Micronutrients

As dietitians, we base someone’s formula amount (in ml / day) recommendation on their energy (aka. calorie) and protein needs. So we calculate how much you need first based on your activity levels and medical diagnosis, and then reverse engineer how much formula would give that amount of energy and protein in a day.

For those on commercial formulas, we then assume that a complete micronutrient profile is achieved when your recommended energy and protein needs are delivered. We can easily see the micronutrient profile of the formula at the back of the pack. So for example, say the back of the pack says 3.4mg of Vitamin E in 100ml of formula and you are having 800ml of that formula per day. That means you are receiving 27mg of Vitamin E per day.

For those on homemade blended formulas, we’d need to run the recipes through a food analysis program to get the micronutrient breakdown. More cumbersome, but definitely possible.

Even though it may seem that someone on home tube feeding is getting “constant nutrition”, micronutrient deficiencies still do arise just like they happen in those eating through their mouth.

So, whilst no home tube feeding guidelines have specified regular micronutrient blood tests should be done in the home tube fed population, it’d be best practice to do so especially for those who are:

  • newly established on home tube feeding
  • have had recent surgery along their digestive tract affecting nutrient absorption
  • are malnourished (have a had >5% loss of body weight in the last month or > 10% in the last 6 months)
  • undergoing regular active medical treatment (like chemotherapy) that can affect their appetite
  • showing clinical signs of micronutrient deficiencies such as hair loss, low energy levels, dry corners of the mouth, etc.

Allow me to break it down further for you …

How much of each micronutrient should I be having in a day?

Browse all the micronutrients available on this government owned platform. It’s brilliant!

Continuing the vitamin E example above, an adult male needs 10mg/day and a female 7mg/day. Maximum amount that should be had in a day for adults is 300mg/day. So the 27mg/day coming from the formula is just fine. Remember, your body may not absorb all that is going through anyway so 27mg/day is well above the recommended and well below the maximum amount.

What blood tests can be done to check my micronutrient profile?

It’s important to remember that nutrient toxicity is a real thing just like deficiency! So, to much of a nutrient can have real negative side effects as well. So, even with nutrients, make sure you TEST your levels BEFORE your supplement yourself. Your doctor can order the below blood tests for you.

Not all pathology test centers can do all the below tests so you may have to go hunting for one that has the capacity to do them all.

MicronutrientPathology test
Vitamin ASerum retinol
Vitamin B12Serum vitamin B12, methylmalonic acid
Vitamin CSerum vitamin C (ascorbic acid)
Vitamin DSerum 25-hydroxyvitamin D, parathyroid hormone
Vitamin ESerum alpha-tocopherol
FolateSerum, red blood cell folate
IronSerum ferritin, iron, iron-binding capacity
ZincSerum zinc
SeleniumSerum selenium
CopperSerum copper
Source: Iyer K, DiBaise JK. AGA Clinical Practice Update on Management of Short Bowel Syndrome: Expert Review. Clinical Gastroenterology and Hepatology. 2022:20(10):2185-2194. Available from: https://www.cghjournal.org/article/S1542-3565(22)00561-4/fulltext?dgcid=raven_jbs_etoc_email

What are the clinical signs of micronutrient deficiencies that I should look out for in myself / my patients?

Body regionSignPossible deficiency
SkinPetechiae (tiny spots of bleeding under the skin)
Purpura (purple colored spots on the skin)
Pigmentation
Edema (fluid build up in hands and legs)
Pallor
Decubitus (ulcers on skin covering bony areas)
Unhealed wounds
Vitamin A, C
Vitamin C, K
Niacin
Protein, vitamin B1
Folate, iron, vitamin B12
Protein, energy
Vitamin C, protein, zinc
NailsPallor or white coloring
Clubbing or spoon-shape
Excessive dryness
Darkness in nails
Curved nail ends
Iron, protein, vitamin B12
Head/hairDull/lackluster
Banding/sparse
Alopecia (hair loss)
Depigmentation of hair
Scaly/flaky scalp
Protein, energy, biotin, copper, essential fatty acids
EyesPallor conjunctiva
Night vision impairment
Photophobia
Vitamin B12, folate, iron
Vitamin A
Zinc
MouthGlossitis (swelling and inflamed tongue)
Gingivitis (swollen gums)
Stomatitis (sore or inflammation inside the mouth)
Cheilosis (swollen lips)
Pale tongue

Vitamin B2, B6, B12, niacin, iron, folate
Vitamin C
Vitamin B2, iron, protein

Niacin, vitamin B2, B6, protein
Iron, Vitamin B12
Nervous systemMental confusion
Depression, lethargy
Weakness, leg paralysis
Fatigue
Muscle cramps
Vitamin B1, B2, B12, water
Biotin, folate, vitamin C
Vitamin B1, B6, B12
Vitamin B6, calcium, magnesium
Energy, biotin, magnesium, iron
Adapted from: Reber E, Gomes F, Vasiloglou M, Schuetz P, Stanga Z. Nutritional Risk Screening and Assessment. Journal of Clinical Medicine. 2019:8(7), P1065. DOI: https://doi.org/10.3390/jcm8071065

We hope this post has shed some light on micronutrients in people receiving home tube feeding. This topic is heavily unresearched in the medical world but interest amongst researchers is definitely rising so watch this space!

Happy reading and home tube feeding,

Tube Dietitian.