Updated guidelines for tube feeding.

Residents with swallowing disorders are becoming increasingly common. Here's how to maintain their nutritional status.

Many nursing home residents suffer from neuro logical dysfunction due to stroke, head injury, Parkinson's disease, multiple sclerosis, alzheimer's disease and other types of dementia. One unfortunate outcome can be the loss of swallowing function, necessitating that nutrition be given via a tube. According to a study in the New England Journal of Medicine, from 1982 to 1986 the frequency of tube feedings in long-term care rose from 21 percent to 29 percent.[1] This trend is likely to continue and nursing homes will need to adopt quality assurance programs that include specific items for their residents on tube feedings.

When is Tube Feeding

Necessary?

First, why does the patient need a tube, and have other attempts at feeding been documented? Patients with even minimal swallowing ability can often be successfully fed when given the right type of diet and assistance in feeding. Many hospitals with rehabilitation units now have "Feeding Teams" that consist of a speech therapist, occupational therapist and a dietitian. This concept can be expanded to the nursing home setting to ensure every chance has been given to maintain or restore eating function.

I studied a group of patients with loss of swallowing ability and found that they could be successfully fed orally using a calorically-dense formula.[2] Oral supplements are often ordered, as one can be given 3 times per day, either with meals or between meals. Standard supplements are I calorie per cc and are the consistency of milk. I established an alternative system using a 2 calorie per cc formula given as 60cc six times per day. This provided the same number of calories as the standard method but did so in half the volume. Furthermore,the thicker texture of the calorie-dense product facilitated swallowing without aspiration. Patients took in more formula and showed improved weight gain using this alternative method.

Tube Feeding Options

When all options for oral intake have been tried without success, a tube feeding must be implemented to prevent starvation and dehydration. There are three basic types of tubes: 1) those that go through the nose and into the gastrointestinal tract (NG tube); 2) those that are surgically placed into the intestine (jejunostomies); and 3) those that are placed percutaneously into the stomach using an endoscope (gastrostomy).

While the first is the least invasive, it is also a temporary solution. NG tubes made of silicone must be changed once a month, and those made of polyvinyl chloride should be Changed weekly since this material stiffens in gastric acid. These tubes commonly clog because they are small-bore and have the added disadvantage that they can be easily dislodged by the resident.

Surgically placed jejunostomies, although more secure than NG's, are susceptible to being dislodged. If this occurs, they cannot be replaced without another trip to the operating room. They are also small in diameter and require that a thin formula be used.

The best alternative for the long-term care resident is the percutaneous endoscopic gastrostomy. This procedure can be done at the bedside, but generally physicians place these tubes in an outpatient clinical setting. It does not require anesthesia and can be done in less than an hour. Feedings are usually started within 24 hours. The first replacement of the gastrostomy tube should be done by the physician using an endoscope. After the initial tube is out, a replacement gastrostomy tube can be placed into the stoma by a nurse. This should be done every 2-3 months if using a silicone tube. Latex tubes usually require replacement monthly.

Choice Of Formula And

Administration

Formula choice should be made by the physician with input from the dietitian. In general, isotonic feedings are best tolerated. Feedings should be started full strength at a rate of 25 to 30 cc per hour. There is no need to dilute formulas that are isotonic. This was a procedure done in the past when formulas were hypertonic. Advance the formula by 20 cc every 6 hours, being sure that gastric residuals are not above 100cc. Once the patient is stable at the desired rate, gastric residuals do not have to be monitored. Keep in mind that most tube feeding protocols in print were developed in hospitals for acutely ill patients. In long-term care, tube feedings are being given due to lack of ability to swallow, not because there is gastrointestinal dysfunction.

Tube feedings can be given via pump or gravity. The main difference is usually ease of administration. However, in some cases of gastric paresis, dumping syndrome and diabetes, the slow and controlled delivery of formula is necessary to prevent aspiration, diarrhea and blood sugar swings, respectively. With either type of administration the set should be changed daily to prevent bacterial contamination of formula. Pumps must be kept clean to ensure proper operation.

Intermittent or cyclical feedings are generally preferred to continuous in nursing homes. Continuous feedings prevent the feeding system from being turned off at any time. This usually results in patients not receiving their entire formula prescription. Furthermore, residents may be able to participate in some facility activities during the day and can do so more freely without being tethered to their feeding bag. Night time feedings offer many advantages in this setting. They can be initiated at bed time and turned off in mid-morning for most people. In addition to allowing more freedom, this type of regimen is more conducive to eating in those patients who are being rehabilitated.

Water Requirements

Flushing of feeding tubes is important to prevent clogging and to ensure adequate hydration. At least 50cc of water should be used to flush before feedings are started, when feedings end and before and after administration of medications. A simple way to remember how much water is necessary for hydration is to give one cc of water per calorie of formula.[3] Most formulas are 75-80% water.

Other Tube Feeding

Considerations

Some other things to remember when tube feeding are: - Keep the head of the bed elevated to

prevent aspiration - Monitor gastric motility of drugs;

when changing from food to formula,

the prescription may need to be decreased - Fiber, although good for absorbing

water and therefore aiding in normal

elimination, also delays gastric emptying

and can cause gas and bloating - The most frequent cause of diarrhea

in tube fed patients is concurrent antibiotic

use, so don't be too quick to

blame the feeding. - Gastric motility slows with age and

disease; if aspiration or regurgitation 

occurs, cut back the rate of feeding - There may come a time when the tube

feeding should be discontinued; keep

in mind that death by starvation is

usually slow; death by dehydration

occurs quickly.

References

[1.] Shaughnessy PW, Kramer AM. The increased needs of patients in nursing homes and patients receiving home health. The New England Journal of Medicine 1990; 322:1. [2.] Raymond JL. Calorie-dense feedings given during medication pass improves supplement intake in senile nursing home patients. The Journal of the American Dietetic Association 1991;91:9. [3.] Nutrition Support Handbook edited by K. Teasley-Strausburg. Harvey Whitney Books, Cincinnati, OH, 1991,

Janice L. Raymond, MS, RD, CNSD, is Manager of Medical Education of Clintec Corporation, Deerfield, IL.