Tube Feeding

                                                                

A feeding tube is a medical device used to endow with nourishment to patients who cannot get hold of nutrition by mouth, are incapable to gulp down securely, or need nutritional supplementation. The state of being fed by a feeding tube is called gavages, enteral feeding or tube feeding. 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.

Indications for using a feeding tube

There are dozens of conditions that may require tube feeding. The more common conditions that necessitate feeding tubes include prematurity, failure to thrive (or malnutrition), neurologic and neuromuscular disorders, inability to swallow, anatomical and post-surgical malformations of the mouth and esophagus, cancer, Sanfilippo syndrome, and digestive disorder.

Types of feeding tubes

Nasal Tubes:

Nasal tubes are non-surgical and temporary. The choice between nasogastric (NG), nasoduodenal (ND) and nasojejunal (NJ) depends on whether your child can tolerate feeding into the stomach or not.

• NG-tubes enter the body through the nose and run down the esophagus into the stomach.
• ND-tubes are similar to NG-tubes, but
• NJ-tubes extend even further to the second they go through the stomach and end in the first portion of the small intestine (duodenum).portion of the small intestine (jejunum). Bypassing the stomach can be beneficial for those whose stomachs don’t empty well, who have chronic vomiting, or who inhale or aspirate stomach contents into the lungs.

Gastric Tubes (or G-tubes):

The most common type of feeding tube is the gastrostomy (G) tube. G-tubes are surgically placed through the abdominal wall into the stomach.

There are a number of types of G-tubes. Any kind of G-tube can be placed initially. Often it is the surgeon or the gastroenterologist who determines the first type of G-tube placed. These are some of the most common types of G-tubes you may encounter.

• PEG and Long Tubes: These are one-piece tubes held in place either by a retention balloon or by a bumper. They are often used as the initial G-tube for the first 8-12 weeks post-surgery.
• Low Profile Tubes or Buttons:  These tubes do not have a long tube permanently attached outside the stomach.  Instead, they have a tube called an extension set that is attached for feeding or medication administration and then disconnected when not in use. When an extension set is not attached to the button, it lies fairly flat against the body. There are two types:
• Balloon buttons:  These are held in place by a water filled balloon. These are the most common G-tubes used in children. They can be changed at home.
• Non balloon buttons: Non-balloon buttons are harder to pull out than balloon buttons.  Non-balloon buttons cannot be replaced at home. They are placed in the doctor’s office or at the hospital, sometimes with sedation or a topical pain reliever.
•  

When you first enter the world of tube feeding, it feels like there is a whole new language to learn. Knowing more about the different types of tubes and understanding the lingo really helps you better navigate the most appropriate options for your child.

GJ-tubes:

When you need to bypass the stomach for feeding, there is the Gastro-jejunal (GJ) tube. GJ-tubes are placed in the stomach just like G-tubes, but inside the stomach there is also a thin, long tube threaded into the jejunal (J) portion of the small intestine. The vast majority of children who get GJ feeding tubes begin with G-tubes; it is rare for a GJ-tube to be placed initially. Most GJ-tubes have separate ports to access both the stomach (G port) and the small intestine (J port), though some tubes, often called Trans-jejunal (TJ) tubes, only allow access to the small intestine. GJ-tubes are available both as buttons or long tubes.

Jejunal (J) Tubes

A jejunostomy feeding tube (J-tube) is a tube surgically or endoscopically inserted through the abdomen and into the jejunum (the second part of the small intestine).Alternatively a jejunostomy commonly refers to a surgical fistula created connecting the jejunum or the abdominal wall. There are several techniques for placement, including a direct surgical or endoscopic technique, or a more complicated Roux-en-Y procedure. The J-tube may use a long, catheter-like tube or a button. Depending on the placement type, the tube may be changed at home, or may need to be changed at a hospital. A J-tube is helpful for individuals with poor gastric motility, chronic vomiting, or at high risk for aspiration and in those in whom gastrostomy tubes are contraindicated.

Effectiveness

The effectiveness of feeding tubes varies greatly depending on what condition they are used to treat.

Children

Feeding tubes are used widely in children with excellent success for a wide variety of conditions. Some children use them temporarily until they are able to eat on their own, while other children require them longterm. Some children only use feeding tubes to supplement their oral diet, while others rely on them exclusively.

Advanced Dementia

 Patients with advanced dementia who are unable to feed themselves should have another person feed them in preference to the medical intervention of having a feeding tube. In such patients, feeding tubes do not increase life expectancy or protect the patient from aspiration pneumonia. Feeding tubes can also increase the risk of pressure ulcers, require pharmological or physical restraints, and lead to patient distress. There is evidence which shows that patients who get feeding assistance  rather than tubes have better outcomes. In the final stages of dementia, assisted feeding may still be preferred over a feeding tube to bring benefits of palliative care and human interaction even when nutritional goals are not being met.

Eating disorders

Patients with the eating disorder anorexia nervosa may be tube fed if they are significantly malnourished. This can be voluntary or in some cases where the patient is resistant to feeding under the force of legislation about mental health. Patients may tamper with their feeds, which can interfere with the effectiveness of feeding.

ICU

There is moderate evidence for use of feeding tubes in the ICU, especially if requiring mechanical ventilation for more than three days. Nasogastric tubes are often used in the intensive care unit (ICU) to provide nutrition to critically ill patients while their medical conditions are addressed.

Mechanical obstruction and dysmotility

There is at least moderate evidence for feeding tubes improving outcomes for chronic malnutrition in patients with cancers of the head and neck that obstruct the esophagus and would limit oral intake, acute stroke while the patient undergoes rehab, and ALS.

Advantages of getting a feeding tube

·         To maintain hydration and a safe way to administer medications.

·         To have a decreased risk of aspiration pneumonia.

·         To decrease the risk of choking, chewing or swallowing problems when eating.

·         To help you maintain weight, reduce fatigue and improve your resistance to infection.

·         To conserve energy and time getting your food by mouth, simplify your meals, and reserve energy for other activities.

·         Reduce feeding times to less than 30 minutes.

The right time to have a feeding tube placed

·         Most doctors recommend getting a feeding tube early – before you absolutely need one.

·         At forced vital capacity, or FVC, at no less than 50% is optimal.

·         Those considering a feeding tube should know that the sooner you have a feeding tube placed, the better your body will be able to recover from the procedure.

·         When nourishment and respiratory function is better, the procedure can be done with less difficulty and decreased risk of respiratory problems during or after the procedure.

·         When Food intake drops below the recommended levels of the following servings per day

§  Three or more servings of meat or protein alternative.

§  Two or more servings of milk or yogurt.

§  Five or more servings fruits and vegetables.

§  Six to Eleven servings of grains and starches.

§  Four to Seven servings of fats.

§ 

Complications

1)The nasogastric (NG) tube is meant to convey liquid food to the stomach. Thus, its tip must rest in the stomach. When inserted incorrectly, the tip may rest in the respiratory system instead of the stomach; in this case, the liquid food will enter the lungs, resulting in pneumonia and can, in rare cases, lead to death. The incorrect insertion of fine nasogastric tubes which are stiffened with wires has been associated with the puncture of the lungs and pneumothorax; however this is a rarer complication.

2)The gastrostomy tube is associated with its own set of complications. Leakage of gastric contents (containing hydrochloric acid) around the tube into the abdominal (peritoneal) cavity results in peritonitis, a serious complication which will cause death if it is not properly treated. Septic shock is another possible complication. Minor leakage may cause irritation of the skin around the gastrostomy site or stoma. Barrier creams, to protect the skin from the corrosive acid, are generally recommended.

3)All feeding tubes will eventually need to be changed because of wear and tear, or a clogged lumen. The change of a gastrostomy tube is not without risks. The loop-gastrostomy tube is a recent innovation which minimizes the risks of tube change.

Side Effects

Some side effects may occur with tube feeding. Several complications only become evident when enteral nutritional support (ENS) is applied on a long-term basis.

1)Medically fragil   patients remain malnourished during the first year of life despite receiving ENS. Study shows that a majority of children receiving long-term enteral nutritional support are not provided with an adequate amount of energy for their age and showed a lack of appetite.

2)Failure to gain weight is mainly caused by an imbalance of beneficial variables and undesired adverse effect. The main reasons for this mismatch were limited tolerance, nausea, recurrent vomiting, gagging, and retching. This may even result in growth retardation.

3)As a result, the patient might not thrive age-appropriately, despite receiving sufficient amounts of carefully selected nutrients. This condition may lead to tube dependency.

4)According to the World Health Organization, “stunting is a result of long-term nutritional deprivation and often results in delayed mental development, poor school performance and reduced intellectual capacity” whereas “wasting in children is a symptom of acute under-nutrition usually as a consequence of insufficient food intake or a high incidence of infections, especially diarrhea. Wasting in turn impairs the functioning of the immune system and can lead to increased severity and susceptibility” to diseases and increased risk of death”. So, the high prevalence of malnutrition in medically fragile children is keeping them at continuous risk of developing secondary diseases, which can compromise their quality of life and may lead to detrimental outcomes.

Nowadays, medicine provides methods of getting rid of tubes and proceeding to natural oral intake. Tube-weaning programs have been initiated during the last decades using different approaches: inpatient versus outpatient, slow versus swift volume reduction,use of medication, behavioral interventions, hunger provocation, sensory stimulation or an interdisciplinary child-led method, based on psychodynamic  principles.