Patient-reported outcomes on gastrointestinal tolerance and adherence to a pea protein plant-based enteral formula in children and adults
Stanley A. Cohen, Vanessa Millovich, Dwan Newman, Nicole Withrow, Lucille Beseler, Christina J. Valentine
TL;DR
A pea protein-based enteral formula with fiber may improve gastrointestinal tolerance and adherence in children and adults.
Contribution
The study evaluates a plant-based enteral formula's impact on GI tolerance and adherence using patient-reported outcomes.
Findings
A positive trend toward improved gastrointestinal tolerance was observed in both pediatric and adult participants.
The formula's composition, free from allergens and artificial additives, may support better adherence to enteral nutrition.
Using the formula as a first-choice option could reduce formula switching due to GI intolerance.
Abstract
Enteral Nutrition through a feeding tube or orally can improve patient outcomes when tolerated to achieve nutritional requirements. While experts have provided feeding guidelines to enhance safety and efficacy, challenges in gastrointestinal (GI) tolerance such as diarrhea, constipation, bloating and vomiting often complicate adherence. Problems such as malnutrition, morbidity, and mortality occur when gastrointestinal intolerance results in the provision of formulas stopping and starting, and therefore delays, in optimal intake. Formulas vary widely in their composition, including differences in the primary protein source, degree of protein hydrolysis, inclusion of common allergens, fiber content, use of artificial or nonnutritive sweeteners, and use of artificial colors. A distinctive yellow pea protein, plant-based enteral formula (PPPBF) that includes fiber, and is free from common…
Genes, proteins, chemicals, diseases, species, mutations and cell lines named across the full text — each resolved to its canonical identifier and authoritative record.
|
|
|
|
|---|---|---|
|
| ||
| 1–5 years | 87 (22.1) | 49 (23) |
| 6–12 years | 42 (10.7) | 32 (15) |
| 13–19 years | 30 (7.6) | 16 (7.5) |
| 20–40 years | 111 (28.2) | 65 (30.5) |
| 41–60 years | 65 (16.5) | 24 (11.3) |
| >60 years | 57 (14.5) | 26 (12.2) |
| Prefer not to answer | 1 (0.3) | 1 (0.5) |
|
| ||
| Female | 225 (57.3) | 124 (58.2) |
| Male | 165 (42.0) | 86 (40.4) |
| Prefer not to answer | 3 (0.8) | 3 (1.4) |
|
|
|
|
|---|---|---|
|
| ||
|
| ||
| Mouth | 210 (53.6) | 116 (54.4) |
| Syringe | 59 (15.1) | 33 (15.5) |
| Gravity Bag | 37 (9.4) | 18 (8.5) |
| Feeding Pump | 129 (32.9) | 74 (34.7) |
|
| ||
| < 50% | 105 (26.8) | 70 (32.9) |
| 50–90% | 128 (32.7) | 69 (32.4) |
| >90% | 150 (38.3) | 63 (29.6) |
| Unsure | 8 (2.0) | 10 (4.7) |
|
| ||
| < 1 months | 30 (7.7) | 3 (1.4) |
| 1–3 months | 69 (17.6) | 8 (3.8) |
| 3–6 months | 93 (23.7). | 6 (2.8) |
| 6–12 months | 97 (24.7). | 32 (15) |
| 12-24 months | 76 (19.4) | 78 (36.6) |
| >24 months | 22 (5.6) | 52 (24.4) |
| >36 months | 0 (0)* | 30 (14.1) |
| Unsure | 3 (0.8) | 4 (1.9) |
| Prefer not to answer | 2 (0.5) | 0 (0) |
|
| ||
|
| ||
| Allergy to one or more ingredients in other formulas | 47 (12.0) | |
| Doctor or dietitian recommended | 66 (16.8) | |
| Intolerance to one or more formulas used before | 69 (17.6) | |
| Poor growth on previous formula | 8 (2.0) | |
| Poor weight gain on previous formula | 36 (9.2) | |
| Preferred ingredients in PPPBF | 135 (34.4) | |
| Preferred the taste of PPPBF | 7 (1.8) | |
| Other | 24 (6.1) | |
| Unsure | 1 (0.3) | |
|
|
|
|
|---|---|---|
| Gastroparesis | 66 (17) | 38 (17.8) |
| Dysphasia | 34 (9) | 19 (8.9) |
| Head and Neck Cancer | 34 (9) | 12 (5.6) |
| Failure to Thrive | 31 (8) | 20 (9.4) |
| Malnutrition | 29 (7) | 21 (9.9) |
| Other Cancer | 25 (6) | 8 (3.8) |
| Developmental Delay | 16 (4) | 8 (3.8) |
| Cerebral Palsy | 22 (5) | 13 (6.1) |
| Cystic Fibrosis | 15 (4) | 11 (5.2) |
| ALS | 12 (3) | 4 (1.9) |
| Brain Injury | 7 (2) | 5 (2.3) |
| Esophageal Cancer | 7 (2) | 1 (0.5) |
| Stroke | 2 (0.5) | 0 (0) |
| Achalasia | 2 (0.5) | 0 (0) |
| Other | 90 (23) | 41 (19.2) |
| Difficulty swallowing from a disease not described | 34 (8.7) | 10 (4.7) |
| Congenital heart disease | 0 (0) | 1 (0.5) |
|
|
| ||
|---|---|---|---|
|
|
|
| |
| Strongly agree/Agree | 157 (40.1) | 329 (83.7) | 178 (83.5) |
| Strongly agree | 83 (21.2%) | 215 (54.7%) | 104 (48.4%) |
| Agree | 74 (18.9%) | 114 (29%) | 74 (34.7%) |
| Neutral | 63 (16.1%) | 22 (5.6%) | 22 (10.3%) |
| Disagree | 73 (18.6%) | 19 (4.8%) | 9 (4.2%) |
| Strongly disagree | 52 (13.3%) | 4 (1.0%) | 3 (1.4%) |
| Prefer not to answer | 47 (12%) | 2 (0.5%) | 1 (0.5%) |
|
|
|
|
|---|---|---|
| Strongly agree/Agree | 246 (62.6) | 144 (67.6) |
| Strongly agree | 122 (31%) | 68 (31.9%) |
| Agree | 124 (31.6%) | 76 (35.7%) |
| Neutral | 109 (27.7%) | 52 (24.4%) |
| Disagree | 25 (6.4%) | 14 (6.6%) |
| Strongly disagree | 9 (2.3%) | 3 (1.4%) |
| Prefer not to answer | 4 (1.0%) | 0 (0%) |
Peer Reviews
No public reviews on file for this paper yet. If you reviewed it on a platform where reviews are public (OpenReview, ICLR, NeurIPS, ICML), you can paste yours below so the community can read it here.
Videos
No videos yet. Explain this paper in a talk, walkthrough, or lecture? Add one.
Taxonomy
TopicsGastrointestinal motility and disorders · Food Allergy and Anaphylaxis Research · Clinical Nutrition and Gastroenterology
Introduction
Enteral nutrition (EN) is essential for individuals who depend solely on a liquid or reconstituted medical food/formula delivered as tube feedings or as oral intake (1, 2). EN can serve as a sole source of nutrition, function as a meal replacement, or simply provide additional nutritional support. There are published guidelines to promote safe practices and delivery (3); however, there are no consistent standards of practice for clinicians to consider as they choose formulas for their patients (4). Not having a targeted approach to using EN often results in a minimum of 2–3 formula changes prior to achieving tolerance (4). A major consequence of these switches is that a person can be on inadequate nutritional intake for days, weeks and even months before finding a formula that they tolerate (5). Starting and stopping EN delays optimal nutrient intake which can lead to malnutrition or worsen the condition of an already malnourished patient (6). Data suggests that 1/3 of patients admitted to the hospital are malnourished (5) or become malnourished while in medical facilities (6) which impacts health outcomes and mortality (7) and puts a burden on the healthcare system and overall costs of care (8, 9). While disease-related malnutrition is well established as a primary factor in the incidence of malnutrition, a major contributor can be intolerability of the formula regimen (5). In indicated cases, enteral nutrition improves clinical outcomes and is one important proactive strategy to mitigate the risks associated with malnutrition (10). It has been reported that only 5.2% of malnourished hospitalized adult patients in the United States are receiving EN even though it can improve nutritional status (7). IgE mediated, non-IgE mediated and mixed cow's milk allergy (CMA) are common in children and adults that can lead to formula intolerance and decreased adherence (11).
CMA is one of the most common IgE food allergies in early life with an estimated prevalence in developed countries of up to 3% at 1 year of age. In adults, prevalence is lower with estimates around 0.5% (12). However, US population-based surveys reveal this can be much higher, finding 1.9% of the US population (children and adults) having CMA with convincing IgE-mediated symptoms and 4.7% of the US population report that they have a CMA (13). Variability in reported prevalence rates may be attributable to the diagnostic challenges associated with non-IgE-mediated CMA. The rate of IgE-mediated CMA decreases while non-IgE-mediated and mixed CMA increases with increasing age (11). The prevalence of all 3 types of CMA may contribute to intolerance on dairy-based formulas.
To more rigorously characterize patterns of enteral formula utilization, gastrointestinal intolerance, adherence, and formula-transition practices, a survey was administered to pediatric and adult individuals receiving enteral nutrition. The objective was to evaluate differences in tolerance and use patterns between previously prescribed enteral nutrition (EN) formulas and a pea protein, plant-based enteral formula (PPPBF).
Materials and methods
A cross-sectional cohort survey study was performed September of 2019 to understand the patient or patient caregiver experience, usage, and their reported outcomes before using and while using a PPPBF. To gather additional insight into reported usage and health related outcomes, a follow-up survey was sent 12-months later to those who completed the 1st survey. The study protocols were approved by a centralized Institutional Review Board (IRB), Integ Review, Protocols 002 and 003, respectively.
Both surveys were electronic, administered utilizing REDCap^®^ and sent via email. REDCap is a validated research database developed by Vanderbilt University to collect and store information (14). The initial survey (Supplementary Figure 1) consisted of 32-items and was sent to patients and/or the caregivers of patients who had previously requested a sample of a PPPBF (Standard 1.0, Peptide 1.5, Pediatric Standard 1.2, or Pediatric Peptide 1.5, Komplete) manufactured by Kate Farms, Inc. Potential participants were identified for inclusion through an online database (Kate Farms, Inc, Goleta CA). Participants who completed the entire survey were provided with an electronically sent 25 Visa gift card for their time and participation. All data was again de-identified and stored in password protected and locked data sets.
Statistical analysis
The number of respondents who reported use of at least one PPPBF and who completed the surveys constituted the sample size. Descriptive statistics were assessed with frequencies and percentages due to the categorical nature of all data. A chi-square test was employed to determine if there were significant differences in the frequency of reported symptoms on the PPPBF. A post-hoc analysis divided participants into two age groups: pediatric (ages 1–19 years) and adult (ages 20 years and older). Data were then stratified by these groups and compared using chi-square tests, which were also used to identify potential confounders. Null responses were retained and included in the final analysis, and all statistical analyses and plots were generated using R, version 3.6.1.
Results
Participant demographics
The 1st survey was emailed to the list of eligible participants (n = 1,592). There were 398 respondents, of which 392 completed all 32 items of the questionnaire, and were included in the final analysis. When stratified by age, the pediatric cohort (PC) of 159 included 87 (22.1%) who were 1–5 years of age (y); 42 (10.7 %) who were 6–12 y; and 30 (7.6 %) between 13 and 19 y. The adult cohort (AC) of those ≥20 years of age (n = 233; 59.2%) had a majority, n = 111 (28.2%), in the 20–40 y age bracket, with 65 (16.5%) between 41 and 60 y and 57 (14.5%) over 60 y. Females comprised 225 (57.3%) of the total respondents (Table 1). Significantly more participants in the 20–40 y age group identified as self-reporters, when compared to the participants in the >60 y age group (p = 0.005).
The second survey was distributed to the participants who had completed the first survey, resulting in 213 completed responses. Due to the small group size, subsequent analyses were conducted on the entire cohort of respondents. Age was determined not to be a confounder, so results were not reported based on the initial age stratifications. Demographic information can be reviewed in Table 1. Due to small group sizes, subsequent analyses were conducted on the group level.
Use characteristics of enteral formula users
Participants were asked to describe how the formula was used each day and were able to “check all that apply” meaning that they were able to state if the formula was used via a feeding pump and/or by mouth. In the initial survey, more than half answered that the formula was used by mouth (n = 211, 53.7%) and 32.8% (n = 129) used the formula via pump. The responses were similar in the 2^nd^ survey, where more than half answered that the formula was used by mouth (n = 116, 54.5%) and 34.7% (n = 74) using a formula pump (Table 2).
Participant clinical diagnoses
Participants were asked for the main diagnosis that required a formula. They were only able to choose a single answer from those listed, which also included “other” (Table 3). The largest percentage of participants chose “other” in both surveys, 23% (n = 90) and 19.2% (n = 41) respectively. For the cohort from the 1st survey, the top five listed diagnoses were gastroparesis (n = 66, 16.8%), head and neck cancer (n = 34, 8.7%), difficulty swallowing from a disease not described (n = 34, 8.7%), failure to thrive (FTT) (n = 31, 7.9%), and malnutrition (n = 29, 7.4%). The top 5 diagnoses reported by the 2nd survey cohort included gastroparesis (n = 38, 17.8%) as the top diagnosis after “other”, followed by malnutrition (n = 21, 9.9%), FTT (n = 20, 9.4%), dysphagia (n = 19, 8.9%), and cerebral palsy (CP) (n = 13, 6.1%).
Reported outcomes
Both surveys asked about the primary reason for stopping the PPPBF within the previous 12 months. If the formula user was still using the PPPBF at the time of the survey, they were able to select the answer “I am still using the PPPBF.” At the time of the 1st survey, 249 (63.5%) reported to still be using a pea protein plant based enteral formula; of those who reported to have discontinued the PPPBF formula, 49 (12.5%) no longer had a need for formula, and 17 (4.3%) reported to not tolerate the formula. Other reasons for discontinuing the use of the PPPBF included the lack of insurance coverage, 34 (8.7 %); expense, 16 (4.1%); taste, 4 (1.0%) and other, 23 (5.9%). At the time of the 2nd survey, 59.6% of participants (n = 127) reported to still be using the PPPBF. The highest reported reason for stopping the PPPBF was no longer having a need for formula (n = 35, 16.4%), followed by not having insurance coverage (n = 13, 6.1%).
In the 1st survey, almost 3/4 of the respondents, 278 (72.6%) reported that more than 50% of the PPPBF user's total nutrition was obtained through the formula, and 150 (38.2%) noted that the PPPBF provided > 90 %; a year later, at the time of the 2nd survey, slightly less, 29.6% of participants reported that more than 90% of their nutrition was from a PPPBF.
Questions about adherence were included in both surveys. The first survey, 40.1% of participants strongly agreed/agreed that they were able to use at least 75% of their previous formula. When asked about adherence to the PPPBF, 83.7% of participants strongly agreed/agreed they were able to use at least 75% of the recommended amount. In the 2^nd^ survey, 83.6% (n = 178) also strongly agreed/agreed to being able to use at least 75% of their PPPBF, mirroring the initial survey's adherence findings (Table 4).
Both surveys included questions about reported weight change while using the PPPBF. In the 1st survey, weight change was reported by 58.3% (n = 229) of participants as weight gain and 6.4% (n = 25) as weight loss, while 27.7% (n = 109) reported no change in weight. In the 2nd survey, weight gain was reported by 64.3% (n = 137), 22.5% (n = 48) reported no weight change, and 7% (n = 15) weight loss while using the PPPBF.
In both surveys, participants were asked if they felt the PPPBF improved their digestive symptoms. A similar percentage of participants selected “strongly agree or agree” to this statement, 62.6% in the initial survey and 67.6% in the 2nd survey, 12-months later (Table 5).
A post-hoc analysis of the pediatric tube fed patients was completed to investigate the reported symptoms and adherence of those (n = 40) using a PPPBF formula. Comparisons were made to evaluate symptom frequency and adherence between the PPPBF formula and the previous formula. While those on the PPPBF had fewer episodes of each of the tracked symptoms when compared to their previous formula, the most significant changes were less bloating (p = 0.038) and less constipation (p = 0.04). Adherence was markedly better for the PPPBF (p < 0.001) compared to their previous formula, with 36 (97.3%) of those on the peptide (hydrolyzed) PPPBF able to take 75% of their recommended amount vs. 20 (55.6%) able to do the same on their previous formula. Previous formulas reported to be at least one of these types: standard intact dairy protein-based adult or pediatric specific formulations (44.9%), whey or casein peptide (hydrolyzed) protein-based adult or pediatric specific formulations (6.6%), infant formulas (4.8%), commercially available pediatric and adult blenderized formulations (7.4%), and amino acid/elemental protein-based pediatric formulations (5.4%), and “other” (45.9%). This analysis excluded those who did not respond or otherwise did not have a response for symptom frequency and adherence.
Discussion
Enteral nutrition used as a tube feeding, or an oral nutrition supplement (ONS) should be well-tolerated to achieve a nutritional intake goal. Digestive symptoms such as diarrhea, vomiting, bloating, abdominal pain, and constipation can cause prolonged diminished nutrition intake and subsequently influence malnutrition-related side effects (9). This report of the use of a PPPBF over a sustained (12 month) period demonstrates a higher reported adherence and GI tolerance as compared to what was reported for the previously used enteral nutrition formulas. For those still using the PPPBF 12-months later, the reported improved digestive symptoms were similar to the initial survey report, suggesting a sustained benefit. Additionally, weight gain or stability were reported for 86.7 and 86.8% of respondents in the first and second surveys, respectively, with few (6.4% and 7 %) reporting weight loss in the two surveys. Although participants were not asked if the weight loss was intentional. Correlation with tolerance or adherence was outside the parameters of this investigation.
This study does not address the proposed mechanisms behind the improved tolerance that was reported in this cohort. Numerous studies have identified potential health benefits of plant-based diets often attributed to the nature of these diets being high in fiber and phytonutrients (15). PPPBF, in comparison to many dairy or amino acid-based enteral formulas, contains intact or partial hydrolyzed highly bioavailable yellow pea protein with mixed fiber (16).
Due to normal variations seen with different cultivars, growing conditions, and extraction methods, yellow pea protein (YPP), by itself, has a protein digestibility corrected amino acid score (PDCAAS) between 0.18 and 0.89, an in vitro digestibility between 83% and 95%, an in vivo digestibility of 98%. With the addition of limiting amino acids, the PPPBF in this study had a PDCAAS of 1.0. PDCAAS is the preferred method for measuring protein quality; it assesses the ability of a dietary protein to meet the body's amino acid requirements using both the digestibility and the amino acid score in the calculation (17–19). The PPPBF used in this study is made with an organically grown yellow pea protein which contains naturally occurring arginine and both soluble and insoluble fiber. Additionally, the PPPBF has a moderate rate of gastric digestion and is made without the top 9 US food allergens (20). Recent research has demonstrated that YPP has similar abilities to support muscle synthesis compared to whey protein (21, 22).
Cows' milk protein is the most common food allergen and recognized to affect gastrointestinal motility in children, contributing to constipation, a symptom of GI intolerance. No predictive and accurate biomarker for food allergy-associated constipation has been identified (23). The prevalence of food allergy underlying chronic constipation in children resistant to conventional treatment and presenting to tertiary clinics ranges between 28% and 78% (23). The avoidance of food allergens, such as cow's milk, soy and corn protein may be contributing to the reported improved digestive symptoms while on PPPBF of 62.6% and 67.6% of participants in the two survey groups.
PPPBF is made without artificial sweeteners, non-nutritive sweeteners, and artificial colors. In the United States, artificial and non-nutritive sweeteners have been a common ingredient in enteral formulas that contain hydrolyzed or amino acid-based protein sources. There is a growing body of literature linking non-nutritive sweetener intake to both an increase in functional GI disorder symptoms and an impact on gastric motility (24, 25).
While PPPBF contains a mix of insoluble and soluble fibers, the added organic agave inulin is a soluble and fermentable prebiotic fiber that may contribute to maintaining a healthy gut microbiome with minimal GI upset and improved laxation (26–28). Organic agave inulin is classified as a low viscosity fiber (29). Such fibers have been shown to exert minimal effects on mouth-to-cecum transit compared with higher viscosity soluble fibers (29). In this cohort, with the exception of “other,” gastroparesis was the most commonly reported primary diagnosis. Given that delayed gastric emptying can substantially influence gastrointestinal function and symptom burden, this finding underscores the clinical relevance of fiber type selection in this population. Furthermore, fermentable fibers have been shown to promote SCFA production, which in turn can improve colonic motility (30).
Strengths and limitations of the study
Several limitations intrinsic to the study design must be considered when interpreting the findings. First, reliance on self-reported survey data introduces the potential for recall bias and subjective interpretation, which can affect the accuracy of reported outcomes such as GI tolerance, adherence, and weight changes. Participants may have unintentionally misreported symptoms or dietary adherence due to memory lapses or the desire to present themselves in a favorable light, thus potentially inflating perceived benefits or underreporting adverse experiences. Additionally, the lack of standardized definitions for GI intolerance required participants to rely on their own understanding, further complicating data consistency and comparability across responses.
Another limitation is the absence of a detailed review of previous formula types used by participants. While information on prior formula use was collected, the study did not include a systematic manual review of individual survey responses to track specific formula changes. Furthermore, the heterogeneity of the study population and the subjective nature of the survey responses reduce the generalizability and strength of the conclusions.
A strength of the study is that these results are consistent with a retrospective review on GI tolerance recently published (31). That study included 73 pediatric patients with health care providers in 17 different states with the majority specializing in gastroenterology (61.6%). They reviewed electronic medical records of 73 patients who transitioned from a hypoallergenic formula to a PPPBF and input de-identified patient information in Research Electronic Data Capture (REDcap). After the transition to the PPPBF, 38.4% of the patients experienced improvement in GI tolerance, 56.2% experienced no change in GI tolerance, and 5.5% reported worsening (31). Additionally, the percentages of responses to several questions were similar between both surveys, which may mean that those still using the PPPBF 12-months later, had sustained their initially reported level of adherence and improvement in digestive symptoms, or tolerance. Lastly, the surveys in this report are important to acknowledge as a valuable contribution to our understanding of patient and caregiver-reported outcomes while using a PPPBF, given that the literature on pea protein use in a clinical setting is limited.
Clinical implications
This study provides clinicians and researchers with an important initial perspective on the clinical profiles and feeding routes of pediatric and adult patients who transitioned to an intact or peptide-based PPPBF. The significance of this study lies in its pioneering focus on pea protein plant-based formulas in medically complex patients requiring nutrition support; a population for whom evidence-based guidance is urgently needed. As the first investigation of its kind, it lays a foundation for future research and clinical practice, highlighting the necessity for rigorous, systematic evaluation of novel enteral nutrition options. While previously published articles assist in reducing formula switching non-specific to PPPBF enteral nutrition, a recent publication guides healthcare providers in selecting plant-based formulas (31). These promising findings and advancements in pea protein plant-based nutrition warrant further investigation through a prospective trial for validation. Of course, the aforementioned limitations intrinsic to the study design must be considered when interpreting the findings. To address these gaps, future research should incorporate objective data sources, specifically, utilizing electronic medical records to verify and document formula changes, allowing for precise tracking of nutritional interventions and outcomes. Additionally, gathering detailed information from both participants and healthcare providers regarding prior formula use and regimen recommendations would help clarify the influence of formula switching and support more nuanced analyses with stronger conclusions.
Conclusion
Patients and caregivers reported responses to surveys a year apart, captured clinical and quality of life outcomes as they are perceived. Together, the findings highlight the critical impact of enteral nutrition (EN) formula selection on patient outcomes, emphasizing how the initial choice can influence GI tolerance, adherence, and lower the potential risk of malnutrition and its untoward effects.
The reference list from the paper itself. Each links out to its DOI / PubMed record.
- 1Doley J. Enteral nutrition overview. Nutrients. (2022) 14:2180. doi: 10.3390/nu 1411218035683980 PMC 9183034 · doi ↗ · pubmed ↗
- 2A.S.P.E.N. Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. (2002) 26:1SA−138SA. doi: 10.1177/014860710202600101111841046 · doi ↗ · pubmed ↗
- 3Malone A Carney LN Carrera AL Mays A editors. Chapter 2. In: ASPEN Enteral Nutrition Handbook. 2nd edn. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition (2019). p.65–96.
- 4Eveleens RD Joosten KFM de Koning BAE . Definitions, predictors, and outcomes of feeding intolerance in critically ill children: a systematic review. Clin Nutr. (2020) 39:685–93. doi: 10.1016/j.clnu.2019.03.02630962102 · doi ↗ · pubmed ↗
- 5Wischmeyer PE. Overcoming challenges to enteral nutrition delivery in critical care. Curr Opin Crit Care. (2021) 27:169–76. doi: 10.1097/MCC.000000000000080133395086 PMC 8276753 · doi ↗ · pubmed ↗
- 6Barker L Gout B Crowe T. Hospital malnutrition: prevalence, identification, and impact on patients and the healthcare system. Int J Environ Res Public Health. (2011) 8:514–27. doi: 10.3390/ijerph 802051421556200 PMC 3084475 · doi ↗ · pubmed ↗
- 7Gramlich L Guenter P. Enteral nutrition in hospitalized adults. N Engl J Med. (2025) 392:1518–30. doi: 10.1056/NEJ Mra 240695440239069 · doi ↗ · pubmed ↗
- 8Aloy Dos Santos T Luft VC Souza GC . Malnutrition screening tool and malnutrition universal screening tool as predictors of prolonged hospital stay and hospital mortality: a cohort study. Clin Nutr ESPEN. (2023) 54:430–5. doi: 10.1016/j.clnesp.2023.02.00836963890 · doi ↗ · pubmed ↗