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Short Communication: Gastroenterology

Unexpected Poor Growth in Pediatric Patients on Food-based Enteral Therapy: Case Series and Suggested Practice Changes

David, Jennie; Huston, Parker; Manville, Kaylee; Burdo-Hartman, Wendelin; Kaiser, Sarah; Arand, Brian; Hockaday, Maureen; Rosenston, Lauren; Sejkora, Ellen; Dempster, Robert

Author Information
Journal of Pediatric Gastroenterology and Nutrition: November 2021 - Volume 73 - Issue 5 - p 599-603
doi: 10.1097/MPG.0000000000003256


What Is Known/What Is New

What Is Known

  • Pediatric patients with significant feeding challenges may receive enteral feeding therapy by feeding pump to ameliorate nutrition, growth, and overall well-being.
  • Previous research has identified concerns for feeding pump accuracy in delivering enteral feeding therapy.

What Is New

  • Pediatric patients with significant feeding challenges may display unexpected and poor growth on enteral feeding therapy related to feeding pump inaccuracies, particularly pediatric patients receiving food-based formulas.
  • This is of significant concern for potential harm to this population that may result in poor nutrition, growth, or overall well-being.
  • Clinical recommendations from the authors’ collective experiences are offered to identify and improve unexpected and poor growth in this population.

Enteral feeding therapy is a common treatment for pediatric patients with oral feeding difficulties to ameliorate deficits in nutritional intake. Research on enteral feeding pump accuracy has identified up to 14% discrepancies between the set feeding rate (eg, X ml/hour) and the amount of formula actually delivered by the pump (1,2). For context, a child who is prescribed 1000 calories per day by enteral feeding may only receive 860 calories, resulting in poor growth and nutrition despite appropriate adherence to the treatment regimen., Clinicians are presently unable to verify the nutritional intake actually delivered to a child via an enteral feeding pump. In pediatric patients, weight gain is frequently used to monitor caregiver adherence to the treatment plan, malnutrition status, and overall well-being. Consistently poor weight gain in a child using enteral feeds may give rise to concerns about caregiver nonadherence, which occasionally escalates to suspicion of medical neglect and involvement of child protective services. Issues cited above regarding feeding pump inaccuracy may, however, influence the weight gain of children regardless of parent follow-through (1,3). Although this concern has been identified in the literature for over 20 years (4,5), few options are available for ensuring accuracy in enteral feeding care, and no current guidelines exist to ensure reliable delivery of necessary calories and nutrition for pediatric patients using enteral feeding pumps.

Recently, novel commercial formulas have become available for use with enteral feeding pumps. Food-based formulas have been prescribed but not adequately studied for their suitability and compatibility with existing feeding pumps, which have been designed and calibrated exclusively with liquid formulas (6,7). These food-based formulas are often most beneficial for reducing vomiting and reflux in a subset of children reliant upon enteral feeding (8,9). Food-based formulas, however, differ in viscosity from standard formulas, possibly exacerbating feeding pump inaccuracy (10).

The present article reviews 2 complex pediatric feeding cases, which engendered concerns for the accuracy of enteral feeding pumps while receiving food-based formulas. We also propose potential changes to common practice standards to minimize risk to patients while using these important therapies to improve growth and development.


Team members reviewed charts to identify patients receiving enteral nutrition via feeding pump for the previous 12 months and who were followed in a multidisciplinary feeding clinic through a large Midwestern Children's Hospital. Relevant data, such as enteral formula type, feeding pump type and rate, and anthropometric information were extracted. Initial results are presented below. Data from the retrospective chart review are analyzed by descriptive statistics and review of growth charts by weight (percentile and z score).


Retrospective chart review identified 5 complex pediatric feeding patients in the past 12 months who demonstrated unexpected failure to gain weight while on enteral feeding interventions and using an Infinity feeding pump. Participants were between 2 and 14 years of age (M = 5.2, SD = 4.97) and were 40% girls (n = 2) and 60% boys (n = 3). Patient medical histories, type of formula, and type of feeding tube can all be found in Table 1. All participants were found to have been transitioned to food-based enteral therapies because of tolerance concerns, such as vomiting, or family preference. Standard of care was to transition patient to a food-based formula at the same caloric estimates given sensitivity and tolerance concerns in this population. All parents received extensive training in administering feeds via Infinity pump with observation from the team to ensure parents had appropriate skills, including education on providing the goal volume of the feed plus 15 mL for priming. Two of these cases are summarized here and are representative of this cohort of patients who displayed unexpected and poor growth.

TABLE 1 - Description of the 5 patients with noted poor growth on food-based formulas
Patient ID Gender Age, years Formula (s) Feeding pump Medical history
1 Female 3 Compleat Pediatric Organic Blends; Nourish Infinity Pump Cardiac defects, hydrocephalus, agenesis of corpus callosum, septo-optic dysplasia, microcephaly, intrauterine growth retardation, perinatal hepatitis C exposure, congenital hypothyroidism
2 Male 4 Compleat Pediatric Organic Blends Infinity Pump Bilateral cleft lip and palate (repaired), multiple congenital anomalies, Patent Ductus Arteriosus (repaired), ventricular septal defect, pulmonary stenosis, global developmental delay
3 Male 14 Nourish; Compleat Pediatric Organic Blends Infinity Pump Tracheoesophageal fistula, congenital diaphragmatic hernia (repaired), esophageal stricture, chromosomal abnormality, gastrointestinal dysmotility, GERD, moderate intellectual disability, dysphagia, Nissen, asthma
4 Female 2 Compleat Pediatric Organic Blends Infinity Pump Tetralogy of Fallot (repaired), cleft palate microcephaly, supraventricular tachycardia, 4q35.2 deletion
5 Male 4 Compleat Pediatric Organic Blends Infinity Pump Cerebral palsy and dysphagia

Patient 1, a 3-year-old girl, was born prematurely at 29 weeks gestation, and has a pertinent history of multiple cardiac defects, hydrocephalus, agenesis of corpus callosum, septo-optic dysplasia, microcephaly, intrauterine growth retardation (IUGR), congenital hypothyroidism, shunt, spastic quadriplegic cerebral palsy, epilepsy, dysphagia, and global developmental delay. This child presented to the feeding program for evaluation at 10 months of age with oral hypersensitivity and vomiting. There were many attempts to reduce her vomiting via medications and changes to her feeding regimen, including manipulation of caloric density, feeding volumes, and changes of formula composition. The decision was made to switch her to a commercially available food-based formula (Compleat Pediatrics Organics Blend). The child's weight fell precipitously after the formula transition, with no reports of illness or tolerance issues. The caregiver reported concerns of child's hair loss. Prescribed feeding volume was increased because of the weight loss but did not improve the outcome. The child was subsequently switched to another food-based formula (Nourish) because of manufacturer supply issues but appropriate weight gain was still not achieved. After further increase to prescribed formula volume, the child continued to show weight loss and there were concerns of leftover formula in the bag, despite the caregiver having measured out the correct amount before each tube feeding. The parents ran a self-test at home with pump rate set to 300 mL/hour and volume set at 150 mL. Each time, the pump only delivered 105 mL (delivering 630 kcal/day at 64 kcal/kg instead of the recommended 900 kcal/day at 90 kcal/kg) into the measuring cylinder. On the basis of these controlled trials, the dietitian recommended a transition to 20% of the feed to be a liquid 1.5 kcal/ounce formula (Kate Farms Pediatric Peptide 1.5). Additional trials were completed following this change, and revealed only 130 mL of the expected 150 mL were delivered. Further adjustment was made to the proportion of Kate Farms formula in the mixture to 4 oz Compleat Pediatrics Organic Blend with 1½ oz Kate Farms Pediatric Peptide. The child was then noted to have expected weight gain. Her caregiver reported she was receiving the recommended volume from the pump as noted by the feeding bag emptying. Patient 1's growth chart can be found as Figure 1; of note, this child's growth chart is displayed using cerebral palsy growth curves (11).

Patient 1's growth chart.

Patient 2, a 2-year-old girl, was born at 35 weeks, 6 days, and her mother's pregnancy was complicated by oligohydramnios and late intrauterine growth restriction. This child had Tetralogy of Fallot, cleft palate, microcephaly, 4q35.2 deletion, and developed supraventricular tachycardia shortly after birth. She had her Tetralogy of Fallot repaired at 4 months of age. She struggled with feeding and poor growth and a gastrostomy tube was placed at 8 months of age. She tolerated enteral feeds well. The child was growing well on a nonfood-based formula (Similac Prosensitive), and was eating small amounts of pureed foods.

The family expressed a desire for transition to a homemade blended formula and was transitioned to a commercially available food-based formula, Compleat Pediatric Organic Blends. She was not tolerating bolus feedings at the time and was fed via pump. At her next visit, the child's weight had decreased, without any notable illnesses or changes to her feeding plan other than the new formula. Despite adjustments made by the child's dietitians, weight continued to decrease over several months. After discovering several other patients with similar case histories, concerns for volume inaccuracy were raised. She was prescribed 140 mL of formula 4 times per day, though her pump was found to only be delivering 100 mL per family report (delivering 480 kcal per feed instead of the recommended 672 kcal per feed). The child's target volume on the pump was adjusted to 180 ml to correct this error and ultimately deliver the desired 140 ml. Over the next 6 months, the child's target feeding volume was increased gradually through changes to the setting on the feeding pump; however, the child's growth trajectory did not match the increase in prescribed calories. Only when she began to make progress with oral intake in feeding therapy did she gain weight as expected. Patient 2's growth chart can be found as Figure 2.

Patient 2's growth chart.

The unexpected growth patterns of these 2 complex pediatric feeding patients were associated with changes between food-based and nonfood-based formulas delivered via feeding pump. Patients were found to have changed to food-based enteral formulas shortly before issues began. A further change in nutrition source, either a different formula or increased oral intake, helped to resolve the issues, but not before both patients and their caregivers endured months of frustration and malnutrition. In 1 case, costly medical testing was undertaken to understand the disparity between supposed calorie intake from enteral feedings and lack of expected growth.


Pediatric feeding patients may display unexpectedly poor growth while receiving food-based enteral feeding interventions. The 2 patients outlined above demonstrate this phenomenon while receiving food-based formulas through enteral feeding pumps, and the various efforts of their respective families and medical teams to identify and ameliorate these challenges.

The outlined concerns are notable for the potential harm to this patient population. Consequently, it is vital for providers to be aware of these challenges for timely intervention. On the basis of the authors’ collective experiences in managing these challenges, the following recommendations are provided:

  • 1. Recommend administering tube feeds via bolus syringe instead of feeding pump whenever possible for food-based formulas to ensure the full volume is delivered.
  • 2. Suggest placing desired volume, plus priming, into feeding bag at each meal to allow visual comparison at the end.
  • 3. If needed, collaborate with families to adjust dose of the feeding pump to achieve the desired amount of formula delivered if there are known differences between pump setting and formula delivery. This involves trial and error and may not be appropriate in all situations.

Our findings highlight a possible interaction between food-based formulas and feeding pump accuracy, such that patients who transition to these formulas may be at risk for unexpectedly poor weight gain. This is a critical concern for complex pediatric feeding patients and may be engendering harm because of malnutrition and family stress. Future research should evaluate the medical outcomes of complex pediatric feeding patients receiving enteral therapy and identify interventions to increase the accuracy of formula received for weight gain and overall health.


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enteral feeding therapy; pediatric feeding; feeding pump

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