What is Enteral Feeding?
Enteral feeding refers to the delivery of nutrient-rich liquid feedings through a tube to provide nutrition. 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 for growth, development, function, and health.
What conditions may require enteral feeding?
Gastrointestinal disorders, such as disorders of absorption, digestion, utilization, secretion and storage of nutrients.
- Failure to thrive
- Neuromuscular disorders, such as muscular dystrophy, spinal cord defects, and cerebral palsy or damage to the central nervous system
- Cardiopulmonary disorders and conditions of hyper-metabolism, such as burns and cancer.
Enteral feeding can be used for both short-term rehabilitation until a child can feed on its own, and long-term nutritional management if necessary. It can be used for supportive therapy, in which the tube supplies a portion of the needed nutrition, or primary therapy, in which the tube delivers all the necessary nutrients. 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. Most children, who receive enteral feedings and are capable, can also continue to receive oral feedings to fulfill the pleasurable and social aspects of eating. All infants and young children who receive enteral feeding require oral-motor stimulation for developmental reasons that will promote oral motor function for speech and feeding.
Benefits of Enteral Feeding
Tube feeding benefits the child by improving growth and nutritional status, and frequently can improve the primary condition, increasing the likelihood that the child will develop the ability to feed independently. By ensuring that the child’s nutrient needs are being met, tube feeding can free the family from anxiety, bring some peace of mind, and improve quality of life. Additional benefits include improved hydration, improved bowel function, and consistent medication. Tube feeding is a safer and less expensive alternative than total parenteral nutrition (feeding intravenously and bypassing the digestive system). Children who are either malnourished or at high risk for becoming malnourished can benefit from tube feeding.
Disadvantages of Enteral Feeding
There are disadvantages with enteral feedings. If the child has gastroesophageal reflux, aggressive enteral feeding may increase his/her risk of aspiration (sucking food into the airway) or vomiting. Other physical disadvantages are diarrhea, skin breakdown at the insertion site of the tube, or anatomic disruption. Mechanical disadvantages can include a dislodged or occluded feeding tube, which parents need to be instructed in how to manage. Metabolic risks include hyperglycemia (high blood sugar) and hyperphosphatemia (an electrolyte disturbance).
When is a feeding tube considered appropriate or necessary?
- Inability to consume at least 80% of energy needs by mouth
- Total feeding time takes more than four hours per day
- Weight loss or no weight gain for a period of three months (less for younger children and infants)
- Weight for height (or length) less than 5th percentile for age and sex
- Triceps skinfold less than 5th percentile for age
- Serum albumin less than or equal to 3.0 g/dl
Who determines if my child needs a feeding tube?
An interdisciplinary team should decide if tube feeding is appropriate and when to begin. 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 for consultation and to initiate oral motor therapy. Before tube feeding is started, the child needs a medical work-up for the following purposes:
- To rule out contraindications for enteral feeding
- To diagnose possible gastrointestinal problems (e.g., gastroesophageal reflux, risk of aspiration)
- To determine the optimal delivery site for the feeding (i.e., stomach, duodenum, jejunum, or nasal)
- To determine an appropriate program for oral-motor stimulation
Where is the feeding tube located?
The feeding tube is placed either nasally or surgically and the choice of placement depends on many factors:
- Expected duration of the tube feeding
- Preference of the caregiver(s)
- Local resources for dealing with possible complications
- Family’s ability to learn the feeding technique required by the particular placement
Tube Placement Options:
Nasoenteric Feeding Tubes
Tubes are passed through the nose to various points in the GI tract.
- avoids general anesthesia or surgical procedure
- low incidence of complications
- risk of aspiration (Inhaling the liquid formula into the lungs)
- requires X-ray confirmation of correct tube placement
- suited only to short-term (less than 6 weeks) use
Tubes are placed either laparoscopically (minimally invasive), operatively, or percutaneously (through the skin) and are generally located in the abdominal region. This method is also commonly called G-tubes, or PEG tubes.
- can be used immediately or within hours of being placed
- can be used for long-term support
- can be used when the child also presents with significant disease of upper GI tract (esophagus, stomach and duodenum)
- tubes are placed under the skin (percutaneously), which avoids risks of surgery and general anesthesia
- laparoscopic feeding tubes allow patients to return home the same day after procedure
- may require endoscopy, abdominal ultrasound, or radiologic procedure with injectable contrast media before placing the tube
- endoscopy may be difficult or impossible in presence of tumor, obstruction, altered anatomy, or severe obesity
- laparoscopically or operatively placed tubes require general anesthesia
- potential for chronic wound complications
Feeding problems and oral-motor problems may improve with development, time, treatment, and therapies. All enteral feeding techniques are reversible. Discontinuation of enteral feedings require the same careful planning with an interdisciplinary team, and often requires the same detailed work-up that goes into the decision to start.
Our Approach at North Shore Pediatric Therapy
At North Shore Pediatric Therapy, our multidisciplinary therapists provide outpatient therapies for children with feeding tubes, and recommendations for children who may need a feeding tube. North Shore Pediatric Therapy is not medically equipped to place a feeding tube in a child, and will refer out to a specialist for this procedure. However, our NSPT therapists will be a part of the interdisciplinary team to determine the best plan of care for the child throughout the process. Our NSPT therapists also support the families through the process as well as provide any needed therapies to promote and improve the child’s daily function.