The History of Enteral Nutrition Therapy: From Raw Eggs and Nasal Tubes to Purified Amino Acids and Early Postoperative Jejunal Delivery

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Abstract

Although enteral feeding therapy has existed since ancient Egypt, most of the major advances in enteral feeding techniques and formulas took place during the 20th century, including postpyloric tube placement in 1910; continuous and controlled delivery of liquid nutrition in 1916; feeding during surgery and modification of macronutrients in 1918; feeding via a pump in 1930; recognition of the importance of nutrition therapy during injury recovery and the addition of micronutrients and early postoperative feeding in 1940; the introduction of commercial products during the 1950s with chemically defined formulas following a decade later; and the development of modern formulas during the 1970s. The purpose of this review is to provide a historical account of enteral nutrition, including modes and routes of delivery, types of diet, and refinements in delivery techniques and formulas and to offer the history of the therapy as a resource for developing and improving enteral feeding techniques and therapies and implementing optimal patient care strategies. J Am Diet Assoc. 2002;102:399-404.

Section snippets

Early Nasal And Gastric Feeding

In the literature from the 18th and 19th centuries, reports of gastric feedings include use of a variety of mixtures of foodstuffs and many devices to deliver the feedings. The most popular device was a long tube with a funnel or syringe attached to the outside end. Some physicians, particularly to treat children and patients with so-called nervous afflictions, prescribed gastric feedings. Hunter is reported to be the first physician to use an orogastric tube made of a whale bone probe covered

Rectal Feeding

There was debate during the 1800s about the use of gastric feedings vs rectal feedings. Some practitioners attempted rectal feeding only if gastric feeding was not feasible, whereas others believed that colonic absorption through reverse peristalsis could support a patient's nutrition needs. Rectal feeding devices evolved from a piece of pipe with a bladder tied to one end used by Hippocrates, to long pieces of rubber tubing attached to funnels or wooden syringes (1). Jones-Humphreys (9), in

Small Bowel Feeding

The rectal route was used to administer water, saline, and glucose solutions until 1940, although the preferred route of enteral nutrition support had turned to gastric delivery by the early part of the 20th century (1). The main problem with orogastric feeding was intolerance to the feeding. In 1910, Einhorn (1) solved this problem by inserting a small weighted, rubber nasogastric tube and letting it pass into the duodenum. He fed 3 patients via his duodenal tube every 2 hours with a mixture

Jejunal Feeding

Jejunal feeding was introduced shortly after duodenal feeding. In 1918, Anderson (16) reported passing a tube into the jejunum during surgery and feeding a solution of 200 mL peptonized milk, 15 g dextrose, and 8 mL whiskey. This regimen continued every 2 hours postsurgery to reach 2,500 kcal in 24 hours. He suggested that the feeding mixture “may contain whiskey, coffee, or other stimulant as required for immediate stimulating effect.”

During World War II, physicians in the Soviet Union related

Introduction Of Modified Macronutrients

The Stengel and Ravdin feeding solution consisted of a sterile mix of acidified skim milk, commercial pepsin, sodium bicarbonate, sodium chloride and dextrose (19). In addition, these researchers promoted adding 1 cc viosterol offish liver oil, 20 mg thiamin chloride, 50 mg nicotinic acid, and 100 mg of vitamin C as tolerated.

In 1939, Stengel and Ravdin designed the first casein hydrolysate. Their subsequent studies used a peptone hydrolysate supplied by Merck and Company (Whitehouse Station, NJ)

Research On Enteral Nutrition And Patient Outcomes

Co Tui et al published research on the role of enteral nutrition relative to patient outcome in 1940 (20). They treated 8 patients with high-energy jejunal feedings started 2 hours postsurgery. The patients were given a casein hydrolysate and maltodextrose solution that supplied greater than 50 kcal/kg and 0.6 g nitrogen/kg. The patients fed the high-energy solution gained weight, maintained positive nitrogen balance, and remained in bed for half the time of the controls, who were given

Commercial Formulas Are Developed

As procedures for producing commercial enteral products were refined by companies such as Mead Johnson and Wyeth-Ayerst, the debate about the best type of tube-feeding solution was escalated. Many different feeding mixtures, including homogenized solid food substances, combinations of supplemented dairy products; and elemental food substances in sterile, sealed containers were being used.

In 1954, Pareira et al (26) contributed to the debate by publishing the results of a large study of their

Hospital Kitchens Prepare Enteral Products

In 1953 and 1956, Barron and colleagues at Henry Ford Hospital (Detroit, Mich) published a series of papers on enteral feeding 27, 28, 29, 30. Barron advocated the use of tube feedings made in hospital kitchens as better tolerated, more medically sound, and more cost-effective than commercially prepared formulas. According to Barron and Falls (29), “accumulating evidence stresses more and more the complexity of nutritional needs of the human body.... Up to the present time, we know of no

The Development Of Chemically Defined Formulas

Two important events directed enteral feeding toward chemically defined formulas during the late 1950s and 1960s. The issues included the publication by Rose, in 1949, of the essential amino acid requirements of men (31), and hospitals’ increasing emphasis on the use of antiseptic procedures and technologically advanced medical intervention. A large-scale study on chemically defined diets was undertaken at the National Institutes of Health in conjunction with Vivonex Corporation (Mountain View,

The Introduction Of Parenteral Nutrition And The Continued Refinement Of Elemental Feeding

In 1968, Dudrick et al (39) reported the case of an infant sustained for 5 months on parenteral nutrition as her sole source of nutrition support. This was the first report of long-term parenteral nutrition being able to support life. The report was accepted with great enthusiasm, and subsequently, parenteral nutrition became the nutrition treatment of choice for any patient, who because of surgery, infection, ileus, or complications, was not able to eat for more than a few days.

Despite

Modern Commercial Formulas

With the increasing availability and manufacturing of commercial enteral products in the late 1960s and early 1970s, hospitals began to examine the cost of producing their own blenderized products. Although commercial formulas were more expensive to purchase than whole meal or milk-based blenderized diets were to make in the hospital kitchen, the labor savings were substantial (44). In addition, those concerned with equipment, sanitation, osmolarity, and viscosity favored the use of commercial,

Applications

Enteral nutrition products today are based on solutions that were first proposed in the 1930s, and most of today's delivery techniques were first introduced more 90 years ago. The history of the evolution of enteral nutrition should not be overlooked in the quest to improve on current enteral feeding techniques and therapies, but should be used as a resource for developing and implementing optimal patient-care strategies. Researchers and medical practitioners from the early and middle part of

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