Tube Feedings

Tube Feedings

Different Types of Tube Feedings
  • Gastric tube feedings involve the delivery of liquid nutrition directly to the stomach via an enteral tube.
  • Nasogastric tube feeding (through the nose into the stomach) provides necessary nutrition to individuals who can’t eat due to difficulty swallowing, trauma, oral or esophageal obstruction, or injury. 
  • Duodenal or jejunal enteral tube feeding delivers the liquid formula to the small intestine, specifically the duodenum or jejunum. 
  • Nasoduodenal or nasojejunal enteral tube feedings bypass the esophagus and stomach and therefore reduce the risk of aspiration. 
  • Jejunostomy tubes work well for the administration of long term food or medications. 
  • Duodenal or jejunal feedings decrease the risk of aspiration because the formula bypasses the pylorus. However, jejunal feeding reduces pancreatic stimulation and may require specialized adjustments to the diet. 

Special Needs baby that must be feed using nasogastric feeding tube

Lippincott Nursing Procedures (2019) 8th Ed. Philadelphia: Wolters Kluwer, 796.

What You Need to Know About Gastrostomy Tubes

     The most common type of feeding tube is the gastrostomy (G) tube. A surgeon places a G-tube through the abdominal wall into the stomach. There are three options for G-tube surgery:

1. Inserting the G-tube surgically through small incisions using a laparoscope.

2. Inserting the G-tube using a larger open incision through the abdominal wall.

3. Using an endoscopy scope to insert the G-tube into the stomach to create the stoma from the inside.

     The endoscopic method has become the method of choice at many hospitals; however, some institutions still place tubes surgically, and children with anatomic abnormalities or who need other procedures may require a surgical placement.

     There are several types of G-tubes. Any G-tube works initially. Often it is the surgeon or the gastroenterologist who determines the first type of G-tube placed. Below are some of the most common types of G-tubes you may encounter.

Man receiving feeding through stomach tube.
PEG and Long Tubes:

     These are one-piece tubes held in place either by a retention balloon or by a bumper. Surgeons like to use this type for the first 8-12 weeks post-surgery. PEG specifically describes a long G-tube placed by endoscopy and stands for percutaneous endoscopic gastrostomy. Sometimes the term PEG is used to describe all G-tubes. Surgeons may place other styles of long tubes. 

 
Low Profile Tubes or Buttons:

     These tubes do not have a long tube permanently attached outside the stomach. Instead, they have a tube called an extension set they attach for feeding or medication administration, and then they disconnect it when it is not in use. When they disconnect an extension set from a button, it lies relatively flat against the body. There are two types: a balloon and a non-balloon.

 
Balloon Buttons:

     Balloon buttons are held in place by a waterfilled balloon. Balloon buttons are the most common G-tube for children once the stoma (G-tube site) heals, usually in 2-3 months. The use of balloon buttons as a first G-tube is increasing among medical professionals. With training, caregivers learn to replace balloon buttons at home.

 
Non-Balloon Buttons:

     Some surgeons and gastroenterologists prefer the first G-tube to be a non-balloon button. Non-balloon buttons are harder to pull out than balloon buttons. Therefore, Non-balloon buttons must be replaced in the doctor’s office or at the hospital, sometimes with sedation or a topical pain reliever.

 
Sizing for G-tubes

     All G-tubes are sized based on the French scale. The measurement looks at the diameter of the tube across its width. G-tube buttons require a second measurement, in centimeters, based on the length of the tube’s stem (the part of the tube placed in the stoma or tube site). For example, a 16Fr 1.5cm tube has a French size (diameter) of 16 and a stem length of 1.5cm. The size is listed on MIC-KEY and AMT button G-tubes. G-tubes should have enough room between the tube and the skin to allow one or two coins to slide under the tube. If the tube is pressing tightly against the skin or has much more room, your child may need a different stem size.

 

https://www.feedingtubeawareness.org/wp-content/uploads/2015/05/ParentGuide.pdf

Special Needs Children with Feeding Tubes

      If you are the parent of a child that is struggling to eat and not gaining weight, you may be told that the next step to prevent malnutrition involves inserting a gastric tube. The type of tube to be inserted depends on the reason why your child is not eating. 

 

     Nasal tubes are non-surgical and temporary tubes placed through the nose and into the stomach or intestine. The choice between nasogastric (NG), nasoduodenal (ND), and nasojejunal (NJ) tubes depends on whether your child can tolerate feeding into the stomach or not.

 

(The following information is taken from the website: Feeding Tube Awareness Foundation)
 
NG-TUBES

NG-tubes enter the body through the nose and run down the esophagus into the stomach.

ND- OR NJ-TUBES

ND-tubes are similar to NG-tubes, but they go through the stomach and end in the first portion of the small intestine (duodenum). NJ-tubes extend even further to the second portion of the small intestine (jejunum). Bypassing the stomach can be beneficial for those whose stomachs don’t empty well, who have chronic vomiting, or who inhale or aspirate stomach contents into the lungs.

 

Tips for Little Hands and Nasal Tubes
Babies and small children will often try to pull their nasal tubes out. At night, try putting mittens or socks on your child’s hands to keep him/her from pulling the tube out. You can tape the nasal tube (or feeding bag tubing) down the back of the shirt during the day to keep it out of the child’s way. At night, you may want to tape it further down the pajamas. If the pajamas are two-piece, you can run tubing inside the pajama leg to keep children from tangling.
 
 

https://www.feedingtubeawareness.org/wp-content/uploads/2015/05/ParentGuide.pdf 

 
  • Help your family member to sit up or raise the head of their bed to at least 30 degrees.
  • Place some protective towels around them in case the insertion process stimulates their gag reflex, and they vomit or spit up.
  • Choose which nostril to use by evaluating for tenderness, previous trauma, or structural issues that could affect the ease of insertion.
  • Determine the distance you need to advance the tube by measuring against external landmarks.
    • Place the distal tip of the NG tube at the end of your family member’s nose and stretch the tube from the nose to the earlobe on the same side as the nostril. Continue to extend the tube down toward the xiphoid process (The xiphoid process is a sharp point between the breast bones) and then go about halfway down to the belly button.
  • Mark the location of the xiphoid process and the midpoint to the belly button on the tube. The marks let you know how far you have advanced the tube during the procedure.
  • Lubricate the tip of the NG tube with a water-soluble lubricant. Some tubes come pre-lubricated with a substance activated by water.  With those, the chemical liquifies into a gel to form a lubricant when dipped in water.
  • Insert the NG tube through the nostril, angling it down as it advances through the nose to the throat.
    • Have your family member tuck their chin down close to their chest.
    • Gently rotate the tube as you slide it down the throat. If you meet resistance, try having your family member drink a sip of water as you push the tube forward, so they are swallowing the tube along with the water.
  • If the person starts to cough or you see the tube begin to curl in the mouth, withdraw it and begin again.
  • After you have advanced the tube to the predetermined length, check to see if it is in the proper place in the stomach. Attach a syringe to the end of the tube and pull back on the plunger to see if you can withdraw any gastric contents. If you’re in the stomach, you should obtain either remains from the last feeding, or stomach acids (grassy-green, brown, or clear and colorless). You can also insert air into the tube with a syringe and listen with a stethoscope at the stomach to determine if you hear it enter the stomach.
  • If you determine it’s in place, secure the tube with tape. Apply skin prep or other protection to the skin in advance to protect it from prolonged exposure to wearing tape.
  • Mark the tube where it exits the nose to monitor if it changes positions before feedings.
  • Keep the head of the bed elevated 30 degrees whenever a tube feeding is in progress.

Lippincott Nursing Procedures (2019) 8th Ed. Philadelphia: Wolters Kluwer, 526.

     Taping is an art, and there is definitely a process of trial and error to find what works best for you and your child. Often a piece of an extra thin dressing called Duoderm is placed on the skin, the nasal tube is run on top of it, and then a clear Tegaderm dressing is applied on top.

 

Here is a common method:
  1. Prior to placing the NG-tube, clean and dry the cheek and apply a piece of Duoderm Extra Thin to the cheek.
  2. Insert the tube and lay it on top of the Duoderm.
  3. Secure the tube to the Duoderm with a piece of Tegaderm.
  4. Add a small strip of tape closer to the nose (Durapore works well for this).
  5. Tape tube to clothing at the back of the neck to keep the end of the tube accessible.
  1. Unclamp the tube if it’s not in continuous use or stop the feeding, clamp the enteral administration set, and cap the distal end of the tubing.
  2. Verify proper tub placement
  3. After confirming placement, flush the tube with at least 15 ml of water. Watch to make sure your family member tolerates that well.
  4. Administer the medication using a clean enteral syringe
  5. Flush the tube again with at least 15 ml of water
  6. Repeat the procedure with the next medication
  7. Flush the tube one final time with at least 15 ml of water
  8. Clamp the tube and detach the syringe
  9. Replace the cap of the tip of the syringe. Recap the syringe.

Lippincott Nursing Procedures (2019) 8th Ed. Philadelphia: Wolters Kluwer, 522.

Before giving medicine through an NG tube, first, check to make sure that the tube works appropriately.  If the person is vomiting or if you attempt to irrigate the tube or check placement and nothing will go through it, do not try to put medication thought the tube.

Giving medication through an NG tube isn’t as simple as you might think.  Many medicines do not work as intended if they enter the stomach directly.   They have a special coating or time-release factors that affect how they work. If you crush them or slip them in a tube, so they end up directly in the stomach, it throws off how they work, and they are not as effective and may not work at all. Therefore, you must carefully consider how to adapt the medications you give through the tube before switching to that route.

Factors to Consider
  • Can the medication be given through an NG tube?

If the medication is time-released or has an enteric coating to protect it from stomach acid, then it cannot be administered through a tube that ends in the stomach.

  • Is the tube patent?

After checking placement, check to see if the tube is patent. If it has become obstructed, nothing can bypass the blockage, including medication.

  • Medications should be given in liquid format when possible rather than crushed. When crushing pills and mixing them with liquids, they often still create obstructions due to pieces that do not dissolve thoroughly.
  • Give medications separately. Flush the tube with 15 ml of water and give the next medicine to prevent issues with incompatibility, tube obstruction, and altered therapeutic response.

Warning: Aspiration can occur with improper tube placement. Administration of large volumes of liquid medication containing sorbitol or those of high osmolality may cause cramping, abdominal discomfort, and diarrhea.

Lippincott Nursing Procedures (2019) 8th Ed. Philadelphia: Wolters Kluwer, 522.