Tube Feeding (Enteral Nutrition) for Children: Types of Tubes, How they Work, Types of Feedings and Tube Care

Obviously, children who require a tube to be fed need more help than with just the tube and the feeding. They have their underlying problems. and it sometimes takes the parents and caregivers a while to be comfortable with all that means emotionally and with doing the work of caring for the child.

It's not easy in any aspect.

Sometimes, it's even difficult to get used to the idea of the child needing a tube for feeding. And yet parents are often grateful once it's there, because even if the child is still eating by mouth, the tube can just be a safety valve to provide medicines when he or she otherwise refuses them or finds them difficult or if the child has an virus and can't eat temporarily. My favorite story is when I offered to place a tube to help a frail, teenager who was developmentally delayed. It took him an hour to eat each meal and he needed 6 a day to meet all his needs. The mother initially declined because as she said, they were "the best 6 hours of my day."

But almost all the parents truly feel less burdened once the tube is in place and they are used to using it.

TUBE TYPES

There are only a few different tubes really. [find pictures]

  • Nasogastric
  • Gastrostomy (G tube Or PEG)
  • Jejunal (Or GJ tube)
  • Button

They all deliver commercial and homemade supplemental formulas in the stomach or intestines but they have slightly different uses. The formulas may be somewhat different depending where the formula is delivered.

A nasogastric (NG) tube

When feedings are going to be needed for more than a few months, a tube should be placed directly into the stomach or intestine. In most situations, a gastric (or gastrostomy) tube will function well for the delivery of nutrition and medication. The tube goes through the skin over the stomach and then into the stomach itself. Usually this is done with a simple puncture into the abdominal with a needle that is similar to the ones used to draw blood. This called a Percutaneous (through the skin) Endoscopic Gastrostomy (PEG) because a scope is used to position a cushion on the inside so the tube has less of a chance of coming out. When a PEG can't be done for one of several reasons, the procedure can be done with routine surgery. The recovery time is generally longer, but the tubes function the same way.

The tube can be eventually converted to a "button." The long tube extending from the abdomen's skin can interfere with therapy and mobility. And they can be played with or pulled out by accident. The much smaller button gets a tube attached during an actual feeding, but in between the times it's being used, the top flap can be closed. So they are much less likely to get in the way.

In children with developmental delays, these G tubes and buttons have been shown to

  • reduce feeding time,
  • food related choking episodes,
  • frequency of chest infections and
  • family stress,
  • while increasing weight gain.

However, PEGs are not free of complications or concerns. Minor catheter infections are common and there can be more significant complications, including increased reflux and aspiration. The tubes prolong the lives of children with severe delays who also have breathing tubes, but they may actually shorten the lives of those who don't have breathing tubes to protect their airways. The tube itself may not be the cause, since these children also have problems with immobility, malnutrition, swallowing problems and repeated aspiration that may contribute as well. However, the protection offered by a breathing (tracheostomy) tube does suggest that the potential for aspiration with g tubes and buttons is considerable.

Therefore, the stomach's anatomy and function should be evaluated prior to the placement of a feeding tube. If gastroesophageal reflux or delayed stomach emptying is present, an additional surgical procedure can be done at the time of placement to lessen reflux, or a gastrojejunal (GJ) tube can be used instead. These tubes are placed just like regular G-tubes, but then a thinner tube is placed through and run into the small intestine (the first part of the small intestine is the duodenum, the next part is the jejunum). While these tubes overcome the problems of reflux and slow emptying, the fluids have to run slowly, and the fluids themselves are different than what can be delivered into the stomach Fortunately, GJ buttons have also been developed. Medicines can still be given in the gastric part of the button, while the feedings can be dripped into the intestine.

FEEDING THROUGH THE TUBE Feeding your child with a tube is a simple process, sometimes called enteral feeding. The tube or button is attached to another tube that runs from the formula (which is typically in a bag, similar to the IV bags you've seen on all the medical TV shows) down to the attachment and then to your child.

When the fluid is delivered into the stomach, the stomach empties the fluid into the intestine at a pace that is similar to when you or I eat. That gives the intestine time to process each small release. As a result, the fluids can be given in meal-like amounts over a short, 15-20 minute time frame, known as bolus feedings. The feeding is poured, in perhaps 1- or 2- ounce portions, into a syringe or funnel every few minutes, traveling through the tubing to the stomach. Some children receive 3 feedings like this a day, some 5. Some will get a portion of that after a regular meal, making up for what they weren't able to eat by mouth, some will get an entire 8 ounce can or formula or more.

Other children are unable to tolerate a bolus of the fluid and they require drip feedings. The fluid is delivered slowly from the formula bag. A pump regulates the flow. This method of drip feeding can be used for several hours, overnight along with daytime bolus feeds, or for the entire day. They must be used for children with jejunal feedings, because bolus feeds are not absorbed well by the intestine and can cause diarrhea. When needed a separate tube and bag can be attached to release any extra gas build up.

TUBE CARE

After each feeding and whenever medicine is given, a small amount of water needs to be flushed through to clear the tube and prevent it from clogging. That also means that parents and caregivers need to be careful about what's put in the tubes. Any homebrew formula or dissolved medicine needs to be thin enough to easily flow down the tube.

Buttons usually have plastic balloons at their tip inside that are filled with water to held them in place. These can wear down over time and burst, especially if too much water is used. When that happens or if the buttons leak or have other problems, they need to be replaced. That's easily accomplished and many parents or caregivers can be trained to do that themselves. Additionally, children or adults can outgrow their buttons if they gain weight (and girth). Again, that can be accomplished without difficulty, with your doctor re-measuring and rechecking the site.

Understandably, caregivers for children who tube fed Many parents are apprehensive about feeding their children and assuring adequate nutrition for their children. neurologically impaired children may be even more so. Based on the method of delivery, the caregivers should be carefully trained in the preparation and delivery of the feeding. They should be reassured and provided with of medical, nutritional and home care agencies that they serve as resources for them. They should be informed that success may be most dependent on appropriate followup to assess the patients' progress and adjust the feeding regimens.

Dr. Stan Cohen13 May 2015

Dr. Stan Cohen is one of our founders and our CEO as well as the Chairman of our Medical Advisory Board. Dr. Stan is an internationally recognized expert in Read more

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