Tube Feedings

Patient Education > Stomach - Abdomen > Tube Feedings

What is tube feeding?

Tube feeding, also called enteral nutrition, is a way to give patients adequate nutrition when they are not able to swallow or digest food in a regular fashion. Food in liquid form is given to the patient by way of a tube inserted into the stomach or intestines. Tube feeding is an alternative to feeding people orally or intravenously (called parenteral nutrition).

Why are people fed by a tube?

When a person cannot take in enough food or is in danger of malnutrition, tube feeding may be considered. There are a number of reasons that a person may not be able to eat in the usual way. The reason for feeding a person by a tube may be a condition that is temporary or permanent. If a person is critically ill, such as after surgery or a severe medical illness, he or she may be too sick or weak to eat. The doctor may order tube feedings to prevent undernourishment or dehydration while the person is getting better. Other people may need to have tube feedings for longer periods or for the rest of their lives. Some people cannot eat. A person may have trouble swallowing due to a stroke that leaves the throat muscles weak. If swallowing is not normal, the person may aspirate, allowing food to enter into the lungs. Food in the lungs can cause pneumonia, respiratory distress, and even death.

People in a coma cannot eat and may need to be fed by a tube. Diseases of the esophagus, stomach, or intestines (such as cancer) or extensive surgery may make it hard to digest food properly resulting in the need for tube feedings. Sometimes the problem is not related to swallowing or digestion. Some people will not eat or do not take in enough food. This can happen as a result of dementia, depression, and other chronic illnesses. Patients and their families face difficult decisions about whether or not to feed a person with a tube. It is very helpful to have discussed this with a patient when they are well and obtain a signed advanced directive regarding such feedings. Patients may express themselves through advance directives or by naming a power of attorney to act in their best interest, particularly if they cannot participate in the decision due to illness, injury, or coma.

Sometimes patients and their families elect to continue oral feeding and thus accept the risk of aspiration or other tube feeding complication. Others make a decision to allow their illness to take its natural course, understanding it will result in malnourishment, dehydration, or even death.

How does tube feeding work?

Once a decision is made to give nutrition by a tube the physician and/or dietician determines which nutrients (vitamins, minerals, fluids, protein, etc.) and how many calories the person needs each day. An appropriate commercially prepared formula is often selected or blended food formulas are made at home. Feedings can be continuous, intermittent, or bolus. Continuous feedings means a small amount of formula is given without interruption over 12 to 24 hours, usually by a pump. Intermittent means the total amount of formula needed in a day is divided into three to six feedings. Each feeding is then given over 60 to 90 minutes. Bolus feeding involves giving a large amount of formula by syringe in 15 or 30 minutes. The bolus method is generally easier because it is faster, uses less equipment, and is generally well tolerated, but it can cause problems such as diarrhea.

How is tube feeding different from intravenous (IV) or parenteral feeding?

Intravenous nutrition, also called hyperalimentation or parenteral nutrition, provides a patient’s total nutritional needs directly into the blood stream by way of an IV catheter put into a large vein. This type of therapy is usually used for a shorter period of time than tube feedings. It bypasses the person’s digestive system, but is generally more expensive. For long-term therapy, enteral tube feeding uses the person’s own digestive system to absorb the nutrients in a more normal manner. This is always preferable to IV therapy, and therefore, is used whenever possible. Each type of therapy is used in different situations, but physicians prefer to use a patient’s own gastrointestinal tract for feedings if at all possible.

What types of tubes are used to instill tube feedings?

Small plastic, rubber, or Silastic tubes are used. Tubes are changed whenever they become clogged, weakened, cracked, or brittle. Often, this is done at regularly scheduled intervals depending on the type of tube. Tubes can be inserted in several places along the gastrointestinal tract.

Nasogastric placement: The tube is put through the nose, through the back of the throat, down the esophagus, into the stomach or small intestine. This does not require surgery. Many people find the tubes somewhat uncomfortable, and it is easily dislodged accidentally. Smaller, softer tubes have been fashioned to increase patient comfort. These smaller tubes are at higher risk for plugging or kinking. These tubes are usually used when tube feeding is needed for only a short time (days or weeks).
Percutaneous endoscopic gastrostomy (PEG): A small incision is made in the skin of the abdominal wall. Using a lighted instrument (endoscope) passed through the mouth into the esophagus, the feeding tube is placed into the stomach. A balloon in the stomach holds the tube in place against an outer triangular phalange pressed against the skin. These tubes are placed when tube feeding is needed for months or longer.
Jejunostomy: This tube is used for feeding and can be placed surgically in the middle section of the small intestine called the jejunum. It can also be placed through an existing gastrostomy tube, whereby an endoscope grasps on to the tube within the stomach and passes it into the small bowel beyond the stomach. These tubes are also placed when tube feeding is needed for a long time, even permanently.

What problems are associated with tube feeding?

Diarrhea. The gastrointestinal system may not function correctly. Diarrhea is a complication that can usually be improved by changing formulas or giving less formula at one time. Sometimes antidiarrheal medications are used.
Occlusion. There can be mechanical problems with the tube such as clogging, kinking, or getting into the wrong place. If a nasogastric tube is pulled out too far liquid feedings can get into the lungs and cause pneumonia.
Malnutrition of electrolyte or sugar disturbance. The bodies chemistries can be affected by the formula given resulting in too much or too little of various nutrients. The doctor or dietician can recommend solutions or additives for each of these problems. Periodic blood testing is often necessary.
Social, psychological, and ethical issues. These issues often arise with tube feeding, especially when this method of getting nutrition is permanent. Eating is a very important social activity. A person may feel self conscious about eating differently from “normal people.” There may have to be extra equipment in the home for the feedings. A person may need help in preparing or giving the feedings, and may feel dependent on another person. A person who can no longer enjoy tasting, chewing, and swallowing a variety of foods may face a very difficult transition. Anger, sadness, and other emotions will arise. The person may have mixed feelings about relying on tube feedings. Some patients, especially those near the end of life, do not wish to receive any further tube feedings or fluids. Without a tube, this decision could result in death. With the tube, patient’s and their caregivers are faced with an ethical decision whether or not to “force feed” with or without a patient’s permission. For this reason we encourage all patients to discuss this situation openly with their families and fill out an advanced directive giving instructions to their family and caretakers should such an ethical decision arise.

Can a person refuse to be tube fed?

By providing nourishment to the body using a tube, life can be sustained and prolonged. Some people question whether life should be prolonged in this manner. Each individual situation is different. Any competent adult can accept or refuse tube feeding. Once such treatment is started, a competent adult can decide to stop the treatment at any time. When an adult cannot make his or her own decision the doctor turns to the family, legal guardian, or person appointed as a health care power of attorney to make decisions.

It is very helpful for the patient to have an advance directive to ensure that everyone understands the patient’s own wishes, even if they are not competent to make the decision at the time it needs to be made due to illness, coma, etc. Since not taking food and fluids over a period of time will allow a disease process to progress towards death, refusing tube feedings is often a difficult decision for an individual or the family. You can ask to talk with the ethics committee of your local hospital or nursing home. Your physician can help all of the decision makers look at all the options to make the best possible decision for the patient.