A feeding tube is a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation. The state of being fed by a feeding tube is called gavage, 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 ⅓ mm). They are classified by the site of insertion and intended use.
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 disorders.
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.
People with advanced dementia who get feeding assistance rather than feeding tubes have better outcomes. Feeding tubes do not increase life expectancy for such people, or protect them from aspiration pneumonia. Feeding tubes can also increase the risk of pressure ulcers, require pharmacological or physical restraints, and lead to distress. 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.
Feeding tubes are often used in the intensive care unit (ICU) to provide nutrition to people who are critically ill while their medical conditions are addressed; as of 2016 there was no consensus as to whether nasogastric or gastric tubes led to better outcomes.
Mechanical obstruction and dysmotilityEdit
There is at least moderate evidence for feeding tubes improving outcomes for chronic malnutrition in people with cancers of the head and neck that obstruct the esophagus and would limit oral intake, people with advanced gastroparesis, and ALS. For long term use, gastric tubes appear to have better outcomes than nasogastric tubes.
People who have surgery on their throat or stomach often have a feeding tube while recovering from surgery; a tube leading through the nose and down to the middle part of the small intestine is used, or a tube is directly placed through the abdomen to the small intestine. As of 2017 it appeared that people with a tube through the nose were able to start eating normally sooner.
Medical nutrition companies make flavored products for drinking and unflavored for tube feeding. These are regulated as medical foods, which are defined in section 5(b) of the Orphan Drug Act (21 U.S.C. 360ee (b) (3)) as "a food which is formulated to be consumed or administered enterally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation."
Nasogastric and nasojejeunal tubes are meant to convey liquid food to the stomach or intestines. When inserted incorrectly, the tip may rest in the respiratory system instead of the stomach or intestines; in this case, the liquid food will enter the lungs, resulting in pneumonia and can, in rare cases, lead to death.
Complications associated with gastrostomy tubes (inserted through the abdomen and into the stomach or intestines) include leakage of gastric contents (containing hydrochloric acid) around the tube into the abdominal (peritoneal) cavity resulting 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 used to manage this.
A phenomenon called "tube dependency" has been discussed in the medical literature, in which a child refuses to eat after being on a feeding tube, but it is not recognized as a disorder in the ICD or DSM and its epidemiology is unknown.
The most common types of tubes include those placed through the nose, including nasogastric, nasoduodenal, and nasojejunal tubes, and those placed directly into the abdomen, such as a gastrostomy, gastrojejunostomy, or jejunostomy feeding tube.
Nasogastric feeding tubeEdit
A nasogastric feeding tube or NG-tube is passed through the nares (nostril), down the esophagus and into the stomach. This type of feeding tube is generally used for short term feeding, usually less than a month, though some infants and children may use an NG-tube longterm. Individuals who need tube feeding for a longer period of time are typically transitioned to a more permanent gastric feeding tube. The primary advantage of the NG-tube is that it is temporary and relatively non-invasive to place, meaning it can be removed or replaced at any time without surgery. NG-tubes can have complications, particularly related to accidental removal of the tube and nasal irritation.
Nasojejunal feeding tubeEdit
A nasojejunal or NJ-tube is similar to an NG-tube except that it is threaded through the stomach and into the jejunum, the middle section of the small intestine. In some cases, a nasoduodenal or ND-tube may be placed into the duodenum, the first part of the small intestine. These types of tubes are used for individuals who are unable to tolerate feeding into the stomach, due to dysfunction of the stomach, impaired gastric motility, severe reflux or vomiting. These types of tubes must be placed in a hospital setting.
Gastrostomy or gastric feeding tubeEdit
A gastric feeding tube (G-tube or "button") is a tube inserted through a small incision in the abdomen into the stomach and is used for long-term enteral nutrition. One type is the percutaneous endoscopic gastrostomy (PEG) tube which is placed endoscopically. The position of the endoscope can be visualized on the outside of the person's abdomen because it contains a powerful light source. A needle is inserted through the abdomen, visualized within the stomach by the endoscope, and a suture passed through the needle is grasped by the endoscope and pulled up through the esophagus. The suture is then tied to the end of the PEG tube that will be external, and pulled back down through the esophagus, stomach, and out through the abdominal wall. The insertion takes about 20 minutes. The tube is kept within the stomach either by a balloon on its tip (which can be deflated) or by a retention dome which is wider than the tract of the tube. G-tubes may also be placed surgically, using either an open or laparoscopic technique.
Gastric feeding tubes are suitable for long-term use, though they sometimes need to be replaced if used long-term. The G-tube can be useful where there is difficulty with swallowing because of neurologic or anatomic disorders (stroke, esophageal atresia, tracheoesophageal fistula, radiotherapy for head and neck cancer), and to decrease the risk of aspiration pneumonia. However, in people with advanced dementia or adult failure to thrive it does not decrease the risk of pneumonia. There is moderate quality evidence suggesting that the risk of aspiration pneumonia may be reduced by inserting the feeding tube into the duodenum or the jejunum (post-pyloric feeding), when compared to inserting the feeding tube into the stomach. People with dementia may attempt to remove the PEG, which causes complications.
Gastric drainage tubeEdit
A G-tube may instead be used for gastric drainage as a longer term solution to the condition where blockage in the proximal small intestine causes bile and acid to accumulate in the stomach, typically leading to periodic vomiting, or if the vagus nerve is damaged. Where such conditions are only short term, as in a hospital setting, a nasal tube connected to suction is usually used. A blockage lower in the intestinal tract may be addressed with a surgical procedure known as a colostomy, and either type of blockage may be corrected with a bowel resection under appropriate circumstances. If such correction is not possible or practical, nutrition may be supplied by parenteral nutrition.
Gastrojejunal feeding tubeEdit
A gastrojejunostomy or GJ feeding tube is a combination device that includes access to both the stomach and the jejunum, or middle part of the small intestine. Typical tubes are placed in a G-tube site or stoma, with a narrower long tube continuing through the stomach and into the small intestine. The GJ-tube is used widely in individuals with severely impaired gastric motility, high risk of aspiration, or an inability to feed into the stomach. It allows the stomach to be continually vented or drained while simultaneously feeding into the small intestine. GJ-tubes are typically placed by an interventional radiologist in a hospital setting. The primary complication of a GJ-tube is migration of the long portion of the tube out of the intestine and back into the stomach.
Jejunal feeding tubeEdit
- "Tube feeding". 2019-05-09.
- Hannah, E; John, RM (November 2013). "Everything the nurse practitioner should know about pediatric feeding tubes". Journal of the American Association of Nurse Practitioners. 25 (11): 567–77. doi:10.1002/2327-6924.12075. PMID 24170530.
- Craig, GM (December 2013). "Psychosocial aspects of feeding children with neurodisability". European Journal of Clinical Nutrition. 67 Suppl 2: S17–20. doi:10.1038/ejcn.2013.226. PMID 24301004.
- American Academy of Hospice and Palliative Medicine, "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation, American Academy of Hospice and Palliative Medicine, retrieved August 1, 2013
- Murray, A; Mulkerrin, S; O'Keeffe, ST (2019). "The perils of 'risk feeding'". Age and Ageing. 48 (4): 478–481. doi:10.1093/ageing/afz027. PMID 30939597.
- Hanson, L. C.; Ersek, M.; Gilliam, R.; Carey, T. S. (2011). "Oral Feeding Options for People with Dementia: A Systematic Review". Journal of the American Geriatrics Society. 59 (3): 463–472. doi:10.1111/j.1532-5415.2011.03320.x. PMC 3164780. PMID 21391936.
- Kuo, S.; Rhodes, R. L.; Mitchell, S. L.; Mor, V.; Teno, J. M. (2009). "Natural History of Feeding-Tube Use in Nursing Home Residents with Advanced Dementia". Journal of the American Medical Directors Association. 10 (4): 264–270. doi:10.1016/j.jamda.2008.10.010. PMC 2733212. PMID 19426943.
- *Sampson, E. L.; Candy, B.; Jones, L. (2009). Sampson, Elizabeth L (ed.). "Enteral tube feeding for older people with advanced dementia". The Cochrane Library (2): CD007209. doi:10.1002/14651858.CD007209.pub2. PMC 7182132. PMID 19370678.
- Schlein, K (August 2016). "Gastric Versus Small Bowel Feeding in Critically Ill Adults". Nutrition in Clinical Practice. 31 (4): 514–22. doi:10.1177/0884533616629633. PMID 26920643.
- Bishop, S; Reed, WM (December 2015). "The provision of enteral nutritional support during definitive chemoradiotherapy in head and neck cancer patients". Journal of Medical Radiation Sciences. 62 (4): 267–76. doi:10.1002/jmrs.132. PMC 4968562. PMID 27512573.
- Canadian Agency for Drugs and Technologies in Health (13 August 2014). "Nasogastric Feeding Tubes versus Percutaneous Endoscopic Gastrostomy for Patients with Head or Neck Cancer: A Review of Clinical Effectiveness and Guidelines". Rapid Response Reports. CADTH Rapid Response Reports. PMID 25411678.
- Sarosiek, I; Davis, B; Eichler, E; McCallum, RW (March 2015). "Surgical approaches to treatment of gastroparesis: gastric electrical stimulation, pyloroplasty, total gastrectomy and enteral feeding tubes". Gastroenterology Clinics of North America. 44 (1): 151–67. doi:10.1016/j.gtc.2014.11.012. PMID 25667030.
- Greenwood, DI (June 2013). "Nutrition management of amyotrophic lateral sclerosis". Nutrition in Clinical Practice. 28 (3): 392–9. doi:10.1177/0884533613476554. PMID 23466470.
- Lai, L; Ali, SF (September 2015). "Percutaneous Endoscopic Gastrostomy and Open Gastrostomy". Atlas of the Oral and Maxillofacial Surgery Clinics of North America. 23 (2): 165–8. doi:10.1016/j.cxom.2015.05.001. PMID 26333904.
- Wang, L; Tian, Z; Liu, Y (January 2017). "Nasoenteric tube versus jejunostomy for enteral nutrition feeding following major upper gastrointestinal operations: a meta-analysis" (PDF). Asia Pacific Journal of Clinical Nutrition. 26 (1): 20–26. doi:10.6133/apjcn.112015.05. PMID 28049257.
- Affairs, Office of Regulatory (2019-02-09). "Medical Foods Guidance Documents & Regulatory Information".
- Nutrition, Center for Food Safety and Applied. "Medical Foods - Guidance for Industry: Frequently Asked Questions About Medical Foods; Second Edition".
- Tiancha, H; Jiyong, J; Min, Y (July 2015). "How to Promote Bedside Placement of the Postpyloric Feeding Tube: A Network Meta-Analysis of Randomized Controlled Trials". JPEN. Journal of Parenteral and Enteral Nutrition. 39 (5): 521–30. doi:10.1177/0148607114546166. PMID 25146431.
- Santos, SC; Woith, W; Freitas, MI; Zeferino, EB (September 2016). "Methods to determine the internal length of nasogastric feeding tubes: An integrative review". International Journal of Nursing Studies. 61: 95–103. doi:10.1016/j.ijnurstu.2016.06.004. PMID 27328376.
- Metheny, NA; Meert, KL (May 2014). "Effectiveness of an electromagnetic feeding tube placement device in detecting inadvertent respiratory placement". American Journal of Critical Care. 23 (3): 240–7, quiz 248. doi:10.4037/ajcc2014954. PMID 24786813.
- Melis M1, Fichera A, Ferguson MK. (July 2006). "Bowel necrosis associated with early jejunal tube feeding: A complication of postoperative enteral nutrition". Arch Surg. 141 (7): 701–4. doi:10.1001/archsurg.141.7.701. PMID 16847244.CS1 maint: uses authors parameter (link)
- Townley, A; Wincentak, J; Krog, K; Schippke, J; Kingsnorth, S (2018). "Pediatric gastrostomy stoma complications and treatments: A rapid scoping review". Journal of Clinical Nursing. 27 (7–8): 1369–1380. doi:10.1111/jocn.14233. PMID 29266535.
- Krom, H; de Winter, JP; Kindermann, A (June 2017). "Development, prevention, and treatment of feeding tube dependency". European Journal of Pediatrics. 176 (6): 683–688. doi:10.1007/s00431-017-2908-x. PMC 5432583. PMID 28409284.
- Guenter, Peggi (2001). "Enteral Feeding Access Devices". In Guenter, Peggi; Silkroski, Marcia (eds.). Tube Feeding: Practical Guidelines and Nursing Protocols. Gaithersburg: Aspen Publishers. pp. 51–67. ISBN 978-0-8342-1939-7.
- "Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition". NICE. August 2017. Retrieved 30 January 2018.
- "Dysphagia Treatment". NHS Choices. 19 January 2015.
- Thaker, AM; Sedarat, A (September 2016). "Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy". Current Gastroenterology Reports. 18 (9): 46. doi:10.1007/s11894-016-0520-2. PMID 27422123.
- Alkhawaja, Sana; Martin, Claudio; Butler, Ronald J.; Gwadry-Sridhar, Femida (2015-08-04). "Post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults". The Cochrane Database of Systematic Reviews (8): CD008875. doi:10.1002/14651858.CD008875.pub2. ISSN 1469-493X. PMC 6516803. PMID 26241698.
- Siamak Milanchi and Matthew T Wilson (January–March 2008). "Malposition of percutaneous endoscopic-guided gastrostomy: Guideline and management". J Minim Access Surg. 4 (1): 1–4. doi:10.4103/0972-9941.40989. PMC 2699054. PMID 19547728.CS1 maint: uses authors parameter (link)
- Costa, G; Ruscelli, P; Balducci, G; Buccoliero, F; Lorenzon, L; Frezza, B; Chirletti, P; Stagnitti, F; Miniello, S; Stella, F (2016). "Clinical strategies for the management of intestinal obstruction and pseudo-obstruction. A Delphi Consensus study of SICUT (Società Italiana di Chirurgia d'Urgenza e del Trauma)". Annali Italiani di Chirurgia. 87: 105–17. PMID 27179226.
- Mulholland, Michael W.; Doherty, Gerard M. (2011). Complications in Surgery. Lippincott Williams & Wilkins. p. 270. ISBN 9781605475301.
- Gershman, George; Ament, Marvin (2008). Practical Pediatric Gastrointestinal Endoscopy. John Wiley & Sons. p. 126. ISBN 9780470987315.