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Tube feeding and parenteral nutrition

Tube feeding (enteral nutrition) and parenteral nutrition may be used to provide nutrition if you can’t eat or drink. These feeding methods can help you maintain or gain weight and keep your body strong for fighting cancer or infection.

Tube feeding and parenteral nutrition may be used if you:

  • can’t absorb nutrients properly or need extra nutrition such as higher amounts of protein and calories
  • aren’t receiving enough nutrition
  • are having problems with swallowing
  • can’t eat or drink following cancer treatment
  • have an extremely sore mouth or throat
  • have had a bone marrow transplant

Tube feeding

Tube feeding is a way of getting nutritional formula directly into your stomach or small intestine. Some people with feeding tubes continue to eat food and drink liquids by mouth. You may also receive medicines through the feeding tube.

Tube feeding is preferred over parenteral nutrition because it uses the gastrointestinal (GI) tract and is less likely to lead to infection. You can only be fed through a tube if your GI tract is working well.

Different types of tubes and formulas are used. Based on your nutritional needs, your doctor or dietitian will decide what products will work best for you. Blood tests may be used to help find out if you’re getting enough nutrition.

There are different types of feeding schedules:

 

Intermittent, or bolus, tube feedings are given over short periods of time several times throughout the day, often at regular meal times.

 

Continuous tube feedings are given at a steady rate for as many hours as needed.

 

Cyclic tube feeding is an alternative to continuous tube feeding. It is given at a faster rate over a shorter period of time. It’s given at the same time each day for the same amount of time. Cyclic feeding may also be referred to as nocturnal feeding when the tube feeding is done overnight (for example, for 8–12 hours at night while the person is resting or sleeping).

  • Cyclic tube feeding is helpful for people adjusting to an oral diet.
  • It can be used to supplement an oral diet if you cannot eat enough.
  • It’s convenient if you can’t do tube feeding during the day (for example, because of your treatment schedule).

Care of the feeding tube and surrounding skin

The feeding tube and the skin around it need special care. A nurse will show you how to manage this before leaving the hospital. You will be shown how to carry out the feeding, check the placement of the tube and flush it with water. The skin around the tube will need to be cleaned and have a dressing.

Types of feeding tubes

There are different types of feeding tubes. The one used will depend on your unique nutritional needs.

Nasogastric tubes

You won’t need surgery to put a nasogastric (NG) feeding tube in place. They are usually used if nutritional support is only needed for a short time (for example, a few weeks). An NG tube is a long, thin, flexible tube. It is inserted into a nostril and goes down the back of the throat, down the esophagus and into the stomach. Once the tube is correctly positioned, it is taped to your nose or cheek to keep it in place. Placement of the NG tube will be checked with an x-ray before the first feeding is given.

Nasoduodenal and nasojejunal tubes

You won’t need surgery to put a nasoduodenal or nasojejunal tube in place. They are long, thin, flexible tubes. The tube is inserted into a nostril, down the back of the throat, down the esophagus, through the stomach and into your small intestine. A nasoduodenal tube goes into the first part of the small intestine, called the duodenum. A nasojejunal tube goes into the second part of the small intestine, called the jejunum. Once the tube is correctly positioned, it will be taped to your nose or cheek to keep it in place. Placement of the tube will be checked with an x-ray before the first feeding is given.

Gastrostomy and jejunostomy tubes

You will need surgery to put a gastrostomy or jejunostomy tube in place. Unlike other types of feeding tubes, they don’t go through the nose. Gastrostomy tubes are placed directly into your stomach. Jejunostomy tubes are placed directly into the jejunum of the small intestine. Gastrostomy and jejunostomy tubes are used if you:

  • will probably need nutritional support for a long time (more than a few weeks)
  • can’t have a tube pass through your mouth or esophagus
  • vomit frequently (when vomiting, an NG, nasoduodenal or nasojejunal tube may be displaced and may need to be reinserted each time you vomit)

Surgical gastrostomy tube

A surgical gastrostomy feeding tube is passed through the skin directly into your stomach (gastrostomy). Placing the tube requires surgery to make an opening (stoma) through the abdominal wall where the feeding tube enters the body. The feeding tube is held in place with either a stitch or a small inflated balloon around the tube just under the skin. Surgical gastrostomy tubes are usually put in place when you’re having another planned surgery.

Percutaneous endoscopic gastrostomy (PEG) tube

A PEG tube is a gastrostomy feeding tube that is passed through the skin directly into the stomach. An endoscope is inserted through the mouth and down the throat into the stomach to help guide the placement of the feeding tube.

Surgical jejunostomy tube

A surgical jejunostomy tube (J tube) is passed through the skin directly into the jejunum of the small intestine. Placing the tube requires surgery to make an opening (stoma) through the abdominal wall where the feeding tube enters the body. A surgical jejunostomy may be used if you have problems in the upper GI tract, a high risk of aspiration or a blockage (obstruction) in the stomach. A surgical J tube causes fewer problems with leakage, skin irritation, nausea, vomiting and bloating than a surgical gastrostomy tube, but it has an increased risk of diarrhea. Surgical J tubes are usually put in place when you’re having another planned surgery.

Percutaneous endoscopic jejunostomy (PEJ) tube

A PEJ tube is similar to a PEG tube, but it’s placed in the jejunum of the small intestine. Like PEG tubes, PEJ tubes are placed with the help of an endoscope.

Percutaneous radiological gastrostomy and jejunostomy tubes

More recently, gastrostomy and jejunostomy tubes are being inserted by a radiologist. The radiologist uses x-rays to locate the stomach or small intestine and then inserts the tube without using an endoscope.

Tube feeding formulas

Tube feeding formulas are prescribed based on your nutritional needs and the condition of your GI tract. Formulas have different levels of protein, carbohydrates, fat, calories, vitamins and minerals. Sometimes fibre is added to the formula to help prevent diarrhea. The main types of tube feeding formulas are:

  • commercially prepared formulas that are ready for use (for example, Ensure Plus, Resource 2.0, Isosource 1.5)
  • pre-digested and easy to absorb formulas (Peptamen)
  • nutrient-specific (modular) formulas that contain only one major nutrient, such as protein or carbohydrates (for example, Polycose and Beneprotein)
  • disease-specific formulas for various conditions, such as renal failure (for example, Nepro)

Problems that may occur with nasogastric, nasoduodenal or nasojujenal tubes

Diarrhea

When having tube feeds, you may not have the same bowel patterns as when you were eating. To prevent diarrhea, the formula should be given at room temperature at the recommended rate. The strength of the formula or feeding rate may need to be reduced. Make sure all tube feeding supplies are cleaned well or changed daily and practise good hygiene techniques such as washing hands well. The healthcare team may recommend using a lactose-free formula, adding fibre to the formula or taking anti-diarrhea medicines.

Aspiration

Aspiration happens when the nutritional formula enters the lung. This is very serious because it can cause breathing problems and infection.

Signs of aspiration include:

  • coughing or choking during the feeding
  • change in breathing from normal to difficult, noisy or rapid and shallow
  • wet, gurgly voice
  • pale or bluish lips

To prevent aspiration, sit upright or raise the head of the bed during and for 30 to 60 minutes after the feeding. If you think aspiration has occurred, stop the feeding immediately, make sure you are sitting up and your airway is clear, and call for medical help.

Regurgitation

Regurgitation is when food from the stomach comes back into the feeding tube. If regurgitation occurs, the feeding schedule may need to be adjusted. It may be helpful to use a smaller feeding tube and to sit upright or raise the head of the bed during the feeding and for at least 60 minutes after. Medicines may also be given to increase the muscle contractions in the gastrointestinal tract.

Nausea and vomiting

Nausea and vomiting may occur if you are sick or too full, or the feeding is given too quickly. To prevent vomiting, start the feeding at a slow rate and then increase to the desired rate. When feeding, it may be helpful to sit up or have the head of the bed raised. The healthcare team may recommend using a different formula, such as a lactose-free formula.

Gas or bloating

You may experience gas or bloating if the feeding is given too quickly. If this happens, decrease the feeding rate or stop the feeding and then restart at a slower rate after a few hours. Your healthcare team may recommend using a low-fat formula. Being more physically active may also help to reduce gas or bloating.

Dehydration

Dehydration can be caused by vomiting, diarrhea and excess sweating. The amount of formula and how often you flush the tube with water may need to be increased if you’re dehydrated. Signs of dehydration include a dry, sticky tongue, sunken eyes, cracked or dry lips, thirst or a small amount of dark yellow urine.

Constipation

When you are on tube feeds, you may not have the same bowel patterns as when you were eating. To prevent constipation, make sure the recommended amount of water flushes are given and try to be as physically active as possible each day. Your healthcare team may recommend a different formula, more water or medicines to help manage constipation.

Dry mouth

You may experience a dry mouth. Rinsing your mouth often may help. Check with the healthcare team about chewing gum or sucking on mints.

Blocked feeding tube

To prevent a blockage in the tube, it’s important to flush the tube with warm water before and after giving feedings and medicines. Crushing medicines to a fine powder and dissolving them in a small amount of warm water will also help. Contact the healthcare team if the feeding tube becomes blocked. If warm water does not unclog the tube, special enzymes may be needed. If the tube cannot be cleared, it may need to be replaced.

Dumping syndrome

Dumping syndrome occurs when food moves too fast from the stomach into the small intestine. To prevent dumping syndrome, give formula at room temperature and increase the feeding rate gradually. If you experience diarrhea, sweating and flushing after eating, contact the healthcare team. The feeding rate may need to be reduced.

Feeding tube falls out

Try to prevent the feeding tube from falling out by always checking the position of the tube before feeding or giving medicines and measure the length of the feeding tube outside of the body to make sure it is the correct length. If the feeding tube falls out, it will need to be replaced. Contact the healthcare team immediately or go to the emergency department since the tube can be replaced without the full procedure needing to be repeated if caught in time.

Fluid leaking around the tube

To prevent fluid from leaking around the tube, make sure to use the correct flow rate and volume of formula. Frequently flush the tube with water to avoid a blocked tube. Make sure the tube is securely taped to prevent pulling on the stoma.

If leaking occurs, check to see if the tube is blocked or if the tube has moved out of position. Contact the healthcare team if the tube if blocked or has moved out of position.

Problems that can occur with gastrostomy and jejunostomy feeding tubes

Infection or skin irritation

The skin around the tube or stoma site may become irritated or infected. Keep the skin clean and dry and cover with a dressing. Clean the skin daily with soap and water. If a skin infection occurs, call the healthcare team. Signs of skin infection may include red, hot and swollen skin, discharge from the stoma, pain around the stoma, fever or a bad smell around the stoma.

Bleeding

Report any bleeding from the area around the stoma to the healthcare team.

Feeding tube comes out

If the feeding tube comes out, clean the skin around the stoma and apply a sterile dressing. Contact the healthcare team immediately or go to the emergency department since the tube can be replaced without the full procedure needing to be repeated if caught in time.

Parenteral nutrition

Parenteral nutrition (sometimes called total parenteral nutrition, or TPN) provides fluids and essential nutrients directly into the bloodstream through an intravenous (IV) catheter. The nutrients do not go through the GI tract. Parenteral nutrition is used if you:

  • have lost at least 10% of your normal body weight
  • can’t eat or drink by mouth
  • do not have a GI tract that is working well
  • can’t be tube fed for some reason

Parenteral nutrition is prepared by a pharmacist. A doctor and dietician usually work closely with the pharmacist to make sure that the parenteral nutrition solution meets your specific nutritional needs. Blood tests will be done to check the levels of potassium, sugar, sodium and other substances in your blood.

Parenteral nutrition provides:

  • carbohydrates (glucose and dextrose)
  • protein (amino acids)
  • fats (lipids)
  • vitamins (A, B, C, D and E) and minerals (zinc, copper, chromium, manganese and selenium)
  • electrolytes (calcium, potassium, phosphorus, magnesium and sodium)
  • fluids

How parenteral nutrition is given

Parenteral nutrition is usually started in the hospital as a non-stop infusion over a 24-hour period. You will be weighed every morning at about the same time and blood will be taken daily. Electrolytes and liver and kidney function are monitored frequently. This helps the healthcare team determine how you are doing and if the parenteral nutrition solution is meeting your nutritional needs. Some people receiving parenteral nutrition can continue to eat by mouth.

Because parenteral nutrition solutions are concentrated and thick, they must be given through a central venous catheter. An infusion pump controls the rate at which the solution is given. The pump is portable, so once it’s started parenteral nutrition may be given at home. At home, parenteral nutrition is given 8–12 hours per day, depending on your situation. The healthcare team will provide detailed instructions on how to give and manage parenteral nutrition at home. Instructions will also include how to:

  • change the dressing, handle the equipment and keep the equipment and catheter site sterile
  • store parenteral nutrition solutions (it’s given at room temperature)
  • set up the infusion
  • flush the line with heparin (to prevent clogging)
  • troubleshoot problems with the catheter (such as leakage, loose cap, blood clots or the catheter becoming dislodged)

Possible side effects and risks of parenteral nutrition

Side effects and risks of parenteral nutrition include:

  • infection
  • hypoglycemia (low blood sugar)
  • hyperglycemia (high blood sugar)
  • fluid overload
  • blood clotting
  • air embolism
  • inflammation of the gallbladder (cholecystitis)
  • collapsed lung (parenteral nutritioneumothorax)
  • bone disease (osteoporosis)
  • parenteral nutrition-induced liver disease or liver failure
  • weakening of gastrointestinal cells (gastrointestinal atrophy)

endoscope

A thin, tube-like instrument with a light and lens used to examine or treat organs or structures in the body.

An endoscope can be flexible or rigid. It may have a tool to remove tissue for examination. Specialized endoscopes may have tools designed to examine or treat specific organs or structures in the body.

Specialized endoscopes are named for the organ or structure they are used to examine or treat.

aspiration

Aspiration means accidentally sucking or breathing food or fluid into the lungs.

It is also a procedure that uses a needle to withdraw or remove cells, fluid or tissue. For example, a small amount of bone marrow is withdrawn from the hip bone through a needle during bone marrow aspiration.

endoscope

A thin, tube-like instrument with a light and lens used to examine or treat organs or structures in the body.

An endoscope can be flexible or rigid. It may have a tool to remove tissue for examination. Specialized endoscopes may have tools designed to examine or treat specific organs or structures in the body.

Specialized endoscopes are named for the organ or structure they are used to examine or treat.

central venous catheter

A catheter (flexible tube) that is passed through a vein in the neck, groin or chest into the vena cava (the large vein leading into the heart).

A central venous catheter may be used to give continuous infusion of fluids, deliver drugs or collect blood samples. It may also be used to measure the pressure of the blood returning to the heart (central venous pressure or CVP) and how much blood the heart is pumping.

Also called central line, central venous line or central venous access catheter.

embolism

A blockage in a blood vessel caused by a blood clot or other substances.

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