Enteral Tube Feeding

Enteral Feeding
The state of being fed by a feeding tube
also known as Gavage or Tube Feeding
Tube feedings are a way to give fluids, calories and
medications to a child.



Feeding tube
It is a medical device used to provide nutrition to
patients who cannot obtain nutrition by swallowing.
Placement may be temporary for the treatment of
acute conditions or lifelong in the case of chronic
disabilities.
A variety of feeding tubes are used in medical practice.
They are usually made of polyurethane or silicone. The
diameter of a feeding tube is measured in French
units (each French unit equals 0.33 millimeters). They
are classified by site of insertion and intended use.
Enteral nutrition
This is where the nutritional fluid is given into the gut
through a tube going into the stomach or small
intestine.
This is best for you if your digestive system is working
normally but you aren't able to eat enough - for
example, due to a cancer in the head or neck area.

Possible reasons for tube feedings:

Prematurity
Central nervous system problems
Severe cerebral palsy
Burns
Head trauma
After surgery
Inherited metabolic disorders
Gastrointestinal diseases
Severe gastroesophageal reflux
Failure to thrive
Severe refusal to eat food
Severe food allergy
Disorders of the esophagus
Abnormalities of the anatomy of the gastrointestinal tract
Severe cleft lip/cleft palate
Cancer

Enteral nutrition (EN)

Most common methods used :
Nasogastric (NG) feeding - a thin tube is passed down the
nose and into the stomach. It is often used after surgery to
the head, neck, stomach or gullet (oesophagus).

Percutaneous endoscopic gastrostomy (PEG) and
radiologically-inserted gastrostomy (RIG) feeding in
which a tube is passed into the stomach, through the skin and
muscle of the abdomen

Percutaneous endoscopic jejunostomy (PEJ) feeding -
a tube is passed through the skin and muscle of the abdomen
into the top part of the small bowel (the jejunum) just below
the stomach.

Nasogastric (NG) feeding

It is usually recommended if you are likely to need to be
given nutritional support for only a short time. NG
feeding may also be used for people
having radiotherapy to the mouth, throat or gullet, if
swallowing becomes difficult due to swelling from the
radiotherapy.
The major advantage of nasogastric, nasoduodenal, and
nasojejunal feedings over gastrostomy or jejunostomy
feeding is they do not require surgery Therefore, they can
be started quickly and they can be used either for short
periods or intermittently with relatively low risk.
Nasogastric (NG) feeding

Nasogastric feeding is often called a tube that is
inserted through the nose and down the back of the
throat. It travels down the esophagus and into the
stomach. It is primarily used for giving medications
and infant formula or breast milk to babies and
children who cannot take enough formula by mouth to
gain weight.
Nasogastric tube
Subtypes of Nasogastric Tube
Feeding
Nasoduodenal (ND) and Nasojejunal (NJ) Tube Feeding
the tube goes into the nose through the stomach, and feeds
into the duodenum or jejunum
It is used when the patient is at high risk for:
aspiration food going into the lungs
reflux movement of stomach or intestinal contents into the
esophagus
When there is delayed stomach emptying or the stomach is not
working properly
Given as a short term feeding, usually less than 6 weeks
Nasogastric (NG) feeding

What are the goals for NG tube feeding?
To provide nutrition in a way that the child and
family can accept
To achieve and/or maintain ideal growth
To provide the right amount of nutrients
To provide the right amount of water
To help control a control a disease or health problem

Nasogastric (NG) Feeding
COMMON PROBLEMS:
You may find the insertion of an NG tube
uncomfortable and possibly quite distressing. The
procedure is usually completed very quickly, although
sometimes it can take more than one attempt to get the
tube into the right place
Since the end of the tube comes out through the nostril
and is taped to the face, it is obviously visible. You may
find this embarrassing and might feel self-conscious
about it
NG tubes can be pulled out of the stomach if they are
not fixed securely. Before each feed the position of the
tube needs to be checked. In hospital the nurses will
do this or will show you how to do it. Normally, some
fluid is drawn out of the tube and checked with a pH
indicator. If you are at home, you, or a member of your
family, will need to do this before each feed

Common Problems of NG Feeding
Continued
Occasionally the tube may become dislodged. This can
result in the tip of the tube entering the lungs, in which
case it will need to be removed and replaced. Sometimes
the tube may fall out completely and will then need to
be replaced
NG tubes can sometimes become blocked. Water is
flushed down the tube at regular intervals to try to
prevent this from happening. However, if a blockage
occurs and cannot be cleared the tube will need to be
removed and a new one put in.

Common Problems of NG Feeding
Continued
An NG feed can be inconvenient, as the liquid food
often needs to be given slowly into the tube over a
number of hours and during this time you will not
be able to move around freely. Some people prefer
to have their feed given overnight so that they are
not restricted during the day. Your dietitian will talk
to you about the best way of giving the feed so that
it does not interfere too much with your lifestyle. It
may be suitable to use a small portable pump to
regulate the flow of the feed


If the feed is given too quickly it
can flow up into the gullet, which
can be very unpleasant and may
make you feel sick. Medicines can
be given to control this, so let your
doctor know.
Gastrostomy tube feeding
it is the tube insertion is the placement of a feeding tube
through the skin and the stomach wall, directly into the
stomach.
insertion is done in part using a procedure called
endoscopy
After the endoscopy tube is inserted, the skin over the left
side of belly (abdomen) area is cleaned and numbed. The
doctor makes a small surgical cut in this area and inserts a
small, flexible, hollow tube with a balloon or special tip
into the stomach. The doctor uses stitches to close the
stomach around the tube.


Gastrostomy tube feeding
Recommendations
Babies with birth defects of the mouth, esophagus, or
stomach (for example, esophageal atresia or tracheal
esophageal fistula)
Patients who cannot swallow correctly
Patients who cannot take enough food by mouth to
stay healthy
Patients who often breathe in food when eating

Gastrostomy tube
is a tube that goes through an opening in your baby's
skin into his stomach.
also called a G-tube. A G-tube may be used to feed
your baby or give him medicine.
It also may be used to let air or liquid out of your
baby's stomach.
is placed inside an opening that is made in your baby's
abdomen. This opening is called a stoma.

Gastrostomy tube
Part of the tube is inside your babys stomach and part
of the tube extends outside of it (the external tube).
The outside part may be a long tube or may look like a
button that rests directly on top of your baby's skin.
Your caregiver may first give your baby an external
tube and then later replace it with a button.
With a gastrostomy tube, feeding your baby may
become easier. Your baby may gain weight, get enough
nutrition, and become healthier.

Risks of Gastrotostomy Tube
Feeding

Risks for any anesthesia are:
Reactions to medications
Problems breathing
Risks for surgical or endoscopic feeding tube
insertion are:
Bleeding
Infection

Jejunal Tube Feeding

Tube feeding directly into the jejunum (i.e.,
the middle section of the small intestines).
is used for children who cannot use their
upper gastrointestinal (GI) tract because of
congenital anomalies, GI surgery, immature
or inadequate gastric motility, severe gastric
reflux, or a high risk of aspiration.
The jejunal tube bypasses the stomach
decreasing the risk of gastric reflux and
aspiration.

Disadvantages to jejunal feeding
1. Nasojejunal tubes and jejunal tubes passed from a
gastrostomy to the jejunum are difficult to position
and may dislodge or relocate; their position must be
checked frequently by X-ray. A jejunostomy reduces
problems of tube position.
2. Jejunal feedings bypass the digestive and anti-
ineffective mechanisms of the stomach.
Disadvantages to jejunal feeding
Continued
3. They require continuous drip feeding which results in
limited patient mobility and decreased ability to lead a
"normal" life.
4. When compared to gastric feedings, they carry a
greater risk of formula intolerance, which may lead to
nausea, diarrhea, and cramps. Intact nutrients may be
given if the feeding is given in the proximal intestine,
but elemental or semi-elemental feeding are required if
the feeding is delivered more distally. These formulas
are more expensive.

Indications of Enteral Feeding
Enteral nutrition should be considered for any patient
with a functional gastrointestinal tract who requires
nutritional support.
Enteral feeding may be required if adequate oral
nutrient intake cannot be provided in children with
growth failure, weight faltering, or weight decit.
Children with severe neurological dysfunction may
require prolonged periods devoted to oral feeding.

Indications of Enteral Feeding
Tube feeding can provide welcome respite for families
and caregivers who previously may have spent over 6
hours a day assisting with oral feeding.
The risk of aspiration may be reduced by tube feeding.
Enteral tube feeding may provide a safe and reliable
route for the delivery of essential nutrients.

Indications of Enteral Feeding
Enteral feeding may be an option for children with
increased energy needs that are difcult to achieve via
the oral route such as may occur in cystic brosis or
congenital heart disease.
Disorders of the gastrointestinal tract that result in
excessive gastrointestinal losses, such as short-bowel
syndrome, secretory diarrhea, or dysmotility
syndromes, may have improved absorption and
reduction in losses with small volume continuous
enteral feeds of a specialized formula.

Indications of Enteral Feeding
Due to their composition these formulas are often
unpalatable and require tube administration to obtain
adequate volumes of administration. Most patients
receiving parenteral nutrition will also receive some
enteral nutrition.
Enteral nutrition usually provides an important
transition stage as the patient progresses from
parenteral nutrition to oral diet.


Indications of Enteral Feeding
Although enteral nutrition has mainly a
therapeutic intent, it can also be used to prevent
the development of malnutrition, such as can
occur during cancer chemotherapy.
Enteral nutrition has been advocated as a primary
treatment for conditions associated with a
metabolic disturbance, such as the use of
gastrostomy tube feeding to infuse a ketogenic diet
in children with epilepsy.
Indications of Enteral Feeding
A more recent concept is that of minimal enteral
feeding, in which enteral nutrition is provided at a very
slow rate and volume with the aim of presenting
nutrients to the intestinal mucosa without attempting
to contribute signicantly to total-body nutrition. (?)
Advances in the understanding of the role of nutrients
in the modication of inammation and specic
disease processes have led to the development of
disease-specic formulas (eg, for Crohns disease). (?)
Contraindications of Enteral
Feeding
Absence of intestinal function due to failure, severe
inflammation or, in some instances, postoperative stasis.
Complete intestinal obstruction
Inability to access the gut eg. severe burns
High loss intestinal fistulae
Ethical considerations eg. terminal care.
Patients with severe neurological disabilities associated
with oropharyngeal dysfunction may be at risk of
chronic aspiration.


Complications of Enteral Feeding

Gastrointestinal complications
Nausea and vomiting
Approximately 20% of patients receiving
enteral tube feedings experience nausea and
vomiting. Vomiting increases the risk of
aspiration. Causes are multifactorial but
delayed gastric emptying is the most
common problem.


If delayed gastric emptying is suspected,
consider reducing narcotic medications,
switching to a low-fat formula,
administering the feeding solution at room
temperature, reducing the rate of
administration, and administering a
promotility agent.


If the patient appears distended, check gastric
residuals before the next bolus feeding, or every four
hours for continuous feeding. If gastric residuals are
low yet nausea persists, consider antiemetic
medications.

Complications of Enteral Feeding

Diarrhea
Diarrhea is common in tube fed patients,
occuring in 2% to 63% of patients depending on
how it is defined. If clinically significant
diarrhea develops during enteral tube feeding,
consider the following options:
Add fiber, e.g., psyllium
Consider an enteral formula with fiber
Change the formula
Use an antidiarrheal agent

Complications of Enteral Feeding
Constipation
Constipation can result from inactivity,
decreased bowel motility, decreased fluid
intake, impaction, or lack of dietary fiber. Poor
bowel motility and dehydration may lead to
impaction and abdominal distension. A
standard abdominal x-ray is often effective for
diagnosis and will clearly differentiate
constipation from bowel obstructions.
Constipation usually is improved through
adequate hydration and use of fiber-containing
formulas, stool softeners, or bowel stimulants
Complications of Enteral Feeding

Malabsorption/maldigestion
Malabsorption is defined as impaired
absorption of one or more nutrients.
Clinical manifestations include
unexplained weight loss, steatorrhea,
diarrhea, anemia, tetany, bone pain,
bleeding, neuropath, glossitis, or
edema.
Causes of malabsorption are many and include
gluten sensitive enteropathy, Crohn's disease,
diverticular disease, radiation enteritis, enteric
fistuals, HIV, pancreatic insufficiency, and short
bowel syndrome. Knowledge of the patient's
history and selection of an appropriate enteral
product should help reduce or prevent
malabsorption. However, depending upon the
extent of disease, parenteral nutrition may be
necessary.


MECHANICAL COMPLICATION OF
ENTERAL FEEDING
Aspiration
Pulmonary aspiration is an extremely serious
complication of enteral feeding and can be life-
threatening in malnourished patients.
The incidence of clinically significant aspiration
pneumonia is 1% to 4%. Symptoms of aspiriation
include dyspnea, tachypnea, wheezing, rales,
tachycardia, agitation, and cyanosis. Aspiration of small
amounts of formula may not cause immediate symtoms,
but a fever later may suggest development of aspiration
pneumonia.



MECHANICAL COMPLICATION OF
ENTERAL FEEDING
Risk factors for aspiration include:
Decreased level of consciousness
Diminished gag reflex
Neurologic injury
Incompetent LES
GI reflux
Supine position
Use of large-bore feeding tubes
Large gastric residuals
Use of small-bowel feeding tubes, promotility agents,
periodic assessment of gastric residuals, and keeping the
head of the bed elevated may reduce the risk of aspiration.








Tube malposition
Complications may arise during the
placement of a feeding tube or simply
from the presence of one. Feeding tube
placement can cause bleeding, tracheal or
parenchymal perforation, and GI tract
perforation. Placement of tubes by trained
personnel and using appropriate post-
placement montoring should minimize
these complications.

Presence of the feeding tube itself may
cause upper and lower airway
complications, aggravation of esophageal
varices, cellulitis, necrotizing fasciitis,
fistulas, and wound infection. Use of a
small-bore feeding tube and very attentive
nursing care can minimize many of these
problems.


MECHANICAL COMPLICATION OF
ENTERAL FEEDING
Tube clogging
Tube clogging is more likely with intact protein products
and viscous products. Most clogs can be prevented by
routine flusing of the feeding tube, use of clean
technique to minimize formula contamination, and
extreme care when administering medications via the
feeding tube.
The recommended first line method to unclog a tube is
to instill warm water using slight manual pressure. If
this fails, a pancrelipase and sodium bicarbonate
solution may be instilled in order to "digest" the clog.


METABOLIC COMPLICATION OF
ENTRAL FEEDING
Metabolic complications of enteral nutrition are
similar to those that occur during PN, although the
incidence and severity may be less. Careful monitoring
can minimize or prevent metabolic complications.

Refeeding syndrome
Refeeding of severely malnourished patients may result
in "refeeding syndrome" in which there are acute
decreases in circulating levels of potassium, magnesium,
and phosphate. The sequelae of refeeding syndrome
adversely affect nearly every organ system and include
cardiac dysrhythmias, heart failure, acute respiratory
failure, coma, paralysis, nephropathy, and liver
dysfunction.
The primary cause of the metabolic response to
refeeding is the shift from stored body fat to
carbohydrate as the primary fuel source. Serum insulin
levels rise, causing intracellular movement of
electrolytes for use in metabolism.

The best advice when initiating nutritional support is to
"start low and go slow". Recommendations to reduce the
risk of refeeding syndrome include:
Recognize patients at risk
Anorexia nervosa
Classic kwashiorkor or marasmus
Chronic malnutrition
Chronic alcoholism
Prolonged fasting
Prolonged IV hydration
Significant stress and depletion
Correct electrolyte abnormalities before starting
nutritional support
Administer volume and energy slowly
Monitor pulse, I/O, electrolytes closely
Provide appropriate vitamin supplementation
Avoid overfeeding



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