Tube Feeding comparison
Birgit Humpert
Since DHMC almost exclusively uses Nestle formulations it is hard to compare different products used
in-house. Nepro is the only formula on the list that is made by Abbott, and it was chosen because Nestle
does not make a comparable product. The formulary list contains eleven tube feeding products, three
modules (protein powder, Nutrisource Fiber, and Glutasolve) and four oral supplements. The RDs
choose formularies according to patient’s needs. Cost is considered in cases when patients are expected
to be on enteral feeding for a long time, especially if they go home with it. For my comparison I used the
example of a patient who came in on a tube feeding and was switched to a different formula while in
the hospital.
Replete is a basic formula with a high protein content that is used often. Due to the high protein content
it is appropriate for many patient with increased needs due to wound healing, after surgery, with
pressure ulcers, or other catabolic processes. Due to low osmolality it is used for J-tube feeding as well
as G-tube feeding, and generally well tolerated. It comes flavored and could be used as an oral
supplement.
Patient: 63 year old male with history of small-cell carcinoma of tongue base, had mandible resection
and reconstruction of the plate. Due to dysphagia he became entirely dependent on a g-tube 5 years
ago. He started developing osteoradionecrosis a few years ago and developed a fistula 8 month ago. He
is admitted for additional surgery. He is a long-term G tube user and gets 2 cans of Jevity 3 x day at
home. At the time when recommendations for tube feeding are requested it is unclear which Jevity he
has used at home.
177.8 cm, 69.9 kg, BMI of 22.1, IBW 75.5 kg
Labs: Na 137, K 4.4, BUN 12, creatinine 0.75, ca 0.8, PAB 11
Needs: 1890 -2265 kcal (25-30 kcal/kg), 151 g protein (2 g/kg protein), Fluid ~ 2100 ml (30 ml/kg)
Initial TF recommendation at DHMC:
Replete 85 ml/h over 24 h + 4 scoops protein powder
At goal this provides 2140 kcal, 151 g protein, 1683 ml free water (+200 ml for mixing protein powder –
50 ml per scoop), and 100% of RDA for vitamins and minerals. (Fluid requirements are not a big concern
at this point because he is on IV fluids).
Boluses: 5 x 400 ml + 4 scoops protein powder (flush with30 ml before/after each feed) + 4 scoops
protein powder with about 50 ml water per scoop.
At goal this provides 2100 kcal, 149 g protein, 2190 ml free water and 100% of RDA for vitamins and
minerals.
At home the patient would like to switch back to Jevity since he still has a big supply. Prior to admission
he used 2 cans of Jevity 1.5 3 times per day with 180 ml water flushes pre and post each feeding. This
would give him 2130 kcal, 91 g protein (1.3 g/kg), 2160 ml fluid. Due to his low BMI and PAB there is
concern that he would not get enough protein for wound healing from his usual regime. It was
recommended that he adds 8 scoops of protein powder per day. This would increase his calorie intake
to 2330 kcal and his protein intake to 138 g (2 g/kg). Since he would get 400 ml free water from mixing
protein powder he can reduce his water flushes to 120 ml pre and post each feeding.
Cost comparison:
Replete
Replete + protein
powder*
$ 20.67
Cost per day if
$ 18.67
bought through
company web site
Cost per day if
$ 12.67
$ 14.11
bought on amazon
*Beneprotein, price from Nestle web site used
Jevity 1.5
$ 14.25
Jevity 1.5 + protein
powder*
$ 18.25
$ 11.25
$ 14.13
With the need for additional protein (if he would buy it himself) Replete and Jevity 1.5 come out at the
same price if bought online at amazon. Replete is initially more expensive but he would need less
protein powder to meet his needs.
Summary:
Replete is the appropriate formula from the available choices for patients like the one described above
at DHMC who have increased protein needs. The patient would also be able to use this at home.
Jevity 1.5 is a better product for this patient at home because it costs about the same as Replete even if
he uses more protein powder (he might be able to decrease the protein over time when his wounds and
fistula are healed). But unlike Replete it gives him 31 g of fiber per day which would greatly benefit his
gastrointestinal health and immune function.