Enteral Feeding (Tube Feeding)

 Acknowledgements
 Introduction to Enteral Feeding

Acknowledgements

This section is part of a project funded by the State of Washington Office of Children with Special Health Care Needs. The project resulted in the publication of a book of guidelines for nutrition care of children with special health care needs. We offer this section as is because the information on enteral feeding is thorough and complete. We realize that not all information will apply directly to VLBW infants. This section was authored by Annette Pederson, MS, RD.

Introduction to Enteral Feeding

Enteral feeding refers to the delivery of liquid feedings through a tube. Enteral feeding, or tube feeding, is used for infants and children who have a functioning gastrointestinal tract, but are unable to orally ingest adequate nutrients to meet their metabolic needs. Conditions that may require enteral feeding include:

1. Gastrointestinal disorders, such as disorders of absorption, digestion, utilization, secretion and storage of nutrients. This includes anatomic disruptions such as tracheoesophageal fistula.
2. Neuromuscular disorders, such as muscular dystrophy, spinal cord defects, and cerebral palsy or damage to the central nervous system
3. Cardiopulmonary disorders and other conditions of hypermetabolism such as burns and cancer.
4. Failure to thrive
5. Prematurity

Enteral feeding can play a role in both short-term rehabilitation and long-term nutritional management. The extent of its use ranges from supportive therapy, in which the tube supplies a portion of the needed nutrients, to primary therapy, in which the tube delivers all the necessary nutrients. Most children receiving enteral feedings can continue to receive oral feedings to fulfill the pleasurable and social aspects of eating. All infants and young children require oral-motor stimulation for developmental reasons.

Tube feeding benefits the child by improving growth and nutritional status and frequently by improving the primary condition. By ensuring that the child's nutrient needs are being met, tube feeding can free the family from anxiety and, improve quality of life. Enteral feeding is necessary for the child who is not safe to feed because his or her airways need protection to prevent or decrease risk of aspiration. Additional benefits include improved hydration, improved bowel function, and consistent medication. Tube feeding is a safer and less expensive alternative to feeding orally than total parental nutrition.

There are disadvantages with enteral feedings. If the child has gastroesophageal reflux, aggressive enteral feeding may increase his risk of aspiration or vomiting. Other physical disadvantages are diarrhea, skin breakdown or anatomic disruption. Mechanical disadvantages include a dislodged or occluded feeding tube. Metabolic risks include hyperglycemia and hyperphosphatemia.

Children who are either malnourished or at high risk for becoming malnourished can benefit from tube feeding. When one or more of the following factors are identified, tube feeding should be considered:

1. Inability to consume at least 80% of energy needs by mouth
2. Total feeding time more than four hours per day
3. Weight loss or no weight gain for a period of three months (less for younger children and infants)
4. Weight for height (or length) less than 5th percentile for age and sex
5. Triceps skinfold less than 5th percentile for age
6. Serum albumin less than or equal to 3.0 g/dl

An interdisciplinary team should decide whether to begin tube feeding. The team should include at a minimum the primary physician, the nutritionist, and the caregiver(s). If the child has oral-motor feeding problems, the team should also include an occupational or speech therapist. Before tube feeding is started, the child needs a medical work-up for the following purposes:

1. To rule out contraindications for enteral feeding
2. To diagnose possible gastrointestinal problems (e.g., gastroesophageal reflux, risk of aspiration)
3. To determine the optimal delivery site for the feeding (i.e., stomach, duodenum, or jejunum)
4. To determine an appropriate program for oral-motor stimulation

The feeding tube is placed either nasally or surgically and the choice of placement depends on many factors:

1. Preference of the caregiver(s)
2. Expected duration of the tube feeding
3. Local resources for dealing with possible complications
4. Family's ability to learn the feeding technique required by the particular placement

Oral-motor problems may improve with development, time, and treatment. All enteral feeding techniques are reversible. Discontinuation of enteral feedings requires the same careful planning and often the same detailed work-up that go into the decision to start it.

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