Nutrition and Dietetics_Level 6 (3) (1).pdf

Nutrition and Dietetics_Level 6 (3) (1).pdf

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  1142 17.3.5 Learning Outcome4: Demonstrate understanding in enteral nutrition 17.3.5.1 Learning Activities Learning activity Special instructions i) Identify and describe terminologies in enteral nutrition  Define the terms used in dietetics; o Enteral nutrition o Refeeding syndrome o Nutrient adequacy o Bolus feeding ii) Identify and describe tube feeding/enteral nutrition routes  Identify the routes through which enteral feeds can be administered iii) Identify and describe types of enteral formulas  Formulate specials feeds for enteral nutrition  Administer enteral feeds  Monitor the patient during tube feeding  Record any complications experienced during parenteral feeding  Identify and manage complications of enteral feeding 17.3.5.2 Information Sheet Definition of terms Enteral nutrition refers to a way of providing nutrition to the patients who are unable to consume an adequate oral intake but have at least a partially functional GI tract. Bolus feeding: infusion of up to 500 ml of enteral formula into the stomach over 5 to 20 minutes, usually with a large bore syringe catheter a fine tube that can be threaded into the lumen of a blood vessel for infusion of fluids or withdrawal of blood central parenteral nutrition (CPN) vein, usually the superior vena cava continuous drip infusion enteral formula administration into the gastrointestinal tract via pump, usually over 8 to 24 hours per day Refeeding syndrome: low serum levels of potassium, magnesium, and phosphorus with severe, potentially lethal outcome that results from the too-rapid infusion of substrates, particularly carbohydrate, into the plasma with the consequent release of insulin and shift of electrolytes into the intracellular space as glucose moves into the cells for oxidation and there is reduction in salt and water excretion Nutrient adequacy: A result of consumption of sufficient amount of all essential nutrient and energy to meet individual requirements
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  1143 TYPES OF PATIENTFEEDING Enteral and Parenteral Nutrition This refers to the provision of food and nutrients to the patient when the conventional feeding methods are not adequate or cannot meet nutrition needs. These include Enteral and parenteral nutrition. Selection of the mode of feeding is dependent upon several factors. Choice of route of nutrition administration Adopted from JPEN 1993; 17 (4): 1SA. Enteral Nutrition Enteral nutrition is a way of providing nutrition to the patients who are unable to consume an adequate oral intake but have at least a partially functional GI tract. Enteral nutrition may augment the diet or may be the sole source of nutrition. It is recommended for patients who have problems chewing, swallowing, prolonged lack of appetite, an obstruction, a fistula or altered motility in the upper GIT; are in coma or have very high nutrient needs. Enteral feeds are • Standard formula • Hydrolyzed formula.
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  1144 Tube Feeding This isthe delivering of food by tube in to the stomach or intestine. It is indicated whenever oral feeding is impossible or not allowed. Tube feeding routes The decision regarding the type of feeding route/tube depends on the patient’s medical status and the anticipated length of time that the tube feeding will be required. Mechanically inserted tubes; • Nasogastric tubes where by a feeding tube is pushed through the nose into the stomach • Orogastric tubes whereby a feeding tube is pushed through the mouth into the stomach • Nasoduodenal tubes – the tube is pushed through the nose past the pylorus into the duodenum • Naso-jejunal tube – the tube is passed during the endoscopy from the nose past the pylorus into the jejunum Surgically inserted tubes • Oesophagostomy: A surgical opening is made at the lower neck through which a feeding tube is inserted to the stomach • Gastrostomy: A surgical opening is made directly into the stomach • Jejunostomy : A surgical opening is made into the jejunum • Figure below illustrates different routes of enteral nutrition administration. Figure X: Different routes of enteral nutrition administration (Draw if possible)
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  1145 Advantages of Enteralnutrition i) There is a stimulation of GI hormones and consequent regulated metabolism and utilization of nutrients. ii) It ensures adequate nutrient supply to the mucosal wall, and protection against atrophy of intestinal Villi. iii) It offers physiological protection against ulcers due to its buffering effect from gastric acids. Disadvantages of enteral formulas i) GI,metabolic,andmechanicalcomplications—tubemigration;increasedriskofbacterial contamination; tube obstruction; pneumothorax ii) Costs more than oral diets (not necessarily) iii) Less “palatable/normal”: patient/family resistance iv) Labor-intensive assessment, administration, tube patency and site care, monitoring Administration of enteral feeds The administration of enteral feeds should start slowly by giving 1litre in day one and 2 litres in day two as the patient is being closely monitored. The formula should also be stopped slowly (reduce rate by half every 1-2 hours or switch to dextrose IV. For the cyclic mode, give 12 to 18 hours perday. Methods of administration of enteral feeds Method Administration Remarks Bolus feeding Initially – 50ml then increase gradually up to a maximum of 250 to 400ml over approximately 30 minutes, 3 to 4 hourly daily (in 24 hrs) • Most appropriate when feeding in to the stomach • Check aspirate before each feeding • Feeds may poorly tolerated causing nausea, vomiting, diarrhea, cramping or aspiration Intermittent slow gravity feeding. 400 – 500ml infused by gravity over approximately 20 -30 minutes to 1 hr. 3 to 4 hourly daily (in 24 hrs) • Patient retains freedom of movements in between feeds • Improved tolerance of feeds Continuous Total volume of feed required is slowly administered; approximately 100ml/hour over 18 – 24hrs • Most suitable when feeding in to the duodenum or jejunum where elemental diets are most appropriate • May also be suitable for feeding in to the stomach • Method may slow peristalsis • Feeds are better tolerated
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  1146 Tube feeding instructions -Tube feeding should be used at room temperatures, cold mixtures can cause diarrhea - Ensure proper placement of tube and feed at slow constant rate - Prescribed intervals and volumes of feeding should be adhered to - Care should be taken to ensure that the tube feeds meet the patient’s nutrient requirements - Prepared mixture should be well covered, properly labeled including time of preparation and stored in a refrigerator for up to 24 hours - In the absence of refrigeration, quantities lasting only six to twelve hours should be prepared - All feeding equipment should be cleaned before and after each feed - Shake/stir well before use Complications of tube feeding Commonly seen complications can be classified into: gastro-intestinal, mechanical, metabolic, and pulmonary. The table below provides a summary of the complications alongside prevention/management strategies. Gastro intestinal complications Prevention/management Diarrhea • Slow feeding rate • Supplemental fluid and electrolytes • Use lactose free formula • Prevent formula contamination • Consider different formula • Check antibiotic/drug therapy • Check flow rate of feed • Consider Enteral nutrition with added fiber • Use ant diarrheal agent • Check osmolarity of feeds (< 500mosl/l recommended Constipation • Give supplemental fluid. • Check if fiber inadequate or excessive • Check physical activity Nausea or vomiting • Reduce flow rate • Discontinue feeding until underlying condition is managed • Change to polymeric feeds if on elemental diet • Check gastric emptying and review narcotic medications, initiate low fat diet, reduce flow rate
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  1147 Malabsorption/Mal- digestion • Identify thecause (crohn’s disease, radiation enteritis, HIV, pancreatic insufficiency etc) • Select appropriate Enteral product • PN may be necessary in selected patients Abdominal distension • Assess the cause • Check feed temperature (give at room temperature) • Do not give rapid formula administration Medical complications of tube feeding Mechanical complications Prevention/management Tube placement • To be placed by trained personnel using defined protocol to reduce complications Feeding tube • Use small bore feeding tube to minimize upper airway problems Tube clogging • Select appropriate tube size • Flash with water • Dilute formula with water Dislocation of tube • Ascertain tube placement before each feed • Clearly mark tube at insertion Nasopharyngeal irritation • Use small lumen tube. • Use pliable tube Esophageal erosion • Discontinue tube feeding • Recommend parenteral nutrition Metabolic complications Prevention/management (Fluid and electrolyte imbalance, trace element, vitamin and mineral deficiencies, essential fatty acid deficiencies • Check adequacy of daily nutrient supply of macro and micronutrients during EN. • Check possibility of Malabsorption Hyperglycemia • Reduce flow rate. • Give oral hypoglycemic agents or insulin. • Change formula Tube feeding syndrome • Reduce protein intake or increase water intake. • For conscious patients education and counseling is needed Hypernatremia (dehydration) • Increased water intake and reduce sodium • Replace sodium loses Hyponatremia (over- hydration) • Replace sodium loses • Re-asses nutrient requirement, check volume administration, change to nutrient dense formula
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  1148 Pulmonary complications Prevention/management Pulmonaryaspiration • Incline head of bed 300 – 450 during feeding 1 hr after feeding. • Check tube placement. • Monitor symptoms of gastric reflux. • Check abdominal distension. • Check residual volumes before feeds. • Change to jejunal feeding. • Reduce volume of feed. • Change from bolus to continuous feeding Monitoring tube fed patient Monitoring tube fed patients targets to find out two things; • Hydration status • Nutritional response The following activities should be applied and also those summarized in the Table below; • Weight (at least 3 times/week) • Signs/symptoms of edema (daily) • Signs/symptoms of dehydration (daily) • Fluid I/O (daily) • Adequacy of intake (at least 2x weekly) • Nitrogen balance: becoming less common (weekly, if appropriate) • Serum electrolytes, BUN, creatinine (2 –3 x weekly) • Serum glucose, calcium, magnesium, phosphorus (weekly or as ordered) • Stool output and consistency (daily). Checklist for monitoring patients recently placed on tube feeding Action Check 1. Before starting a new feeding • Complete a nutrition assessment • Check tube placement 2. Before each intermittent feeding: 3. Every half hour 4. Every hour 5. Every 4 hours • Check gastric residual • Check gravity drip rate when applicable • Check pump drip rate, when applicable • Check vital signs, including blood pressure, temperature, pulse, and respiration
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  1149 6. Every 6hours • Check blood glucose, monitoring blood glucose can be discontinued after 48hrs if test results are consistently negative in a non-diabetic client 7. Every 4 to 6 hours of continuous feeding • Check gastric residual 8. Every 8 hours • Check intake and output • Check specific gravity of urine • Check tube placement • Chart clients total intake of, acceptance of, and tolerance to tube feeding 9. Every day • Weigh clients where applicable • Check electrolytes and BUN when needed • Clean feeding equipment • Check all laboratory equipment 10. Every 7 to 10 days • Check all laboratory Findings • Re-assess nutrition status 11. As needed • Observe client for any undesirable responses to tube feeding; for example delayed gastric emptying, nausea, vomiting, and diarrhea • Check nitrogen balance • Check laboratory data • Chart significant details TYPES OF ENTERAL NUTRITION FORMULA There are various types of enteral feeds available as ready to use or powdered mixes specifically designed to meet the needs of the patient. The formulas are commonly categorized by the complexity of the proteins they contain. There are two major types of Enteral feeds namely: standard and hydrolyzed. Standard Formulas These are also known as polymeric or intact formula. They are made from whole proteins as found in the diet (e.g. eggs, meat) or protein isolates [semi-purified high biological value proteins that have been extracted from milk, soybean or eggs]. Because they contain whole complex molecules of protein, carbohydrate and fat, standard formulas are used for patients who have normal digestive and absorptive capacity. They come in variety such as standard, high protein, high calorie and disease specific.
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  1150 Hydrolyzed Formulas Partially hydrolyzedformulas contain proteins that are partially digested into small peptides. Completely hydrolyzed formulas are commonly known as elemental formula and they contain protein in its simplest form; free amino acids. Hydrolyzed formulas also provide other nutrients in simpler forms that require little or no digestion e.g. very low fat in form of medium-chain triglycerides (MCT). Hydrolyzed formulas are meant for patients with impaired digestion or absorption such as people with inflammatory bowel syndrome, short gut syndrome and pancreatic disorders. Indications for Enteral Nutrition During periods of decreased oral intake, anticipated less than 50% of required nutrient intake orally for 7-10 days as seen in severe dysphasia (difficulty swallowing), metabolic stress, major bowel resections, low-output fistulas and coma. Neurological disorders and psychological conditions. • Malnourished patients expected to be unable to eat > 5 days • Normally nourished patients expected to be unable to eat >5 days • Adaptive phase of short bowel syndrome • Following severe trauma or burns Contraindications • Intestinal obstruction that prohibits use of intestine • Paralytic illus • Intractable vomiting • Peritonitis • Severe diarrhea • High output fistulas between the GI tract and the skin • Severe acute pancreatitis • Inability to gain access • Aggressive therapy not warranted. Formula selection The suitability of a feeding formula should be evaluated based on a) Functional status of GI tract b) Physical characteristics of formula (osmolality, fiber content, caloric density, viscosity) c) Macronutrient ratios d) Digestion and absorption capability of patient.
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  1151 e) Specific metabolicneeds f) Contribution of the feeding to fluid and electrolyte needs or restriction g) Cost effectiveness Factors to consider when choosing an enteral formula • Gastrointestinal function The type of carbohydrate, protein, fat and fiber in the diet are related to the patient’s digestive and absorptive capacity • Caloric and protein content of the formula • Ability of the formula taken in the amounts tolerated, to meet the patient’s nutritional requirements • Sodium, potassium, magnesium and phosphorus content of the formula esp. for patients with cardiopulmonary, hepatic or renal failure • Viscosity of the formula related to tube size and method of feeding Determining nutrient requirements The type of formula, volume and hence the total nutrient required are determined by the patients physiological condition. Several equations are available for estimating nutrient requirements of patients depending on their clinical condition. The calorie to nitrogen ratio should be >150:1 (1g nitrogen is equivalent to 6.25g protein). If the C: N ratio is less than 200:1, then the protein supplied by such a feed will be inadequate for critically ill patients. Determination of estimated daily fluid allowance In order to meet the nutrient needs of a patient, the nutritionist/dietician needs to calculate the kcal, protein, fluid and nutrient needs according to age, sex, medical status. After the calculations, appropriate formula is selected based on nutritional needs, feeding route and GI function. Usually, enteral feeds are usually administered in fluid state and it is imperative to know the amount of fluids each patient should get (See Table below). Methods of estimating daily fluid allowance Basis of estimation Calculation Body weight Adults • Young active :16 – 30 years • Average: 25 – 55 years • Older: 55 – 65 years • Elderly:> 65 years • 40 ml/kg • 32 ml/kg • 30 ml/kg • 25 ml/kg
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  1152 Children • 1 –10kg • 11 – 20kg • 21kg or more • Energy intake • Nitrogen plus energy intake • 100 ml/kg. • An additional 50ml per each kg > 10kg. • An additional 25ml per each kg > 20kg • 1 ml per Kcal. • 100 ml/g nitrogen intake plus 1 ml per Kcal* How to determine energy and protein requirements Kcal/ml x ml given = kcal % protein x kcal = kcal as protein Kcal as protein x 1 g/4 kcal = g protein • Example: Patient drinks 200 cc of a 15.3% protein product that has 1 kcal/ml 1 kcal/ml x 200 ml = 200 kcal 0.153 % protein x 200 kcal = 30.6 kcal 30.6 kcal x 1g protein/4 kcal= 7.65 g protein Water Increase fluids as tolerated to compensate for losses due to: • Fever or environmental temp • Increased urine output • Diarrhea/vomiting • Draining wounds • Ostomy output, fistulas • Increased fiber intake, concentrated or high-protein formulas Classification of enteral formulas Enteral formula Sub-category characteristics Indications Polymeric Standard Similar to average diet. Normal digestion High nitrogen Protein > 15% of total Kcal. Catabolism Wound healing Calorie dense 2 Kcal/ml Fluid restriction Volume intolerance Electrolyte abnormalities Fiber containing Fiber 5 – 15/l Regulation of bowel function
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  1153 Monomer Partially hydrolyzed elemental peptide based Oneor more nutrients are hydrolyzed, composition varies. Impaired digestive and absorptive capacity Disease specific Renal Whole protein with modified electrolyte content in a caloric dense formula. Renal failure Hepatic High BCAA, low AA, Hepatic encephalopathy Pulmonary High % of calories from fat. ARDS Diabetic Low carbohydrate Diabetes mellitus Immune enhancing Formulas Critically ill Arginine*, glutamine, Omega-3 fatty acids, anti-oxidants Critically ill. Nutrient composition of enteral formulas Proteins In case of burns, injury, after surgery and in severe malnutrition, large quantities of proteins (100-200gm) should be administered. Average patient suffering from other diseases will need 60-70g of protein. Administer protein diet to those with hepatic coma Fat Should be administered in form of emulsions Carbohydrates Sources such as glucose, cane sugar and dextri-maltose can be used About 300-500g should be administered daily depending on the patient’s calorie needs Fluid Daily requirements for an adult are about 2500-3000ml and are easily provided Electrolytes Added into food depending on the needs of the patient e.g. chloride, potassium chloride etc Vitamins Daily requirements should be given in the food Calories An average adult patient will require 1500-2000kcal every day. After surgical operation, injury, burns, in severe protein-calorie malnutrition, provision of 3000kcal may be necessary to meet the increased demand. If adequate calories are not supplied, wasting of body muscle will take place.
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  1154 Enteral Nutrition Feeds ProductsName Composition-100g Powder Indications Manufacturer Infant feeding formulas 1.Prenan* CHO-55.9% mainly Lactose and maltodextrin PRO-14.4% mainly protein and casein. FAT-24.0% MCT, milk fat, corn oil, soybean oil For low birth weight, premature or light for date babies when breast milk is not available Nestle 2. Nan* CHO-56.2% PRO-12.5% FAT-27.7% For infants of normal birth weight[mature, normal for date]when breast milk is not available Nestle Kenya Limited 3. SMA* CHO-55.4% PRO-11.4% FAT-27.7% corn oil, soyn oil, coconut oil For infants and low birth weight light for date babies when breast milk is not adequate or not available Wyeth Lactose free infant formulas 1.Alsoy CHO-55.4% mainly maltodextrin PRO-14.0% soy protein isolate FAT-25% palm, soya and coconut oils For infants and adults when lactose or cows milk should be avoided Wyeth 2. Nursoy CHO-52% corn syrup solids PRO-41% soy protein isolate FAT-27% blend of vegetable oils For infants and adults when lactose or cow milk should be avoided Wyeth 3. Isomil CHO-50% corn syrup, sucrose PRO-15.6% soy protein isolate FAT-28.1% For infants and adults when lactose or cow milk should be avoided Ross labs 4. Prosobee CHO-40% glucose polymer and corn syrup solids PRO-12% soy isolate FAT-48% soy oil, coconut oil For infants and adults when lactose or cow milk should be avoided Mead Johnson
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  1155 High protein powder supplement 1.Full cream powdermilk CHO-37.4% PRO-25% FAT-28% A protein carolic supplement that can be inco-oporated in liquid or solid dicts Nestle KCC 2. Dried skimmed milk powder[DSM] CHO-54% PRO-36.4% FAT-1% A protein carolic supplement useful where low fat diet is required KCC 3. Sustagen CHO-68% corn syrup solids, glucose, lactose PRO-24% Non-fat milk, Whole milk caseinate FAT-8% Milk fat Controlled fat diets Mead Johnson 4. Pregestmil CHO-54% glucose and tapioca starch PRO-11% Hydrolysed casein and amino acids FAT-35% corn oil MCT oil For oral or tube feedings. Useful in malabsorption and low fat modified diets Lederle Labs 5. Gevral CHO-6.7% Lactose, sucrose PRO-17.1% Calcium caseinate FAT-0.6% Useful in high protein, low carolic low fat, low residual diets Laderle Labs 6. Forceval CHO-30% Protein-55% FAT-1% Calories per 100g- 366 Keal A protein, vitamin and mineral supplement ideal for high protein diets, low fat diets and cases of malabsorption useful for patients allergic to lactalbumins Unigreg Limited Nutritionally Complete Liquid Diets 1.Fresubin CHO-13.8g=55% of Total Kcals PRO-3.8g=15% of total Kcals FAT-3.4g=30% of Total Kcals Energy-100Kcal/100 ml Nutritionally complete liquid diet for total or supplemental feeding, tube feeding or oral feeding Low in lactose Freseinius
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  1156 2. Fresubin Isofibre CHO-17g=54.6 oftotal kcals PRO-7.5g=15.1% of total kcals FAT-68g=30.3% of total kcals Energy-1 kcal per ml High caloric formula suitable for tube or oral feeding especially where energy intake is increased, where fluid is restricted and for fat malabsorption Fresenius 3. Fresubin Diebetic CHO-12g=53% of total kcals PRO-3.4g-15% of total kcals FAT-3.2g=32% of total kcals Fibre-1.5g per 100 ml[90 kcal] Nutritionally complete feed for oral or tube feeding in diebetics Fresenius 4. Ensure [with fibre] CHO-58% of total kcals PRO-15% of total kcals FAT-30% of total kcals Nutritionally complete feed for oral or tube feeding as a total diet or supplemental diet Lactose free fibre Abott 5. Ensure [Nutritional powder] . CHO-61.5g=54% of total kcal PRO-15.8g=14% of total kcal FAT-15.8g=32% of total kcal Energy=100kcal per 100ml Nutritionally complete feed for oral or tube feeding as a total or supplement diet Lactose free feed, low ion cholesterol and sodium Abott CASE STUDY Sam a 67 year old man weighing 55kgs and 167cm tall presents with a four month history of post prandial vomiting, inability to swallow solids and liquid and can only swallow saliva. He also has dysphagia and complains of weight loss. 1. Which type of feed is appropriate for Sam 2. Prepare a feeding chart which is suitable for Sam’s condition. 3. Determine the energy and protein requirements in Sam’s enteral nutrition.
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  1157 17.3.5.3 Self-Assessment 1. Definethe following terms; A. Nutrient adequacy B. Refeeding syndrome C. Bolus feeding 2. The provision of food and nutrients to the patient when the conventional feeding methods are not adequate or cannot meet nutrition needs is_____ A. Bolus feeding B. Parenteral feeding C. Enteral feeding D. Nutrition support 3. ______________ is a method of tube feeding whereby the tube is passed during the endoscopy from the nose past the pylorus into the jejunum. A. Nasojejunal tube B. Nasoduodenal tube C. Orogastric tube D. Nasogastric tubes 4. The following statements about continuous feeding method of enteral nutrition except; A. It is most suitable when feeding in to the duodenum or jejunum where elemental diets are most appropriate B. It may be suitable for feeding in to the stomach C. Method may increase peristalsis D. Feeds are better tolerated 5. State the types of tube feeding. 6. Describe enteral nutrition. 7. Discuss the factors to consider when selecting an enteral formula. 8. Classify enteral nutrition based on different categories of patients. 9. Discuss the indications and contraindications of enteral formula. 10. Differentiate between standard and hydrolysed formulas. 17.3.5.4 Equipment and materials used in enteral feeding There are several enteral nutrition delivery systems which include both open and closed delivery systems • Feed preparation equipment for kitchen made feeds and powder feeds include measuring jars and cups and spoons, mixing bowls, blender, flask, sterile water
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  1158 • Ready tohang (RTH) feeds: giving sets for gravity or giving sets for the pump system, Enteral feeding pumps, dual port connector and a feeding bag where applicable • Liquid diets in easy bags: giving sets (gravity or pump), feeding pump and/or dual port connector where applicable • Feed delivery equipment; funnel especially in gastrotomy and Jejunostomy for controlling viscous flow, syringe for naso-gastric bolus or intermittent feeding and the feeding tubes where applicable • WHO guidelines • MOH policies and guidelines • Ministry of Education • Skills lab • Projectors, video clips, charts and other teaching aids • Stationery • Food exchange lists • Food guide pyramid • Invitation of competent expertise • Computers with internet • Library and resource centre NB: Feeding pump is recommended as it eases feeding workload because it flows without constant supervision, enhances accuracy, hygiene and sanitation. 17.3.5.4 References Antia, F. P., & Abraham, P. (1997). Clinical Dietetics and Nutrition (4th ed.). New York, NY: Oxford University Press, USA. Sullivan, R. J., & Cooley, D. A. (2009). Nutrition and major nutrients. In Digestion and Nutrition (1st ed., pp. 33-75). New York, NY: Infobase Publishing. http://www.fao.org/tempref/AG/agn/nutrition/dds_validation.pdf http://www.health.go.ke/wp-content/uploads/2018/11/Clinical-Nutrition-Manual-SOFTY- COPY-SAMPLE.doc Mahan, L.K., & Escott-Stump, S. (2008). Krause’s Food & Nutrition Therapy (12th ed.). Philadelphia: Saunders.