Use of fiber-containing enteral formula in pediatric clinical practice: an expert opinion review

Figures & data

Figure 1. The potential physiological benefits of dietary fiber in humans. SCFA, Short-chain fatty acid.

Table 1. Dietary fiber recommendations for children.

EFSA [19]		UK SACN [51]		USA IOM [17]		Australian NHRMC [55]		Williams et al. [53]
Age	Reference value	Age	Reference value	Age	Reference value	Age	Reference value
1–3	10 g/day	2–5	15 g/day	1–3	19 g/day	1–3	14 g/day	Age plus 5 g/day for those over two years (minimum) up to 10 g/day (maximum)
4–6	14 g/day	5–11	20 g/day	4–8	25 g/day	4–8	18 g/day
7–10	16 g/day	11–16	25 g/day	9–13	Girls: 26 g/day Boys: 31 g/day	9–13	Girls: 20 g/day Boys: 24 g/day
11–14	19 g/day	16–18	30 g/day	14–18	Girls: 26 g/day Boys: 38 g/day	14–18	Girls: 22 g/day Boys: 28 g/day
15–17	21 g/day

EFSA: European Food Safety Authority; SACN: Scientific Advisory Committee on Nutrition; NHRMC: National Health and Medical Research Council.

Table 2. Physicochemical Characteristics of different types of fibers used in EN products.

Classification	Solubility	Fermentability	Viscosity
PHGG	Soluble	Fermentable	Non-viscous
Soy polysaccharide	Insoluble	Fermentable	Non-viscous
Inulin-type fructans	Soluble	Fermentable	Non-viscous
Acacia gum	Soluble	Fermentable	Non-viscous
Cellulose	Insoluble	Nonfermentable	Non-viscous
Resistant starch	Insoluble	Fermentable	Non-viscous
Pectin	Soluble	Fermentable	Viscous

PHGG: partially hydrolyzed guar gum.

Table 3. Examples of fibers in commercially available fiber-containing formulas.

Added Fiber	Type of Fiber	Type of Products*	Energy Density (kcal/ml)	Dose g/Liter	Main Intended Use
PHGG	Soluble	Semi-elemental, w/PHGG Semi-elemental, high-energy Semi-elemental, high-protein Semi-elemental, w/Fiber Polymeric, w/real food ingredients, high-energy Semi-elemental, w/real food ingredients	1.2 1.5 1.2 1.0 1.5 1.5	12 6 4 4 12 12	TF
Agave Inulin	Soluble	Semi-elemental, plant-based Semi-elemental, plant-based, high-energy Polymeric, plant-based	1.0 1.5 1.2	8 12 12	TF ONS
Mixture of Acaia Gum, FOS, Inulin	Soluble	Polymeric, w/real food ingredients, reduced-calorie	0.6	10	TF
Mixture of Pea Fiber and PHGG	Mixture of non-soluble and soluble	Semi-elemental, plant-based, w/real food ingredients Polymeric, plant-based, w/real food ingredients Polymeric, high-energy	1.4 1.0 1.5	10 10 8.4	TF Dual use
Mixture of Inulin and FOS	Soluble	Semi-elemental, high-energy Semi-elemental, w/fiber	1.5 1.0	3 4	TF
Mixture of Pea, FOS, and Inulin	Mixture of non-soluble and soluble	Polymeric	1.0	3	Dual use
Mixture of Soy Polysaccharides, Resistant Starch, Inulin, Arabic gum, Cellulose, Oligofructose	Mixture of non-soluble and soluble	Polymeric Polymeric, high-energy	1.0 1.5	8 8	Dual use
Mixture of Short Chain FOS and Soy Fiber	Mixture of soluble and non-soluble	Polymeric	1.0	12.6	Dual use
Short Chain FOS	Soluble	Polymeric, w/fiber Polymeric, high-energy Polymeric, reduced-energy Semi-elemental Semi-elemental, high-energy	1.0 1.5 0.75 1.0 1.5	12.6 12.6 12.6 3 4.6	Dual use
Fibers from Real Food	Mix	Polymeric, w/real food	1.2	16.6	TF

TF – tube feeding; Dual use – Formula can be used as a sole source of nutrition or as Oral Nutritional Supplements (ONS); Semi-elemental – peptide-based formula.

The table was generated based on information available on the companies’ internet sites, accessed Oct 2022.

*Not exhaustive list.

Box 1 Summary of Experts’ Recommendations

Dietary fiber plays an important role in pediatric nutrition by supporting gut health and microbiome and promoting normal laxation. The current evidence supports using fiber in enteral formulas as first-line nutritional therapy. Nonetheless, practical guidance on the use of fiber-containing EN in the pediatric population is still lacking.
1) Who are the target patients for the enteral formula with fiber? Fiber should be considered for all patients requiring enteral nutrition and can be gradually introduced from 6 months of age. Healthcare professionals should use their clinical judgment in specific cases where the use of fiber is poorly tolerated.
2) What type of fiber should be considered? Several types of fibers have been used. Although individual fibers may reduce the incidence of diarrhea and constipation, the use of a mixture of bulking and fermentable fiber has been suggested as a preferable approach particularly for long-term feeding. Despite the lack of universal agreement, it has been proposed that soluble fiber should account for at least 30% of the fiber blends, which mimics the ratio found in normal food. The future, a more personalized approach to fiber may be advised.
3) How much fiber is recommended for tube-fed children? There is no universal consensus on the dose of fiber to use in tube-fed children with acute and chronic illness due to a lack of clinical data. The fiber content of most current enteral formulas does not match the fiber intake recommendations of healthy children and the fixed amount of fiber present in enteral formulas does not allow to adjust the dose of fiber unless extra fiber is added separately. The current pediatric requirements for fiber intake should be considered as a reference both for healthy children and those who need nutritional support. Dietary fiber should be introduced gradually, especially in fiber-naïve children, with an individualized symptom-based approach.
4) Should tube feeding with fiber-containing enteral formula be considered a first-line nutritional therapy? Current evidence supports the use of dietary fiber in enteral feeding formulas as a first-line nutritional therapy.
5) What is the ideal feeding approach? The introduction of a fiber-containing formula should be considered in children requiring enteral nutrition. A progressive introduction of fiber is advised in children receiving fiber-free or low-fiber formula. Patients should continue on the fiber-containing formula they tolerate best, with fiber intake adapted to their tolerance, as there are no specifically defined contraindications. Long-term fiber intake might be recommended to prevent recurrence of GI problems.

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