Nutrition Support Blog: More on Micronutrients and Feeding Site
August 12, 2011
Our last blog discussed the increased risk of micronutrient deficiencies in patients that have undergone gastric bypass. Another category of patients at risk for micronutrient deficiencies from bypassing the optimal sites for nutrient absorption are those who receive enteral nutrition (EN) into the small bowel.1-3 Copper nutrition appears to be at particular risk with prolonged jejunal feeding.1-3 We really do not have good data about how frequently micronutrient deficiencies may occur in patients receiving long term jejunal EN. There is a clear need to gather more data about copper, iron, zinc and selenium status within this population, especially when one considers that we are likely to see more patients receiving long term small bowel feeding in the future.
Patients with limited calorie expenditure and receiving decreased volume of formula, those with increased nutrient losses (diarrhea, ileosotomy), or increased nutrient needs (wound healing), may be at particular risk for nutrient deficiencies. It is possible for subtle deficiencies to remain undetected while still affecting immune function or wound healing. In patients with existing neurologic compromise or multiple medical problems, the insidious development of even a severe micronutrient deficiency could easily go unnoticed. The belated discovery of micronutrient deficiencies related to jejunal EN is a reminder that we should have a good reason (data) before we bypass portions of the GI tract for feeding. Clearly, there are patients that require or benefit from small bowel feeding. However, our experience with gastric bypass and nutrient deficiencies that initially go unnoticed makes me worried that we are unintentionally creating future nutrition problems in some patients.
We have encountered some clinicians that may have become overzealous in their enthusiasm for small bowel feeding tube placement--some place tubes beyond the pylorus, “while we were there” or “because it won’t hurt.” The occurrence of nutrient deficiencies related to jejunal feeding (as well as the suggestion of increased clostridium difficile risk with jejunal feeding) is a reminder that we very likely have a stomach for good physiologic reasons.
- Nishiwaki S, Iwashita M, Goto N, et al. Predominant copper deficiency during prolonged enteral nutrition through a jejunostomy tube compared to that through a gastrostomy tube. Clin Nutr. 2011 May 17.
- Jayakumar S, Micallef-Eynaud PD, Lyon TD, et al. Acquired copper deficiency following prolonged jejunostomy feeds. Ann Clin Biochem. 2005;42(Pt 3):227-31.
- Beck JA, Glick N. Copper deficiency anemia and neutropenia in a jejunostomy-fed patient. PM R. 2009;1(9):887-8.
“Prediction is very difficult, especially about the future.” —Niels Bohr
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