 – 1600 hrs
  • 2 cartons (500 mL) via gravity drip over 2 hrs + 135 mL water pre/post at 2000 – 2200 hrs