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Crohn's Disease Forum » Treatment » Enteral Nutrition & TPN » About Enteral Nutrition, Elemental Nutrition, and Total Parental Nutrition


10-06-2011, 05:44 PM   #1
DustyKat
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About Enteral Nutrition, Elemental Nutrition, and Total Parental Nutrition

Enteral/Elemental Nutrition (EN)

Elemental is general term used to cover liquid diets. They are considered to be a complete diet and are designed for a person to survive long term without any food intake. These types of diets are used for a number of reasons in Crohn's Disease and include the following:

- Research has shown that these type of diets are as effective as steroids at inducing remission. They are therefore a viable alternative and do not have the associated side effects that steroids do.

- As a treatment to reduce symptoms prior to surgery.

- As bowel rest as they put no stress on the digestive system.

- As part of a continued maintenance program when in remission.

- To assist with weight maintenance or gain.

- They may become an integral part of a persons nutritional intake if extensive surgery has been performed and the ability to digest food has been compromised.

Modes of Delivery:

Elemental - Generally refers to an oral liquid diet but there is crossover between this term and elemental. The types of products used include Boost, Ensure, Carnation Instant Breakfast Drink, Fortisip, Osmolite, Modulen.

Enteral - Refers to the delivery of a liquid diet via a tube - naso-gastric, naso-jejunal, naso-duodenal, tube feeding, gastrostomy feeding or jejunostomy feeding.

Liquid Supplements
*Please note - The following are a sample of what is available. They may not be available in all countries or they may be marketed under different names. Full lists of available products can be found by going to the manufacturers websites in your country of origin. Manufacturers include Abbott, Nestle and Nutricia.

Peptamen or Peptamen Junior for kids Contains protein that has been partially broken down, making it easier to absorb. This may be useful if portions of the digestive tract are inflamed or have been removed. This formula also contains MCT oils that are absorbed more easily, decreasing the undesirable effects of fat malabsorption (diarrhea, gas and bloating). This formula is not highly concentrated, which also may help decrease diarrhea. An 8 ounce ready-to drink can provides 240 calories, 10 grams protein; made by Nestle. Recommend adding flavor packets to improve palatability.

Peptamen 1.5 Same composition as Peptamen but offers more calories per can. An 8 ounce ready-to-drink can provides 360 calories, 16 grams protein; made by Nestle.

Modulen IBD A mild formulation, which may help control diarrhea. It also contains a growth factor which may decrease inflammation. It contains MCT oil for better absorption of fat. An 8 ounce serving made from powder provides 240 calories, 9 grams protein; made by Nestle.

EnLive! Useful for nutrition before surgery, fat malabsorption, lactose intolerance and gluten sensitivity. This is a clear liquid supplement that is a good source of protein and calories. An 8 ounce. ready-to drink box provides 300 calories, 10 grams protein; made by Ross.

Lipisorb High in MCT oil, which is an easily absorbed form of fat -- useful for fat malabsorption. An 8 ounce ready-to drink can provides 325 calories, 14 grams protein; made by Mead Johnson.

Subdue Partially broken down protein plus MCT oil for better absorption of fat. An 8 ounce ready-to drink can provides 240 calories, 12 grams protein; made by Mead Johnson.

Vivonex May be indicated for severe problems with absorption. This formula is very low in fat and is "elemental" or contains completely broken down protein, so the intestines can absorb nutrients easily. An 8 ounce ready-to drink can provides 240 calories, 11 grams protein; made by Novartis
VivonexPlus: is available in unflavoured 79.5g (2.8 oz) sachets that you add water to. Once mixed it can be left at room temperature for up to eight hours. (Although most formulas taste best well-chilled). It is manufactured by Nestle in the U.S. and available in Canada.

Optimental This product is also elemental (completely broken down proteins) and contains MCT oils for easier absorption. It is lactose free and contains high levels of antioxidants. An 8 ounce ready-to drink can provides 237 calories, 12 grams protein; made by Ross.[1]


Total Parental Nutrition (TPN)

Total parenteral nutrition is another way of supplying all your nutritional needs. The nutrients are given directly into the bloodstream via a vein. This intravenous feeding generally is reserved for people who are unable to digest food or are severely malnourished. People with severe inflammation not responsive to medications, complications from Crohn's disease such as fistulas, or a very small amount of bowel left that is insufficient to digest and absorb food may also receive TPN. [2]

This can also be used pre surgery to rest the bowel and pre and post surgery to maintain/build weight.

Outcomes

Although, in many cases, EN is as successful as steroids at inducing remission research indicates that it does have high relapse rates once ceased as a treatment. As a result it is recommended to have other interventions in place to increase the chances of maintaining remission over a longer period of time.

Interventions may include one of the following:

- Continuing EN at a reduced rate in combination with a normal diet.

- Introduction of an immunosuppressant type medication.

- Use of the Elimination Diet.


Since I am far from an expert on this anyone please feel free to edit as they see fit. I don't have much knowledge on the products used either.

References
[pos]1a[/pos][1] http://www.ucsfhealth.org/education/...bowel_disease/
[pos]2a[/pos][2] http://www.emedicinehealth.com/diet_...e/page8_em.htm
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Last edited by DustyKat; 10-10-2011 at 02:40 PM.
10-06-2011, 06:52 PM   #2
happy
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Dusty,
Thanks for doing this. This is a great start. I think that you meant to say that "they do not have the associated side effects that steroids do."

I also think that a statement needs to be made that most research shows that many people relapse when they return to normal eating unless they continue with a partial EN diet, LOFFLEX diet, or full elimination diet.

I am not sure about including TPN in this thread. TPN is not usually an 'elective' or 'alternative' treatment like EN. TPN does have potential serious side effects that EN does not have. These include risks from having an IV, such as infection and thrombosis, and from TPN itself, such as liver and kidney problems that are potentially very serious--even fatal. (You can find this info on Wikipedia which I know is not always reliable, but the same info can be found on other reliable 'medical' sites as well.)

To avoid confusion, if a reference is made to TPN in this thread, I think that a statement should be made that TPN is not the same as EN and that TPN can have some very serious side effects.
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Enteral Nutrition induced remission in August 2011
Maintaining remission on Full Elimination Diet
10-06-2011, 07:01 PM   #3
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Just a couple of notes to Dusty's post...

1. Point 1 - a viable alternative and do **NOT** have the associated side effects that steroids do

2. In the list of products for Enteral - the few patients I know of at the children's hospital in Toronto all use Tolerex.

Perhaps, just for info/interest, Stephen's GI gave me an explanation of the 'why' enteral diets work. The info could be added in...

While TPN gives the benefits of nutrition, weight gain and bowel rest, studies showed that patients receiving TPN did not maintain remission at the same rates as those treated with Enteral (and, I suppose, Elemental) diets. The GI explained that they realized this was because by continuing to 'feed' the intestinal system, the 'good' bacteria was actually being strengthened and was able to fight unhealthy bacteria and repair intestinal damage. The maintenance period then maintains the strength of the 'good' bacteria thereby maintaining remission. Treatment by TPN did not allow for this benefit.

Patients who are brought into remission through steroids and then put on maintenance Enteral therapy showed lower rates of success in maintaining remission. This is believed to be due to the initial exclusive period of EN which allowed the 'good' bacteria to reach a certain strength. By introducing the enteral therapy after remission, the 'good' bacteria may not have strength to maintain remission.

Note, though, that maintaining remission successfully through EN (regardless of whether EN was used to induce remission) is not as successful as with other medications.

(Sorry, a very 'layman's' explanation - feel free to polish it up!)
10-06-2011, 07:03 PM   #4
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Oh, and David, you were asking who has been on EN. I have been on it twice this year: once for four months and then again for two weeks. I am currently (9 weeks and counting) maintaining remission with a full elimination diet following EN.
10-06-2011, 09:09 PM   #5
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Oh, and David, you were asking who has been on EN. I have been on it twice this year: once for four months and then again for two weeks. I am currently (9 weeks and counting) maintaining remission with a full elimination diet following EN.
Can you elaborate on what you do with the full elimination diet? Thanks
10-06-2011, 10:28 PM   #6
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DustyKat,
Ok, I'll give TPN a whirl. Someone will need to edit, though. I'm not very good at formatting.

Total Parenteral Nutrition (TPN) is not to be confused with Elemental/Enteral Nutrition.

TPN is a special formula given to people whose digestive systems cannot tolerate any type of food (neither liquids nor solids). Instead, the formula is given into the body through a needle inserted into a vein (an IV). There are risks to using this type of nutrition because of 1) the use of an IV can cause infections and blood clots (that can be fatal) and 2) the complex balance of electrolytes, nutrients and fluid volume that the body requires is easily upset so serious (even fatal) liver, gallbladder, kidney, bone and blood sugar problems can develop.

People using this method of nutrition need to be closely monitored by their health professional.

Hope this helps. the sources I used are The Merk Manual: http://www.merckmanuals.com/professi...n.html#v883517 and the Mayo Clinic: http://www.mayoclinic.org/home-tpn/about.html
10-06-2011, 11:16 PM   #7
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David,
A full elimination diet that follows a course of EN is meant to maintain the remission that the EN has induced. The idea is that you gradually reduce the amount of formula while slowly reintroducing food. Once the amount and nutrition of the solid food is adequate and you are still maintaining remission while mostly eating solid food, the formula is stopped. (Some people choose to continue partial EN to maintain remission.)

The full elimination diet that I am following is described in Dr. John Hunter's book, " Inflammatory Bowel Disease". Basically, once in remission from EN, you start eating one food, gradually increasing the amount of that food over several days until you are eating normal servings of that food. If you develop symptoms over the course of time that you are reintroducing the food, it is assumed that the food is the cause and you remove the food, go back to EN solely until you are symptom-free (usually a few days) and start again with the next food, leaving off the symptomatic food until the end of the process when you re-introduce that food again.

Some foods are restricted in the amounts that can be eaten because it is known that they cause problems for people with IBD. For example, fruits and veggies (cooked, skinless, without seeds or stalks) are limited to two servings each per day. Later in the process these types of foods can be increased to see what amount of fibre in these foods a person can tolerate. Fats in any form and fibrous foods (legumes) are limited; many common allergens are left until the end of the elimination (grains other than rice, dairy products, tree nuts, seeds, citrus foods).

So, what does it look like? I started with rice, followed by: chicken, pears, carrots, soya milk, soya margarine, peas, potatoes (including sweet), olive oil, egg whites, honey, stone fruits, white fish, rooibos tea, small amounts of well-cooked chard (no stems) and very small amounts of good quality chocolate with no dairy and only cocoa mass and cocoa butter and sugar. (I gotta enjoy life) It has taken me 9 weeks to be able to eat all of these foods.

It is a challenge to eat like this, especially while travelling and while eating out; however, it is worth is to me. By remission I mean that I live a relatively normal life except for my energy level as I am still malnourished from being ill for so long, although I am improving. I do have frequent digestive issues as I try new foods, so I add slowly. I am also still losing weight although this is tapering off (I was obese before-now I am in the mid-normal range.)
10-07-2011, 01:55 AM   #8
DustyKat
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Here are some links you might find useful David:

This site gives a good overview of EN, types of formulas, why it is used and the pros and cons of each method:

http://www2.kumc.edu/pharmacy/Nutrit...ion%20(EN).pdf

I think Abbott and Nestle are the two main manufacturers of EN products.

Abbott brands are listed on the left of the site:

http://abbottnutrition.com/our-products/brands.aspx

Nestle brands:

http://www.nestle-nutrition.com/Products/Default.aspx

Nestle also has a separate site for Modulen IBD:

http://www.nestlenutrition.com/en/nu...se_product.htm

This lists the Nestle products specific for IBD:

http://www.nestle-nutrition.com/Prod...8-65da544aba87

Nutricia is another manufacturer.

Oral nutrition supplements:

http://www.nutricia.com.au/clinical/...pplements.aspx

Malabsorption supplements:

http://www.nutricia.com.au/clinical/...bsorption.aspx

Sometimes David the choice between oral and enteral is simply down to being able to tolerate the taste.

Dusty.

Last edited by DustyKat; 10-07-2011 at 06:53 PM.
10-07-2011, 04:26 AM   #9
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Sorry, had to leave off...

Also David, you will find that the enteral preparations can differ quite significantly in their makeup to the oral ones.
10-07-2011, 06:40 PM   #10
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I added a load of info on some of the various liquid supplements to the OP. I'm missing plenty Feel free to reply with info to add!
10-08-2011, 01:49 PM   #11
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Thank you guys for doing this!!
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Dx'd Crohn's April 1996
Bowel Resection w/appendectomy Oct 1996
Gallbladder removed Nov 2005
4 procedures in March/April 2010 to remove a kidney stone
Dx'd Dyshidrotic Eczema April 2011
Dx'd Pancreatitis July 2011
2nd bowel resection 10/12/11 - I have 130cm of small intestines left!
Dx'd Chronic gastritis April 2012

Currently taking:
Cholestyramine powder 1-2x daily
Remicade 5mg/kg every 8 wks
Vitamin D3, B12
10-08-2011, 06:10 PM   #12
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David and DustKat,
We could add that not all formulas are available in every country.

Also, VivonexPlus, which is what I use, is available in unflavoured 79.5g (2.8 oz) sachets that you add water to. Once mixed it can be left at room temperature for up to eight hours. (Although most formulas taste best well-chilled). It is manufactured by Nestle in the U.S. and available in Canada.
10-08-2011, 08:42 PM   #13
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Done.

Let me know if there are any issues with the latest editing.

Dusty. xxx
10-09-2011, 10:37 AM   #14
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Thanks DustyKat.
10-09-2011, 10:43 AM   #15
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We probably should add a statement that many people relapse once they resume eating solid food so they choose to continue supplementing with EN or to follow a partial or full elimination diet when they resume eating, in order to maintain remission.
10-10-2011, 05:51 AM   #16
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Done.

Please don't hesitate to tell me if I have anything wrong!

Dusty. xxx
10-10-2011, 02:11 PM   #17
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Hi DustyKat,
Thanks again for sticking with this. You inadvertently dropped the 'i' from immunosuppressant.
10-10-2011, 02:40 PM   #18
DustyKat
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Corrected.
11-09-2011, 02:01 PM   #19
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Thank you all for this information! I have my first appt next week to talk about what to do, so this is def going to be mentioned.
01-11-2012, 12:05 PM   #20
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Hi, thanks for starting this forum...a posted back where I posted my first EN thread back in the fall...

Ben did EN as primary therapy for his Crohn's (esophageal, stomach, small bowel, large bowel) starting via NG tube which was taped to his face for 8 months...he started on 90% of calories formula and eat what he wanted to 10%...he used to eat a bit of dinner. He was 6, and it was hard walking around and going to school with the tube on his face.

Our hosp. in C-bus OH wouldn't place a g-tube cuz of his gastric crohn's so we switched to #1 in US Cincy Children's and they did place a PEG tube. Ben is still doing EN at night, now it is about 60% of his calories, he stopped tolerating 100%. He was rescoped last week and also did his first pill cam, (which got stuck...is there a forum for tests?) and there has been lots of healing everywhere but small bowel - which is not eligible for resection due to extensive inflammation. He starts remicade on Friday.

So we are done with EN, but I recommend young crohnies trying it, for healing, weight and height gain and a med vacation, which will be few and far between over their lifetimes.....

It is labor intensive, and kept Ben in pullups, and me needing to change all bedding every day. So, it is with mixed emotions that we say farewell to EN..at least for now!
01-11-2012, 02:18 PM   #21
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Thanks for the update and information!

It's good to know that the EN has been mostly successful but I am sorry to hear that his small bowel is still giving him problems. I hope the Remicade is as successful! Good luck to you and your boy!...

And no there is no specific testing forum, hmmmm, may be something to think about!

Dusty. xxx
01-11-2012, 02:31 PM   #22
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And no there is no specific testing forum, hmmmm, may be something to think about!
Indeed. I like the idea.
01-11-2012, 04:51 PM   #23
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Hi Again,

I was looking at this forum and thought of a few things to add...Ben's Crohn's is heavily in his small bowel and he needed growth catch up so he was a good candidate for this treatment. And I was scared to death to start him on remicade....

He started out on 90% of calories 2 years ago, which was 7 cans of 1 calorie Pediasure (Abbott Labs)...so 1680 calories per night...this was the formula that got Ben into a remission the first couple of months..

We tried to adjust over the 2 years for labs (his albumin - protein levels are chronically low, so we tried supplementing with protein, which I learned was the culprit to several episodes of nausea and vomiting next day. I think his small bowel was getting overloading with protein that it couldn't absorb or pass so it went back the other way?

We also tried to shorten the time it took to administer the feeds...by switching to various amounts of 1.5 calorie pediasure...he could never tolerate more than 3 cans per night...again, too much protein?? Also, he has a tendancy to be constipated so most nights I added Miralax + water, and we also switched to pediasure with fiber formula.

In the end, in a last attempt to get him back into remission, we had him on 100% calories (about 1800 via formula) but he still snacked a bit at dinner time on food, and then he started being sick next day on this regimen. So, had to cut back on it and realized he just can't tolerate EN as primary therapy anymore.

I have always had the feeling that the prescribed amount of calories wasn't enough as kids with Crohn's need more calories for all the inflammation going on..just as calories are adjusted and increased for trauma and burn patients.
08-17-2012, 05:04 PM   #24
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HI , I have a question. My son is taking Ultra Clear Sustain. How does that compare to the other elementals?
02-16-2013, 09:06 PM   #25
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xx

Last edited by itsme2; 05-05-2013 at 02:53 PM.
04-27-2013, 02:26 PM   #26
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Anyone know which tastes the best for kids and which doesnt have the unwanted items in there like carageenan? Thanks
06-04-2013, 07:09 PM   #27
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Hi All,
I too am curious which one's would be best suited to oral supplementation as opposed to the naso-gastro tube.
My son is newly dx crohn's, mostly small bowel. Experiencing malabsorption, malnutrition, and on Remicade. I mentioned the supplemental EN to his GI but he brushed it off saying it wouldn't be palatable enough and wouldn't be effective. I want to try it to help him get back on his feet. A little nutritional boost couldn't hurt. all the GI would suggest was over the counter Boost or Pediasure. I suspect these are not adequately absorbed.
I won't accept the GI's conclusion before even giving EN a try, but finding the right one would make the attempt more successful...

Thanks
06-04-2013, 07:25 PM   #28
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Hi lilikoi and

We haven't really done EN at our end but I will link you to the parent's forum:

http://www.crohnsforum.com/forumdisplay.php?f=49

and then to the kids on EN thread:

http://www.crohnsforum.com/showthread.php?t=36345

There are loads of fab parent's hanging out there that have experience with EN, both orally and via NG and they will be able to advise you on the breakdown of the different formulas.

I will leave your post here but you might like to also post this question in the parent's forum.

Unfortunately the US isn't as big into EN as other countries are. EEN (Exclusive Enteral Nutrition) can be just as successful at inducing remission as steroids in children. You will find that most using it as a first line treatment do EN exclusively, so no food, for about 6-8 weeks. Others don't use it exclusively but in line with other treatments and lastly it is used as a supplement to assist with weight gain and growth.

Welcome aboard!

Dusty. xxx
09-05-2014, 05:29 PM   #29
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I have recently been diagnosed with CD after requiring massive blood tranfusion, but I think that I have had it for a number of years. I had UC until 1999 and had J-Pouch constructed. Does anyone know if elemental diet supplements in powder form are available in Australia? I know that I can order from the US but am curious what is available locally. Thanks. Loffy.

Last edited by lofenoxal; 09-05-2014 at 05:30 PM. Reason: wording
03-12-2015, 11:05 PM   #30
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Hello. I have a question DustyKat, you mentioned several interventions under Outcomes. Will you consider the SCD diet as an intervention?
Thank you
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