Non-oral Feeding

Non-oral Nutrition

Definitions

Enteral feeding	Delivery of nutrients and hydration into the gastrointestinal tract.
Nasogastric feeding (NG)	Placement of a tube for nutrient ingestion in the nose.
Percutaneous endoscopic gastrostomy (PEG)	Endoscopic placement of a tube through the abdominal wall directly into the stomach.
Jejunostomy (J-tube)/ PEJ	Surgical/ endoscopic placement of a tube for nutrient ingestion through the abdominal wall directly into the jejunum.
Cervical esophagoscopy/pharyngoscopy	Surgical placement of a tube through the lateral pharyngeal wall directly into the upper oesophagus.
Total parenteral feeding (TPN)	Administration of nutrients through a central vein.
Intravenous hydration	Administration of fluids for hydration only.

Enteral Feeding

Indications	Contraindications
·   1 to 2 weeks of no nutrient intake (unable to orally ingest nutrients/ unsafe oral feeding). ·   Can be temporary/permanent. ·   Placing tubes into the stomach allows for digestion at a controlled rate (rather than into the small intestine).	·   Mechanical obstructions. ·   Severe vomiting/ upper GI bleeding ·   If the patient is not able to ingest nutrients via the GI tract.

Nasogastric Feeding (NG-tube)

Indications

·   Indicated when enteral feeding is required for a short period of time i.e. recovery of swallow function is expected.

·   Typically used for under 30 days.

Contra-indications

·   Nasal obstruction

·   Confused/agitated patients – may not cooperate/ tolerate the discomfort of tube insertion as placement can be quiet traumatic.

Placement of the NG-tube

·   Patients are asked to swallow the tube as it is pushed through the nose into the stomach.

Complications

·   GI and mechanical complications can occur.

·   Vomiting, cramping, diarrhea, risk of self-extubation

·   Risk of aspiration if the tube is inappropriately placed.

Gastrostomy Feeding (e.g. PEG)

Surgical opening into the stomach to allow the placement of a feeding tube. Gastrostomy is the most prevalent type of long term enteral feeding.

Indications

·   Patients who cannot/ will not orally eat.

·   If the resumption of oral feeding is likely to take longer than 30 days.

·   May be used for patirents with dysphagia.

·   PEG = non surgical (a fibreoptic endoscope is used).

Contra-indications

·   Overall medical condition of the patient i.e. are they medically stable.

·   Patients with severe irreversible illnesses, especially the elderly.

Jejunostomy

·   For patients who have a previous history of tube-feeding aspiration pneumonia, reflux esophagitis, or when there is a reason the stomach cannot be used.

·   Often used with patient swho have severe reflux.

·   Diarrhea is a common complication due to the patients difficulty in regulating absorption via the intestine.

Intravenous Nutrition

·   Used when patients have a non-functioning GI tract.

Complications of Enteral feeding

Aspiration	1.     Aspirtion of oral secretions – tube feeding may not eliminate the primary source of pulmonary aspiration in patients with severe dysphagia. 2.     Reflux aspiration – increased reflux may occur with NG feeding since the tube passes through the pharynx and may lead to transient relaxation of the LES. 3.     Body position aspiration – patients need to be at 45 degrees when tube fed if they are in a supine position they are at risk of tracheal aspiration.
Enteral feeding regimens	1.     Bolus feeding – administration of formula intermittently throughout the day using a syringe, pump or gravity. Syringe feeding = rapid + can be associated with GI reflux and vomiting. It  does however ‘normalise’ the digestive system. 2.     Continuous feeding – speed of feeding is controlled with a pump/ gravity. Roubenoff (1992) recommend slow continuous drip feeding to reduce the risk of aspiration regardless of placement. Feeding is slow. But nutrient absorption is enhanced. A gradual progression from continuous to bolus feeding is recommended to normalise the bodies consumption of nutrients.
Diarrhoea	·   Common complication of enteral feeding
Medications	·   Drug absorption and metabolism may be altered/ interrupted during tube feeding.

Deciding on non-oral feeding

1.     Comprehensive formal/ informal dysphagia assessment – gain information on the patients medical condition, physiology and personal attributes.

2.     Patient’s preferences/ capacity – does the patient have capacity to make a decision regarding feeding options.

3.     Prognosis for recovery

Legal/ Ethical issues

·   Quille (1992) tube feeding is not viewed as ‘basic, humane care that must always be provided’

·   If a patient pulls out a feeding tube, it is a non-verbal indicator that they do not give consent for the tube.

·   PEG tubes are less likely than NG-tubes to be pulled out.

How to progress form non-oral to oral nutrition

Groher and Mckaig (1995)

·   Suggest that bolus feeding continues for 3-5 days before oral trials are attempted, to allow the stomach time to ‘stretch’ and reinitiate the hunger cycle.

·   They recommend that one meal be introduced orally for 1 week, with more meals added as the patient is able to tolerate oral feeding.

·   Tube feedings are adjusted depending on the patients oral intake.

·   The introduction of oral food requires consultation with the medical team (nurse, physician, dietician, pharmacist) to monitor health, nutritional status and any significant changes.

·   Criteria necessary for increased oral nutrition= indicators of nutritional status (fluid+calorific intake), and overall health status, such as strength, endurance and respiratory condition.