WHEN YOU CAN’T EAT ORALLY…..
By Ms Loy Kia Lan
Nurse Clinician, Nutrition Support Service
Singapore General Hospital

Tube Feeding is generally prescribed for persons requiring nutritional support over a long period of time. They may need Total Nutritional Support (unable to eat and must get all nutrition from tube feeding) or only Supplemental Nutritional Support (able to eat but cannot get enough nutrition from meals alone).

There are various methods of tube feeding which requires different types of feeding tubes inserted into different parts of the digestive tract. They are:

a	Nasogastric (NG) Tube Feeding. This method uses an NG feeding tube inserted through the nose, down the throat and into the stomach.
b	Percutaneous Endoscopic Gastrostomy (PEG) Tube Feeding. A PEG tube is inserted using a flexible scope through the skin into the stomach.
c	Nasojejunal (NJ)Tube Feeding. The NJ tube is inserted through the nose, down the throat, pass the stomach and into the jejunum which is a part of the small intestines.
d	Jejunostomy (J)Tube Feeding. The Jejunostomy tube is inserted into the jejunum by making a small opening through the skin. This would require several physical adjustments.

What You Need To Know

Formula Feeds

The essential nutritional components such as protein, carbohydrate, fats, vitamins, minerals and water are delivered to the person in formula feeds containing the proper mix of nutrients to meet the individual‘s needs.

Prior to hospital discharge, the doctor or dietitian will prescribe the formula and the amount of water to be given with the feeds. The nurse will give you the feeding schedule and teach you the feeding method. You can buy these formulas in pre-mixed liquid form or powdered at the hospital pharmacy, private retail pharmacies and supermarkets.

Medications

Medications fed through the tube must be in dissolvable powder or liquid form. This prevents blockage or clogging of the feeding tube by solids or sediments. Whenever possible, ask the doctor to prescribe medications in powdered or liquid form. Tablets must be crushed to a fine powder and dissolved in water. Capsules need to be opened and use only the powder within. Always check with the pharmacist before crushing the tablets or opening capsules because this may sometimes change the medications’ efficacy. Do not mix any medication with formula feeds.

Tube Feeding Position
To prevent vomiting or aspirating the feeds into the lungs, do not lie the person flat during feeding but keep the person in an upright position and for at least one hour after feeding.

Care of the nose
If the person is feeding through a nasogastric tube, the presence of the NG tube may cause soreness or crustiness around the nostril. On a daily basis, change the tape holding the tube in place, taking care to avoid having the tube rub the nostril. Clean the nostrils at least once a day with a soft towel or cotton bud moistened with warm water to remove nostril crust. Apply lip balm or moisturizing cream to the inside edges of the nose. If you notice redness, bleeding or numbness, report conditions to the doctor or nurse.

Adjusting to tube feeding
Eating is a social experience. Some people may want to take their tube feeding at the same time the family is eating. On the other hand, some people take the tube feeding in private but sit and socialize with family and friends while they are eating or after the meal is over. But whatever approach is most comfortable, make sure that the person spends time with the family and friends even if not during meals.

The person also faces the challenges of learning how to perform daily activities with the tube in place. Other common physical adjustments include learning new knowledge and skills in managing the tubes, preventing complications, trouble shooting and problem solving when complications arise.

Common problems with tube feeding

Tube clogged or blocked
To prevent clogging of the tube by food or medication, flush the tube with at least 20 ml of water after every feeding. If the tube is totally clogged, irrigate with warm water or aspirate with 60 mls syringe. Carbonic fizzy soda drinks like Coca Cola, Sprite or Ice Cream soda may be used to unclog partially blocked feeding tubes.
Care should be taken while irrigating to avoid excessive pressure on the catheter. If these remedies fail, the feeding tube should be changed.

Specific gastrostomy or jejunostomy tube care
A person with a gastrostomy or jejunostomy tube will need to cope with the tube care at the insertion site (stoma).

1) Care of the stoma
The stoma should be cleansed daily with mild soap and water. A good time for cleaning the stoma is during a bath or shower. You can also use a cotton swab or cotton bud to clean in a circular motion. After cleaning, allow the site to air dry. Always check for signs of redness, pain or soreness, swelling or unusual discharges around the stoma. Report any signs of these symptoms to the doctor if they occur. Be sure to rotate the gastrostomy tube once a day to prevent pressure from the gastrostomy tube exerting pressure on the stomach over a prolong period of time causing ulcer and bleeding.

2) Leakage around the tube
Leakage around the tube may occur because the feeding tube has been pulled away from the stoma site or the stoma tract has become enlarged.
Gentle traction on the feeding tube will bring the gastric wall, and abdominal wall together and aid in tract formation. The external disc or bolster should be readjusted to assure a secure fit to prevent leakage around the tube.

3) Wound infections
Pus drainage may accompany the tube due to foreign body reaction or infection around the stoma. The insertion site should be cleansed several times each day and allowed to air dry. Coverage by dressing may be needed temporarily until the discharges disappeared.

4) Dislodgement of gastrostomy feeding tube
Confused persons may try to remove or pull out the tube. If the tube is pulled out, DO NOT PANIC or try to replace the tube into the stoma. Apply a dry gauze dressing at the stoma and send the person to Accident and Emergency Department immediately. The doctor may insert another tube into the stomach to keep the stoma tract open.

Conclusion
Beyond the physical adjustment to tube feeding, there are a host of psycho-social issues that make managing tube feeding challenging that can lead to emotional ups and downs, even depression. Nasogastric tubes in particular are clearly visible and will draw attention to the person especially in public areas. Being on tube feeding requires a person to actively commit to managing the nutritional therapy and accepting certain restrictions. Having a supportive family and / or a group of friends is an important factor in helping the person adapt to his / her new life. With positive support, the person with tube feeding is better able to gain and preserve a greater sense of independence and self-confidence. Many patients find fulfillment and empowerment by learning as much as they can about their particular diagnoses, conditions and therapies and then participating as fully as possible as part of the health care team.