Nasogastric Tube Feeding

The nasogastric (NG) tube usually is used when tube feeding will be required
for a short time (i.e., less than three months) although in some cases it can be
used for several years. 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.
The disadvantages of NG feeding include nasal or esophageal irritation and
discomfort (especially if used long-term); increased mucus secretion; and
partial blockage of the nasal airways. Nasogastric feeding may contribute to
recurrent otitis media and sinusitis. With infants, NG feeding can decrease the
suck/swallow mechanism. Two additional disadvantages are the possibility
that the tube will perforate the esophagus or the stomach and the possibility
that the tube will enter the trachea, delivering formula into the lungs. If
formula enters the lungs, severe or fatal pneumonitis can result; therefore, it is
essential to confirm that the NG tube is in the stomach before feeding begins
Gastrostomy Tube Feeding
Gastrostomy tubes are well suited for long-term enteral feeding. Patient
comfort with gastrostomies is an advantage over NG tubes. Gastrostomies do
not irritate nasal passage, esophagus, or trachea, cause facial skin irritation,
nor interfere with breathing. Gastrostomies are stable and more physiologic,
allowing continued oral eating. There are button gastrostomies and other skin
level feeding tubes that are easily hidden under a child's clothing. These
require less daily care and interfere less with a child's movement.
Gastrostomies use a large-bore tube, which allows a more viscous feedings
and decreased risk of tube occlusion.
Disadvantages of gastrostomy feeding include the surgery required to place
the tube, possible skin irritation or infection around the gastrostomy site, and a
slight risk of intra-abdominal leakage resulting in peritonitis. Of special
concern is the child with poor gastric emptying and/or severe reflux or
intractable vomiting. These children have increased risk of aspiration. Please
see section on aspiration.
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.
However, even for children with gastric retention and a high risk of aspiration,
there are disadvantages to jejunal feeding. First, 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. Second, jejunal feedings
bypass the digestive and anti-ineffective mechanisms of the stomach. Third,
they require continuous drip feeding which results in limited patient mobility
and decreased ability to lead a "normal" life. Finally, 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.
Bolus Feeding
Bolus feedings are delivered four to eight times per day; each feeding lasting
about 15 to 30 minutes. The advantages of bolus feedings over continuous
drip feeding are that bolus feedings are more similar to a normal feeding
pattern, more convenient, and less expensive if a pump is not needed.
Furthermore, bolus feedings allow freedom of movement for the patient, so
the child is not tethered to a feeding bag.
The disadvantages of bolus feedings are that they are aspirated more easily
than continuous drip feedings, and in some children, they may cause bloating,
cramping, nausea, and diarrhea. It may not be practical to bolus feed a child
when the volume of formula a child needs is large or requires that the child
needs to be fed around the clock.
Continuous Drip Feeding
Continuous drip feeding may be delivered without interruption for an
unlimited period of time each day. However, it is best to limit feeding to 18
hours or less. Feeding around the clock is not recommended as this limits a
child's mobility and may elevate insulin levels contributing to hypoglycemia.
Commonly, it is used for 8 to 10 hours during the night for volume-sensitive
patients so that smaller bolus feedings or oral feeding may be used during the
day. Continuous drip feeding is delivered by either gravity drip or infusion
pump. The infusion pump is a better method of delivery than gravity drip. The
flow rate of gravity drip may be inconsistent and, therefore, needs to be
checked frequently.
One advantage of continuous feeding over bolus feeding is that it may be
tolerated better by children who are sensitive to volume, are at high risk for
aspiration, or have gastroesophageal reflux. Continuous feeding can be
administered at night, so it will not interfere with daytime activities.
Continuous feeding increases energy efficiency, allowing more calories to be
used for growth. This can be important for severely malnourished children.
When feedings are delivered continuously, stool output is reduced, a
consideration for the child with chronic diarrhea. Continuous infusions of
elemental formula have been successful in managing infants with short bowel
syndrome, intractable diarrhea, necrotizing enterocolitis, and Crohn's disease.
A disadvantage of continuous feeding is that the child is "tied" to the feeding
equipment during the infusion, although feedings can be scheduled for night
time and naptime feedings. Additionally, continuous feeding is more
expensive because of the cost of the pump and additional feeding supplies
which may be necessary. A child's medication needs to be considered as
continuous feeding may interfere with serum concentration of some drugs.
WHEN DO YOU CONSIDER A FEEDING TUBE

Progresslon must be consldered when muklng the declslon. If the putlent
ls ut the end of thelr struggle und cunnot utlllze nutrlents u feedlng tube
muy not be helpful.

If the ubove llsted technlques for sufe swullowlng ure not successful u
feedlng tube muy be consldered. A physlclun wlll not pluce u feedlng tube
lf ull uttempts ut feedlng by mouth huve been exhuusted. In some cuses
pluclng the tube cun be detrlmentul und muy not be the best declslon.

Here ure some tlmes when feedlng tubes muy be needed:
y severe nutrltlonul problems
y severe dehydrutlon
y usplrutlon pneumonlu on severul occuslons
y greut feur of suffocutlon from choklng or usplrutlon
Types of Feedlng Tubes

There ure severul types of feedlng tubes:
G Tube/PEG Tube - Thls tube goes dlrectly ln the stomuch (percutuneous
=through the skln; endoscoplc gustrotomy=stomuch tube). The G-Tube ls
deslgned to provlde u convenlent uccess route for the dellvery of long term
Enterul Nutrltlon. It ls surglcully pluced lnto the ubdomlnul wull. The tube
ls locuted below the rlb cuge und sllghtly off to the left. The skln
surroundlng the tube should be kept cleun und dry, und ln some lnstunces
covered wlth u guuze dresslng.
A beneflt of the G-Tube ls euse of repluce-ment, putlent comfort und
convenlence of cure. The most populur tubes ure the ull *slllcone Foley
type feedlng cutheters und the button tube. Other tubes uvulluble ure the
Mushroom, MIC, PEG, und Mulecot tube. The French slze und Bulloon
slze ure needed when pluclng un order for u G-Tube.
A typlcul compllcutlon of the G-Tube cun be the moderute umount of
gustrlc leukuge. Gustrlc |ulces ure hlghly corroslve und cun cuuse skln
lrrltutlon.
* However, Foley cutheters ure used prlmurlly for urlnury uppllcutlons und
ure not upproprlute or recommended for tube feedlng.
Types of Feedlng Tubes contlnued
J-Tube (Je|unostomy Tube (PEJ) (PDF formut) The J-Tube ls surglcully
lmplunted ln the upper sectlon of the smull lntestlne culled the |e|unum
whlch ls |ust below the stomuch. The tube wlll be locuted lower und more
towurds the center of the ubdomen, when compurlng lt to the locutlon of u
G-Tube.
The prlmury reuson for use of the J-Tube ls to bypuss the stomuch und to
be fed dlrectly lnto the lntestlnul truct. The putlent must ulwuys be fed wlth
un Enterul feedlng pump. The tube ls sometlmes secured ln pluce wlth
sutures. The skln surroundlng the tube should be kept cleun und dry und
covered wlth u guuze dresslng.
The plucement of the tube ls done by the physlclun. The type of tubes muy
vury.
NG-Tube - The Nusogustrlc Tube ls used for those lndlvlduuls who ure
unuble to lngest nutrlents by mouth. The N.G. Tube ls pluced ln elther
nostrll, pussed down the phurynx through the esophugus und lnto the
stomuch und ls usuully used for short term feedlng. After plucement ls
checked, lt ls then secured to the nose wlth tupe. The umount of tube
requlred cun runge from 36" to 45". Plucement must be checked before
euch feedlng.
Only u llcensed physlclun or nurse muy puss u N.G. Tube. The most
populur tubes ure the Slllcone und the Polyurethune.
Alwuys usk for the French Slze und the Length when ucceptlng un order
for u N.G. Tube.
Bolus/Syrlnge Method
Thls method of feedlng ls uchleved when u syrlnge ls uttuched to the
feedlng tube und formulu ls poured lnto the syrlnge, lt ls ullowed to flow
lnto the tube by gruvlty. Thls method ls very qulck und slmple. The only
equlpment needed for thls method ls u feedlng tube, formulu, und the
proper slze syrlnge.
The recommended types of syrlnges ure:
60cc Cutheter Tlp Syrlnge for feedlng
__cc Luer Tlp Syrlnge for lnflutlng the feedlng tube
Gruvlty Drlp Method
The Gruvlty Drlp Method of feedlng ls uchleved when u gruvlty feedlng
bug set ls used to udmlnlster the putlent's formulu. The bug or set ls fllled
wlth formulu through un openlng ut the top.
The bugs ure murked ln ml. for eusy meusurlng. The bugs ure ulso
equlpped wlth roller clumps to control the flow rute, whlch ls determlned
by the physlclun. Muny bugs huve un lce pouch on the outslde to keep the
formulu fresh durlng feedlngs. The bug must be chunged every 24-hours
to reduce the rute of bucterlu.
Pump Feedlng
The Pump Feedlng Method ls controlled by un electrlcul or buttery
operuted devlce. The pump feedlng set ls threud through the pump und set
to secure the rute of lnfuslon ordered by the physlclun due to the putlent's
pust or current medlcul condltlon.
Shleld Heulthcure Sules Representutlve wlll truln new customers on how
to use the equlpment. Plus the lnstructlons und proper usuge ure locuted
on the slde of the pump. An employee wlll be uvulluble 24-hours u duy, 7
duys per week vlu un unswerlng servlce for emergencles. A buck-up pump
wlll be uvulluble lf needed for replucement.