Which Campbells Soup Has Beef Tongue in It
Using ribotyping to trace foodborne aerobic spore-forming bacteria in the factory: a case study
A.C.M. van Zuijlen , in Tracing Pathogens in the Food Chain, 2011
16.3 Growth of bacterial spores in production
In production of canned soups and sauces unknown numbers of Bacillus spores are always introduced into the product through the raw materials. Production and cleaning regimes should prevent germination, growth and possibly sporulation during the allowed maximum production time. The HACCP-plan for such a line should include sufficient preventive measures to control the formation of numbers of spores that might survive the thermal process.
Historically it was assumed that keeping the product temperature well above 60 °C during processing was sufficient to prevent germination and subsequently the outgrowth and spore forming of aerobic and anaerobic spores. In practice this was supported by having a long history of commercial sterility in canned, sterilised soups and sauces, when using the generally applied thermal processes in retorts and in continuous sterilisation equipment. Examinations showed that during production at these elevated temperatures of above 60 °C, sometimes growth of thermophilic Bacilli, more specific of Bacillus stearothermophilus was observed. When, according to the GMP, the sterilised product is cooled immediately after sterilisation to below 42 °C, outgrowth of these spores is successfully prevented. These products are, of course, not intended for tropical countries, because this would require more severe sterilisation programs, in excess of F0 = 15 minutes.
As stated in the introduction, non-sterility problems caused by outgrowth of Bacillus spores occurred when new ways of packaging and sterilisation were introduced. These introductions were accompanied by upscaling soup production into larger, more automated production lines, with the intention of producing longer runs of the same recipe without intermediate rinsing or cleaning.
To establish maximum holding times in the line a number of soups were tested, originally at 50 °C because this was assumed to be the critical temperature for outgrowth of aerobic and anaerobic spores. Analyses for mesophilic aerobic spores were performed after pasteurisation of the soup for 15 minutes at 80 °C; the plates were incubated at 40 °C. Figure 16.1 gives an example of what frequently occurs when soup is waiting in the line to be filled. Especially in low-acid soups, with a pH > 5.50, rapid growth can occur of the total aerobic plate count, often already exceeding 107 CFU/g after four hours. Increase of anaerobic spores was never observed, but at 50 °C the aerobic spore counts increased from 10–50 CFU/g to 1000–5000 CFU/g.
Fig. 16.1. Growth of Bacillus spores in soup at 50 °C.
To establish maximum production runs as part of the line HACCP-plan samples were taken from the line during runs lasting longer than eight hours. Samples were collected from equipment throughout the whole line, starting with the soup preparation (weighing, mixing and cooking) and finishing in the filling department.
Most samples were taken from places where the product visibly collected and remained seated for longer times, such as from the wall and shaft of the stirrer in the vessels, from the lobes of a pump and from the upper part of the wall in the fillers. Because of the high temperatures here, 70 °C–80 °C, aerobic plate counts and spore counts were performed at 55 °C.
Surprisingly, especially from the hot part of the line, starting with the pump after the cooking vessel, rapid increase in total aerobic plate count and in aerobic spores was observed.
The example in Fig. 16.2 shows rapid growth of the total aerobic plate count already after six hours, resulting in counts above 107 CFU/gram after 12 hours production. After approximately eight hours the aerobic spores started to increase and after 16 hours have reached a level of 106 CFU/g. These numbers are far too high to be able to assure safety or stability of the sterilised product during its shelf life. Generally it is assumed that the thermal process should be able to either kill or sufficiently damage 1000 spores per gram to assure ambient stability.
Fig. 16.2. Growth of Bacillus spores in equipment during production.
In the example here it was shown that possibly germination, but certainly growth and sporulation of aerobic spore-formers, could take place at high production temperatures. To be able to assess the probability of this to occur in soup during production, soup was taken from the final filler in production and incubated at controlled temperatures at 60, 70 and 80 °C for a maximum of 16 hours. Total aerobic plate counts and aerobic spores (15 minutes, 80 °C) were analysed and plates were incubated at 55 °C.
Figure 16.3 shows results of one these incubation trials. This chicken soup was taken from the filler, which is the stage immediately before sterilisation. At 60 °C growth of total aerobic count and aerobic spores was much faster than at 55 °C. Already after four hours the total aerobic count reached its maximum level of 106 CFU/g and after eight hours the aerobic spores also reached the same level of 106 CFU/g. Extending the incubation time to 16 hours did not increase these levels any more.
Fig. 16.3. Growth and sporulation of Bacilli in soup at 60 °C, 70 °C and 80 °C.
Also at 70 °C growth occurred of both the total aerobic plate count and of aerobic spores, though the levels remained lower that at 60 °C. After eight hours incubation the total aerobic plate count reached its maximum level of a little over 105 CFU/g and after 12 hours the aerobic spores reached its maximum level of just under 103 CFU/g.
At 80 °C no growth of aerobic bacteria and aerobic spores was observed any more. The conclusion from these experiments therefore was that up to 70 °C, outgrowth of aerobic spore-forming bacteria followed by formation of spores was possible.
From different soups, either sampled in the production line, or from incubated samples at 55, 60 or 70 °C, a number of strains were isolated from the plates for typing with the RiboPrinter. All isolates were first checked for growth at 37 °C, making sure that only potential mesophilic spore-formers were typed. As stated earlier, thermophilic spores are regarded to be unimportant for these ambient stable products.
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Water Management, Treatment and Environmental Impact
H.K. Karapanagioti , in Encyclopedia of Food and Health, 2016
Inside the Food Final Product
Some processed foods such as canned soups require water to be prepared. In this case, water is used to prepare the food, and this water is also included in the final product. If water is used untreated from a spring, from a well, or from the municipality supply, it is thought to provide a special character to the food taste. If it is undesirable for water to add any taste to the final product, then the local water is treated. For example, water hardness (that occurs mainly due to the presence of calcium and magnesium ions) or conductivity (that occurs mainly due to the presence of dissolved ions in water) can add taste (e.g., salty) to the final product. Water pH, that is, a measure of acid or base in water, can also make the final product taste sour (low pH) or bitter (high pH). Some minerals such as calcium can interact with some of the ingredients found in food, such as proteins, phosphate, and enzymes, with both desirable (stable) and undesirable (less bioavailable) results.
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Canning of soup
In A Complete Course in Canning and Related Processes (Fourteenth Edition), 2016
Abstract
Soups are liquid meals, and canned soups are very popular throughout the world, with thousands of different recipes being packed. Most soups are meat and/or vegetable based and as such are generally low acid. Therefore a full sterilisation process is used; however, if the pH is in the acid range, the product can be safely pasteurised. Recipes vary as the market requires, but this chapter gives some basic recipes that can be adapted to suit the target consumers. Processing time and temperature combinations are not given as these will vary depending on the kinds and quantities of raw ingredients.
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Developments in plastic materials and recycling systems for packaging food, beverages and other fast-moving consumer goods
T.A. Cooper , in Trends in Packaging of Food, Beverages and Other Fast-Moving Consumer Goods (FMCG), 2013
Some examples of pouch packaging
As noted above, this is a rapidly growing field, so only a few examples can be discussed here.
Campbell's Soup and Heinz are both offering soup products in pouches in 2012, as well as sauces (Campbell's) and tomato ketchup (Heinz). Campbell's is targeting the new pouched products at trendy millennials for whom canned soups seem archaic but who are attracted by the modern aesthetics and appeal of pouches printed with elaborate graphics. Heinz aims to improve its price position relative to cheaper private labels, taking advantage of the 10–15% savings in packaging costs as well as the reduction in shipping costs.
Heinz Dip & Squeeze pouch packaging for ketchup was introduced in 2010 to supersede the ketchup sachet, which had been on the market for 42 years but which many consumers found difficult to open. Dip & Squeeze is a red bottle-shaped pouch made of polyester laminated to a high-barrier sealant web and has a laser score at the top for easy opening and squeezing. Alternatively, the lid can be peeled back from the opposite end for dipping rather than squeezing, and the package contains three times the amount of ketchup found in the traditional sachets. It is now available across the US and more than a billion have been sold. Heinz is also introducing a 10 oz size spouted stand-up ketchup pouch with a reclosable cap to sell for US$ 0.99 to complement its normal 20 oz bottle, which sells for US$ 1.99. The ketchup is dispensed by removing the cap and squeezing the flexible package – no more shaking the bottle!
Campbell's Go! Soup, introduced in the summer of 2012, is a premium line with trendy flavors like coconut curry with chicken and shiitake mushrooms and is packaged in a pouch with attractive graphics to attract a younger market. Campbell's is also launching a line of skillet sauces packaged in pouches later in 2012 for easy preparation of upscale dishes such as shrimp scampi or Thai green curry chicken. Both these products will be packaged in retortable stand-up pouches made from tailored, high-barrier laminated structures. The 14 oz microwavable Go! Soup pouch material is an all-plastic laminate and the 9 oz Skillet Sauce pouch is a plastic/aluminum laminate. These are single-use products so the pouches are not resealable. The sauce pouch is not designed to be microwaveable but to be emptied into a skillet for cooking with other ingredients. 106 , 109
Kraft recently introduced the YES Pack – a squared-off pouch made of a high-strength flexible nylon-PE blend film, with dual handles and a rigid plastic mouth, holding one gallon of salad dressing for commercial operations. This is a squeezable package, so almost all of the contents can be removed without scraping the sides of a rigid package. Another recent trend is the use of stand-up pouch packaging for wine, such as the Astrapouch, which holds the equivalent of two 750 ml bottles. It employs a resealable, one-way plastic spout to keep opened wine fresh for up to a month when refrigerated. 110
Stick packs are also increasingly being used for nutraceuticals and energy drinks. The stick packs were originally designed to facilitate pouring the contents into a water bottle (e.g. Crystal Light On the Go flavored drink powder stick packs to replace tubs). However, they can now be used for low-cost direct-to-mouth packaging for 'active' lifestyles. An example is encapsulated caffeine (Encaff Products Inc.), which can be poured directly onto the tongue without needing water (i.e. energy drinks without the water). This also opens up opportunities for nutraceuticals and pharmaceuticals to provide convenience and dosing accuracy. Another example is Good Times Beverages individual cocktail pouches for convenience in making single frozen cocktails. The pouches can be placed in the freezer, squeezed several times and the contents poured into a glass or drunk straight from the pouch.
Pouch packaging is also being designed for permanent, flexible, reusable packaging, which is washable and extremely portable, such as the Vapur-Ampac foldable, water bottle.
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Starch Use in Foods
William R. Mason , in Starch (Third Edition), 2009
4 Development of Monosubstitution
Acetylation was the first form of monosubstitution used in food starches. Waxy maize acetylated distarch adipates came into use in the mid-1950s, driven by demand for pie fillings with improved stability to winter distribution. Acetylation was achieved by reaction with acetic anhydride 17,18 or vinyl acetate. 19 The improved smoothness and sheen attainable led canned soup and sauce processors to switch from using only native corn or potato starch, and popularized the more general use of modified waxy maize starch. The improved freeze–thaw stability of acetylated crosslinked waxy maize starch led to the marketing of frozen sauces, initially on vegetables, but also in entrees and pies by the 1960s. 20 The use of hydroxypropylation 21 was commercialized in the early 1970s with epichlorohydrin or phosphoryl chloride as the crosslinker. Hydroxypropylation provided an increased level of stability so that the quality attainable in puddings and frozen sauces was dramatically improved. Encapsulation with emulsion-stabilizing dextrins began in the mid-1960s. Corresponding modified food starches for use in beverage emulsions came into use in the mid-1970s. 22
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Global Food and Nutrition: World Food, Health and the Environment
Jacqueline B. Marcus MS, RD, LD, CNS, FADA , in Culinary Nutrition, 2013
The Puerto Rican Diet, Nutrition and Health
Puerto Ricans are more inclined to develop arthritis, cancer, diabetes (three to five times higher than the general US population), gastrointestinal disorders, heart disease, high blood pressure and obesity.
Almost three-quarters of the foods and beverages in Puerto Rico are imported from the United States. As a result, the Puerto Rican diet—particularly that of Puerto Rican youth—has become quite Americanized. Favorite foods include fast foods such as hot dogs and pizza, plus canned soups, cold cereals and spaghetti. Carbonated beverages have replaced traditional unsugared fruit juices.
The typical Puerto Rican diet has many positive features. It is high in a variety of complex carbohydrates from breadstuffs, corn and rice. Incomplete proteins, such as those found in legumes, rice and beans, are often eaten in combinations that are both economical and healthy.
A typical Puerto Rican diet includes some calcium through dairy milk and milk products and greens. Milk is consumed in café con leche (coffee with milk) and flan (custard). However, increased low-fat dairy products and a variety of vegetables would improve the intake of calcium, fiber and other vitamins and minerals.
Puerto Ricans should be discouraged from consuming too much sugar from refined carbohydrates and using excessive cooking fats by learning a greater variety of preparation styles. Bilingual children can play a major role in promoting the best traditional dietary practices with healthier modifications [20].
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Celery
S.K. Malhotra , in Handbook of Herbs and Spices, Volume 3, 2006
18.6.1 Processed products from celery leaves and petioles
The long fleshy petioles and leaves are valued for their flavour and texture and are used as salad and in the preparation of some value added products and have been documented by Pruthi (2001).
Dehydrated celery
Celery stalk and leaves are dehydrated and are commercially available in the USA and the UK markets as:
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10 mm celery stalk dice
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leaf and stalk flakes
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stalk and leaf granules
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celery powder.
These various styles of dehydrated products are used for flavouring soups, broth base, canned tuna fish, stuffings and stewed tomatoes and as a garnish on potato salad and meat sauces.
Celery stalk products
Stalk products have been reported to retain the deepest green colour. This is frequently protected by the addition of minute amount of sodium bisulphite or sodium sulphite. Celery flakes are used in dry soup mixes, canned soups, sauces, stuffings, casserole products and vegetable specialities. Granulated or powdered celery is a good choice for canned and frozen sauces and dry mixes for bread and soups. Cross cut and diced celery is used in canned and frozen soups, relishes, vegetable specialities and salad mixes.
Processed celery juice blends
Processed celery juice blends in combination with vegetables have been prepared successfully and marketed. Organic celery and tomato; organic celery and carrot juice blends are becoming popular as nutritious drinks and have been reported to function as a cleansing drink that is good for recovery from many chronic illnesses.
Freeze-dried celery
Cross-cut slices of celery stalks are also available in freeze-dried form. The freeze-dried process is also effective in retaining original shape and crispness of celery. This product makes a crisp garnish for potato salad, casseroles, chinese dishes, gelatin salad, pickles and relishes. Overall quality for retention of nutrients is better in freeze-dried celery petioles.
Blanched celery
Blanching removes the green colour in the petioles and is accomplished by excluding light from leaf stalks while plants are still growing in the field. This process makes the leaf stalks more tender but reduces the strong flavour and nutrients particularly vitamin A. A small segment of customers still demand blanched celery. In the past, blanched celery was more popular but these days there is more demand for green celery owing to the presence of more natural nutrients.
Pickling celery
Celery petioles are also processed for the preparation of pickling. Such processed celery for pickling has a ready market in the USA and some European countries. The stalk celery and root celery can both be used in the processing industry for preparation of picklings. In the pickling process the tender petioles of celery are cured in dry brine and subsequently preserved by using spices and condiments or vinegar. Celery petiole pickling can also be prepared in mixing with other vegetables and mixed pickling can be prepared. Pickled celery is known as a good appetizer and adds to the palatability of different kinds of meals.
Canned celery
Tender celery petioles both blanched or green are ideal for canning. The unit operations include sorting and grading, washing, peeling (if required), coring and pitting, blanching, (if required), cane filling and brining. Usually canned celery is processed at high temperatures 115–121 °C (high pressure of 10–15 lb/inch2 ) in the autoclave. The temperature and time of processing vary with size of can. Celery petioles are usually canned for later use in the off season or in combinations in canned soups, meats and culinary sausages.
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Context for new or expanded facility
In Practical Design, Construction and Operation of Food Facilities, 2009
Food Industry Overview
Various studies have been published of the food industry from an economic and consumer point of view (McCorkle, 1988; Connor, 1988). While these references are old, they are still accurate in an industry that does not change very quickly. The food industry is the largest by economic impact in the USA, with annual sales of over $500 billion. The industry is very diverse, but major segments include those that process raw commodities into ingredients and foods; those that preserve and modify ingredients into foods and ingredients; and those that produce consumer food products.
Examples of each include:
Raw commodities
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Meat animal slaughter (beef, pork, poultry)
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Sugar milling and refining
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Flour milling
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Oil seed processing
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Corn wet and dry milling
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Dairy processing (milk, cream, butter)
Intermediate
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Baking (bread, cake, cookies, crackers)
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Ice cream
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Confectionery
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Vegetable freezing
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Fruit and vegetable dehydration
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Baby foods (fruit and vegetable purees)
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Dry cake mixes
Consumer products
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Soft drinks
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Beer
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Wine
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Canned soups
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Fruit and vegetable juices, aseptic, canned and hot filled
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Prepared meals (refrigerated, frozen and shelf stable).
These examples are not intended to be comprehensive, but rather are to present a small taste of the diversity and variety of the industry.
Corresponding to the wide range of products are the many processes involved, ranging from the relatively simple size reduction and physical separation of flour milling to the sophisticated biochemical process of fermentation and aging involved in making wine. In between are combinations of culinary and engineering art and science to reproduce on a large, commercial scale the flavor, texture and nutrition of home-prepared dishes and meals.
Food companies can be very large, with sales approaching $25 billion per year, and relatively small, with sales that might not exceed $1 million per year. (See the August issue of Food Processing (Putnam Media, Itasca, IL) each year for a list of the top 100 food companies.) In the list for 2007, the top five companies, by food sales in 2006 were:
| 1. Kraft Foods Inc. | $23 118 Million |
| 2. Tyson Foods Inc. | 23 059 |
| 3. Pepsico Inc. | 22 178 |
| 4. Nestle (USA and Canada) | 20 688 |
| 5. Anheuser-Busch Cos. Inc. | 11 888 |
In contrast, the last five on this list were:
| 96. J & J Snack Foods | $515 Million |
| 97. American Seafoods Group LLC | 510 |
| 98. Pierre Foods | 488 |
| 99. B & G Foods | 411 |
| 100. Ruiz Foods | 400 |
| Ventura Foods | 400 |
It took $400 million in sales to make the top 100. Sales of $1 billion put several firms tied at 74th. The top 48 firms had sales of $2 billion or more.
Consolidation among large companies has made the largest multinational firms very large indeed, with operations all over the world. In the context of designing and operating facilities, one consequence is that such firms need to be cognizant of customs, regulations and cultures very different from those of their home country. As one small example, it is common in many countries to provide one or more hot meals each day to the workforce. Sometimes, dormitories are also provided for a work force that may have moved a long distance to get a job. This means that a food facility may need to have a full kitchen and extensive living quarters on site. These are not commonly found in US food facilities.
Religious and cultural practices often affect what foods are popular. Muslim and Jewish adherents do not eat pork; Hindus do not eat beef; Muslims avoid alcohol; and Chinese apparently like corn chowder, among other preferences. Such cultural practices affect what food products are likely to sell well in a given market and thus what a given facility is intended to do.
The distribution systems in developing countries may be relatively primitive due to poor roads, lack of refrigeration in homes and stores, and the lack of a commercial infrastructure. These conditions mean that the scale of operation may need to be smaller than it would be in the USA. Products that are shelf stable, as compared with frozen or refrigerated, are better suited for developing countries. Food manufacturers may need to establish their own system of distribution centers and wholesalers, whereas third parties in the USA often handle these functions.
Some facilities may be located to take advantage of local raw materials. Thus, for example, sugar mills are in tropical areas because sugar cane is a tropical crop. Sugar mills produce raw sugar, which is about 97% pure sucrose, and is shipped closer to markets in temperate areas for further refining. Tropical oils, such as palm oil and palm nut oil are harvested and the raw oil produced close to the palm plantations, with refining taking place closer to shipping points on the coasts of Southeast Asia.
Another factor in facility location is the relative density of the raw material and finished product. For instance, potato chip snacks, which have a low bulk density, are commonly made near population centers, while frozen and dehydrated potato products are usually made near potato producing areas.
Wheat flour mills in the USA tend to be located near wheat producing areas and near water ports on rivers, lakes or oceans. Flour users, such as bread bakers are closer to markets. Cookie and cracker bakers may have larger and fewer plants because cookies and crackers are denser than bread and have a longer shelf life.
The customers of food manufacturers are not usually consumers but the stores and food service institutions that serve consumers. About 50% of food consumed in the USA is consumed outside of the home, so the manufacture and distribution of products for food service are increasingly important. These products are different in many ways from those intended for use in the home or factory. Food service products are often refrigerated or frozen, are usually portion controlled, and may be heavily influenced by culinary concepts. This means they are conceived and developed by chefs or people with some culinary training and are meant to be used by kitchen personnel in restaurants, colleges, hospitals and prisons. Consumer food products, in contrast, are often developed by food scientists and food technologists.
Consumer food products tend to be sold in supermarkets, convenience stores and, increasingly, in mass merchandisers. Often these customers have their own distribution systems and centers (DC). Usually, food manufacturers have distribution centers as well, so there can be some redundant handling as a product moves from factory to distribution center to another distribution center and then to the store. Rationalizing the food distribution system is a major cost reduction opportunity, but the ideal solution has not emerged yet.
Some products require direct store delivery (DSD), usually because they are perishable or have such high sales volume that they need frequent deliveries. Bread, milk, soft drinks and salty snacks are examples of foods delivered daily to most stores. DSD is an expensive distribution system because it is labor intensive and because fuel costs have been increasing. DSD driver/salespeople are often paid a commission on sales, which provides a substantial incentive, but adds to costs. Some are company employees while others may be independent contractors who own their equipment. Independent contractors often service vending machines for snacks, soft drinks and confections. DSD once was largely a cash business, with store owners paying on the spot. This is less common now. Managing and controlling a widely dispersed sales and delivery force can be a challenge.
Mass merchandisers have been influencing the food industry because they demand low prices, very good service and, often, special packaging (especially in 'club' stores). They also move very large amounts of product, so accommodating them is a major objective. Food manufacturers often open dedicated sales offices near the headquarters of mass merchandisers so as to service them better.
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Fresh and cured meat processing and preservation
Steven M. Lonergan , ... Dennis N. Marple , in The Science of Animal Growth and Meat Technology (Second Edition), 2019
Summary
Processed meats are manufactured from fat and muscle of wholesale cuts, trimmings from carcasses, and some nonmuscle cuts such as liver. Processed meats can be divided into fresh processed meat and cured and smoked processed meat. Examples of fresh processed meat are ground beef, mechanically separated meat (MSM) from bone, mechanical and enzyme tenderization of steaks, moisture and marination of fresh pork products, and frozen meat items. Examples of other processed meat products are canned ham, canned SPAM, canned soups with ham, Vienna-style wieners, and stews. Ready-to-eat meats (RTE) can also be obtained in sliced cooked loaves, snack sticks, jerky, roast beef, and other delicatessen items.
Cured and processed meat products make up a large number of the processed meat items sold in the United States and Europe. Curing and salting meat is one of the oldest forms of meat preservation. Earlier than 3000 BC, the salting of meat for preservation was practiced. Most curing procedures use a salt-based brine or pickle for manufacturing the cured meat products. These curing ingredients have a major influence on the flavor of cured meat. The most common commercial method for introducing the brine into a cut of meat is by a low-pressure pump injection system. These methods are used for curing and processing hams and bacon as well as Windsor Chops and Canadian bacon. Other examples of cured and processed meat items are dried beef, cured beef brisket called corned beef, and turkey ham. Another important ingredient in the brine mixture is sodium nitrite. It is responsible for the cured meat color, adds flavor, and can help prevent the development of spores from microorganisms such as C. botulinum. Most cured meat products are also heated or cooked in a smokehouse to enhance the flavor and surface color of the meat. To maintain good color of the cured meat products, packaging the meat with oxygen-impermeable packaging materials is essential.
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Nutrition and Cystic Fibrosis
Zhumin Zhang , HuiChuan J. Lai , in Nutrition in the Prevention and Treatment of Disease (Third Edition), 2013
2 Dietary Intervention
a Oral Supplements
For infants experiencing inadequate weight gain, increasing caloric density of the feedings is the first step. This can be achieved by fortifying breast milk or by concentrating formula. For infants who are taking solids, additional calories can be added to infant cereal with the addition of carbohydrate polymers (e.g., Polucose) and/or fats (e.g., vegetable oil, MCT oil, or Microlipids).
Dietary intervention should begin with dietary modification to increase caloric density of the diet—that is, addition of high-calorie foods to the patient's regular diet without dramatically increasing the amount of food consumed. For example, margarine or butter may be added to many foods, and half-and-half can be used in place of skim milk or water when preparing canned soup. More examples of how to maximize the caloric density of the diet are given in Table 42.7. If dietary modification is ineffective, use of energy supplement may be introduced. However, it is important to ensure that the energy supplement is not used as a substitute for normal food intake.
Table 42.7. Maximizing Calories for Healthy Patients with CF
| Adding calories to foods | High-calorie foods and snacks a |
|---|---|
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|
- a
- Assess age appropriateness, especially with respect to choking risk in young children, before recommending.
Source: Adapted from Borowitz et al. [80].
b Enteral Feedings
Enteral feeding can be initiated when oral supplementation does not improve growth and nutritional status significantly. The goals of enteral feeding should be explained to the patient and family—that is, as a supportive therapy to improve quality of life and outcome—and their acceptance and commitment to this intervention should be realistically assessed.
Enteral feeding can be delivered via nasogastric tubes, gastrostomy tubes, and jejunostomy tubes. The choice of enterostomy tube and technique for its placement should be based on the expertise of the CF center. Nasogastric tubes are appropriate for short-term nutritional support in highly motivated patients. Gastrostomy tubes are more appropriate for patients who need long-term enteral nutrition. Jejunostomy tubes may be indicated in patients with severe GERD; use of predigested or elemental formula may be needed with jejunostomy feeding.
Standard enteral feeding formulas (complete protein and long-chain fat) are typically well tolerated. Calorically dense formulas (1.5–2.0 kcal/ml) are usually required to provide adequate energy. Nocturnal infusion is encouraged to promote normal eating patterns during the day. Initially, 30–50% of estimated energy requirement may be provided overnight. Pancreatic enzymes should be given with enteral feeding. However, optimal dosing regimen is unclear with overnight feeding.
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