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Tool Facilitates Fast, Accurate Assessments of Enteral Feeding Regimens

Calculator saves time, reduces error


There’s an important component of patient care that sometimes gets overlooked – providing proper nutrition.


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“Nutrition is such an integral part of an individual’s wellness, and when you have chronic illnesses, it’s an even more critical piece of your therapies and getting you back to optimal health,” says Sandra Kim, MD, Chair of Pediatric Gastroenterology, Hepatology and Nutrition at Cleveland Clinic Children’s. “We need to understand all of the nuances that go into complete nutrition – calories, proteins, fats and all the critical nutrients you need.”

That can be challenging and laborious. So, Diana Schnee, MS, RD, CSP, LD, a registered dietitian at Cleveland Clinic Children’s, developed an enteral nutritional calculator to quickly and accurately assess enteral feeding regimens.

Developing a comprehensive calculator

Schnee created the calculator in Microsoft Excel out of necessity. Physicians routinely asked her to analyze feeding regimens for patients with chronic illnesses who use enteral nutrition products to ascertain if the formula was meeting their needs and whether they needed additional vitamins. This required Schnee to perform dozens of calculations for each nutrient, then reassess the calculations to account for added vitamins.

“Dietitians love to have all the numbers,” says Schnee. “But in order to do all the math, it took me at least 20 minutes per patient, and there is a lot of room for error.” She sees up to 12 patients a day, so the task was consuming a large part of her time spent in clinic.

“By using the tool, dietitians can take care of more patients, more effectively, which frees up time for other things, such as face-to-face time with patients and families,” says Dr. Kim.

Although formula companies provide calculators for their own products, they have shortcomings. Schnee says they don’t permit dietitians to add in vitamins or compare intake to the upper limits to look for potential toxicities. Her enteral nutritional calculator allows for a complete analysis.

“When you are dealing with children with chronic illnesses, nuances and personalization are so important,” says Dr. Kim. For instance, a child with a gastrointestinal tract inflammation may not be able to absorb certain nutrients. The tool can account for all the variables.

“With my calculator, I can drag and drop in different formulas, add vitamins at different doses and then compare the intake of the formula plus the vitamins to the child’s needs based on their age and weight and compare it to the upper limits to make sure we have adequacy, but not toxicity,” she says.


Putting parents’ minds at ease

Schnee included all the necessary calculations in the enteral nutrition tool, which she updates periodically to add new pediatric formulas and vitamins. She and her dietitian colleagues at Cleveland Clinic Children’s currently use the calculator on their laptops, but Schnee hopes to integrate it into the electronic medical record or create an app for clinicians to use it on their mobile devices.

The enteral nutritional calculator is an invaluable tool for Schnee’s daily work in clinic. One of her patients is a 4-year-old who has been unable to tolerate the transition from an infant formula to a pediatric one. Using the calculator, Schnee identified a small dose of an adult liquid multivitamin that could be added to the infant formula to ensure the patient’s nutritional needs are being met.

“While it’s not ideal to have a 4-year-old on an infant product, we are riding it out because the patient’s condition is so complex and this approach works. We will revisit the patient’s feeding regimen when she’s bigger,” says Schnee. “It has been such a relief to the mom to know that her child is getting what she needs.”

The calculator has also been incredibly useful during the formula shortage that began in 2022.

“The amount of formula changes we have done for children is unprecedented,” says Schnee. “It’s taken up a huge chunk of time, but the calculator gives us a sense of what to look for.” For instance, dietitians can consider if a patient’s potassium levels will rise or calcium will dip on a new formula.

Plans for wider use

For now, the enteral nutritional calculator is only available internally at Cleveland Clinic. But Schnee would like to further develop and commercialize the tool, which can be used for anyone from birth to 70 years old, so it becomes widely available to all dietitians to aid their practice.

“We are proud of our Cleveland Clinic Children’s team and experts like Diana, but we want to make sure that every child, every teen and every adult – regardless of where they receive care – have access to this valuable tool,” says Dr. Kim.


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