Enteral feeding allows long-term delivery of nutrition into the stomach or intestines of those who are unable to maintain sufficient oral intake to maintain their nutritional needs. (204) A small minority of those born with OA/TOF need enteral feeding in adulthood, either due to associated co-morbidities or due to the complications of OA/TOF. The latter group include those who have never managed to sustain their nutritional needs with oral intake alone and those who have previously been able to eat and drink to maintain their nutritional needs in childhood and adulthood, but this is no longer possible. (31)
There are a number of indications for enteral feeding. These include impaired swallowing, obstructions to swallowing, fistulae in the neck or digestive tract, malnutrition. (204) All of these may occur (albeit rarely severe enough to need enteral feeding) in those born with OA/TOF. The NICE guidelines concerning nutritional support for adults suggest nutritional support from enteral feeding should be considered in those with a BMI of less than 18.5kg/m2, unintentional weight loss of more than 10% in the last three to six months, a BMI of less than 20kg/m2 and unintentional weight loss within the last three to six months. (205)
Whilst the initiation and management of enteral feeding falls solidly within the purview of secondary and tertiary care, those healthcare professionals in primary care may still be approached for advice about the management and difficulties with enteral feeding. However, NICE recommends that those receiving enteral tube feeding in the community should be monitored by those who are trained in enteral feeding and nutritional monitoring and they should also train the patient and their carers in management of their equipment and possible adverse signs to report. This monitoring should be by a multidisciplinary team of dieticians, district nurses, GPs community pharmacists and gastroenterologists/upper GI surgeons and other healthcare professionals as needed. (205)
Types of enteral tube feeding
Nasogastric (NG) tube: This is a flexible tube passed into the stomach or jejunum via the nostril.
Percutaneous gastrostomy: Toussaint et al. define this as the ‘establishment of an artificial access in the stomach, through the abdominal wall, which can be performed surgically (PSG), endoscopically (PEG) or with image guidance. Insertion of the gastrostomy tube can be done via the oral or the abdominal route’. (204)
Percutaneous gastrostomy with jejunal extension: Here, the access into the stomach is used to insert a feeding tube into the jejunum.
Percutaneous jejunostomy: As with gastrostomy, there is the establishment of artificial access to the jejunum through the abdominal wall, either surgically or endoscopically. These are preferred to gastrostomy feeding if there is gastroparesis, altered anatomy, severe GORD or gastric or duodenal access obstruction.
The only published data about enterally fed adults born with OA/TOF is contained within Hannon et al.’s (31) paper ‘Outcomes in adulthood of gastric transposition for complex and long gap esophageal atresia’. In their patient group, all of the 13% of their patients whose long-gap OA was repaired with gastric transposition who still needed enteral feeding were fed through jejunostomy. However, surveying the adult members of a Facebook support group for those born with OA/TOF showed that those who needed enteral feeding starting in adulthood were initially trialled on NG tubes, and some then progressed to gastrostomy tubes with a jejunostomy extension as well as jejunostomy feeding. This would correlate with the many reasons jejunostomy access is preferred, as one or more will be present in all born with OA/TOF needing enteral feeding.
Here, the focus is on complications that may present in the community, due to long-term placement, rather than due to the procedure itself.
These are similar to PEG complications. Additional problems include the extension tube moving back into the stomach, and the tube clogging more frequently as it is smaller in diameter.
These are similar to PEG complications. (204)
Complications due to enteral feeding
The British Association of Parenteral and Enteric Nutrition (BAPEN) recommends the following assessment and management. (207)
If vomiting persists:
Consider possible causes:
This occurs for the same reason as in other situations, due to lack of fluid, immobility, lack of fibre or due to medications.
Administering medication through feeding tubes
Most medications are not licensed for use through feeding tubes, so administration of drugs through this route relies on the clinical judgement of the prescribing doctor and advice of community or hospital pharmacists. BAPEN advises the following approach. (208)
Formulations administered through feeding tubes
Do not crush:
NJ tubes and medication:
BAPEN advises: ‘NJ tubes have greater potential to block due to longer length and smaller lumen. Some medicines are unsuitable for NJ administration as this bypasses gastric and duodenal absorption. Hyperosmolar medicines can cause GI side effects as the diluting effect of the stomach is bypassed. Advice from a pharmacist should always be taken before medication is administered via an NJ tube.’ (208)
Whilst enteral feeding provides a lot of health benefits for those that need it, it does have a psychological impact. There is no published research on those adults born with OA/TOF who are enterally fed, but literature on adults with other reasons for enteral feeding has shown a number of common themes. These include:
Possible strategies that may help