Enteral Nutrition (Tube Feeding)

What is Enteral Nutrition?

During cancer treatment and recovery, patients may not be able to get all the calories and nutrients they need by mouth. Tube feeding, or enteral nutrition, provides nutrition in liquid or formula form through a tube placed into the stomach or intestine. Some medicines may also be given through the feeding tube.

There are generally two ways feeding tubes are placed:

1. Through the nose (non-surgical)
2. Through a small cut or incision in the abdomen (surgical)

The most common feeding tubes include nasogastric tubes (NG tubes) and gastrostomy tubes (G tubes). However, there are several types of feeding tubes based on how and where they are placed in the digestive system.

Sometimes a patient is simply not able to take in enough calories or protein by mouth. This is no one’s fault. It is important to help children understand that nutrition support is not a punishment. Most children adapt well to having a feeding tube. It is important to keep the child from touching or pulling on the tube. Follow instructions for skin care around the tube site to prevent irritation or infection.

Types of Feeding Tubes

A feeding tube connects to the stomach or small intestine. The location will depend on the patient’s ability to tolerate the formula and digest nutrients. If possible, the tube is placed in the stomach for more normal digestion.

There are 5 types of feeding tubes:

1. Nasogastric tube (NG tube). An NG tube is inserted into the stomach through the nose. The tube passes down the throat, through the esophagus and into the stomach.
2. Nasojejunal tube (NJ tube). An NJ tube is similar to an NG tube, but the tube continues through the stomach into the small intestine.
3. Gastrostomy tube (G tube). A G tube is inserted through a small cut in the skin. The tube passes through the abdominal wall and directly into the stomach.
4. Gastrostomy-jejunostomy tube (GJ tube). A GJ tube is inserted into the stomach like a G tube, but the tube extends through the stomach to the small intestine.
5. Jejunostomy tube (J tube). A J tube uses a small incision to place the feeding tube through the abdominal wall directly into the small intestine.

Nasal feeding tubes, including NG and NJ tubes, are generally used when tube feeding is needed for a relatively short time, usually less than 6 weeks. The tube extends out from one nostril and is secured to the skin using medical tape. NG and NJ tubes have several advantages including lower risk of infection and ease of placement. However, the tube must be taped to the face, and this may bother some children. Other children may have problems with nasal tubes because of irritation of the skin and mucous membranes due to chemotherapy.

Surgically placed tubes (G tube, J tube, GJ tube) are used for a longer time or if a child is not able to have a nasal tube. The opening on the abdomen where the tube is placed is called a stoma. On the outside of the body, patients have a long tube or a “button” or low-profile tube. Once healed, the stoma should not be painful, and children should be able to do most regular activities.

Side Effects of Tube Feeding

The most common side effects of tube feeding are nausea, vomiting, stomach cramps, diarrhea, constipation, and bloating.

Other possible side effects may include:

• Infection or irritation where the tube is located
• Tube moving out of position or getting dislodged
• Formula getting into the lungs.

Most side effects can be prevented by following instructions for care and feeding.

Nutrition in Children with Feeding Tubes

A registered dietitian or nutritionist makes sure that a child’s specific nutrition needs are met. For pediatric cancer patients, a feeding tube is often used to supplement what the child is able to eat by mouth. Other patients may get all nutrients from a feeding tube.

A formula will be prescribed that considers:

• Calories
• Hydration
• Carbohydrates
• Fats
• Protein
• Vitamins and minerals

Many patients can be fed with standard formulas. For infants, breast milk is often preferred. Other children need special formulas for medical conditions such as allergies, diabetes, or digestive problems.

It is important for families to work closely with their nutrition professional. Nutrition needs may change based on health factors and side effects such as vomiting or diarrhea.

Ways to Give Enteral Feedings

There are 3 main ways to give tube feedings: bolus feeding, continuous feeding, and gravity feeding.

Bolus feeding – In bolus feeding, large doses of formula are given several times a day through the feeding tube. This is most similar to a normal eating routine.

Continuous feeding – In continuous feeding, an electronic pump is used to give small amounts of formula over a period of hours. Some children may need continuous feeds to help reduce nausea and vomiting.

Gravity feeding – In gravity feeding, a feeding bag is placed on an IV pole, and a set amount of formula drips through the tube at a slow rate. The amount of time varies by patient.

Enteral Feeding at Home

Children may go home with a feeding tube. The care team will make sure that families know how to give feedings and care for the feeding tube. Families should watch for problems such as:

• Weight gain or loss
• Vomiting or diarrhea
• Dehydration
• Infection

Equipment and supplies that families may need include:

• Formula: Most formula comes ready to use. Some formula comes in a powder or liquid that you mix with water. 
• Syringe
• Feeding adapter tube (if your child has a button for long-term enteral nutrition)
• Feeding pump (if receiving continuous feeding)
• Formula bag with tubing (if receiving continuous feeding)
• IV Pole (if receiving gravity feeding)

General Reminders for Enteral Feeding at Home:

• Always wash hands with soap and water before giving a feeding.
• Make sure the child’s head is positioned higher than the stomach.
• Throw out any ready to feed or prepared formula that has been opened and stored in the refrigerator for 24 hours or longer.
• Refrigerate compounded formula, and discard after 24 hours.
• Ready to feed formulas do not have to be refrigerated.
• Do not let the syringe get completely empty during the feeding.
• Wash the syringe (and adapter if used) with warm water and dishwashing soap after each use.
• When giving nutrition, watch for signs of nausea, vomiting, stomach swelling, or irritability. If this happens, stop the feeding, and call the doctor right away.
• Check the skin around the placement site for signs of irritation or infection.