Enteral Feeding

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.

Complications

Here, the focus is on complications that may present in the community, due to long-term placement, rather than due to the procedure itself.

NG tube

• Discomfort
• Epistaxis/nose bleeds
• Sinusitis
• Tube malposition
• Oesophageal injury

Gastrostomy                                               

1. Peristomal leakage of gastric contents.

Risk factors

• Skin infection
• Irritant contact dermatitis due to excess use of cleaning products
• Increased gastric acid secretion
• Gastroparesis
• Tube torsion
• Buried bumper
• Granuloma tissue in the tract

Treatment

• PPIs and prokinetics can reduce acid secretion and improve gastric emptying. (204)
• Sucralfate powder onto erosions. (206)
• Zinc oxide application.
• Topical steroid cream, eg clobetasone valearate or betamethasone valearate cream, or topical immunomodulators such as tacrolimus or pimecrolimus. (206)
• Fungal superinfection can be treated with a topical antifungal cream such as clotrimazole cream or a mixed cream containing an antifungal and hydrocortisone. (206)

2. Infection of the site. This can occur in up to 30% of patients but is rarely serious. The majority can be managed with oral broad-spectrum antibiotics, though IV antibiotics may be needed if there are signs of sepsis.
3. Buried bumper syndrome. Here the gastric mucosa overgrows the internal part of the PEG, and can occur in up to 3% of PEG patients.

Symptoms

• Peristomal leakage or infection
• Tube difficult to mobilise
• Abdominal pain
• Resistance when formula infused

Risk factors

• Previous malnutrition
• Excess tension on the gastrostomy
• Significant weight gain
• Prior malnutrition
• Poor nursing care of gastrostomy

Management

• Endoscopy or CT scan to confirm diagnosis
• Endoscopic surgery to release the overgrowth and remove the tube part that is overgrown (bumper)
• Open surgery may be needed if overgrowth is severe. (204)

4. Gastric ulcer or erosion of the wall under the internal part of the PEG. This can develop in up to 1%.
5. Fistulae between stomach, colon and skin which may present as long as months after initial placement.

PEG-J

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.

PEJ

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)

1. Vomiting and reflux

Consider acutely:

• Is the patient feeding at 45 degrees or sat up to minimise reflux?
• Is the patient at risk of dehydration – do they need IV rehydration?
• Consider stopping the feed.

If vomiting persists:

• Ask the patient to create a diary of their vomiting.
• Is the feeding regime right for the patient – method, rate, volume, concentration of feed?
• Is the feed the correct temperature?
• Is the patient on any medications that may cause this?
• Is the feeding tube in the right place?

2. Abdominal pain and distension

Causes:

• Constipation
• Build up of gas
• Gastrointestinal obstruction

Consider:

• Check bowel function
• Reduce air going into the feeding tube
• Is the feeding regime right for the patient – method, rate, volume, concentration of feed?
• Consider gastric venting – release gas by attaching an open-ended large syringe to the feeding tube.
• Is the feed the correct temperature?
• Would promotility agents help, or are they the cause of the discomfort?

3. Diarrhoea

Causes:

• Infection
• Medications
• Rate of feeding
• Intolerance to feed
• Migration of the tube

Management:

• Maintain feeding regime unless changed recently
• Electrolyte and hydration replacement
• Stool diary
• Stool culture

Consider possible causes:

• Has the feed been changed recently and can any changes be made to improve symptoms (rate, volume, concentration)?
• Feed temperature
• Tube migration
• Sorbitol content of medication, medications that may cause diarrhoea or alleviate it
• Tube and feed hygiene
• Faecal impaction
• Malabsorption

4. Constipation

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)

Consider:

• Is this medication needed?
• Can an alternative method of administration be used, eg topical, sublingual, rectal, intravenous Orodispersable tablets are not suitable for sublingual administration.
• Can a drug with an alternative method of administration in the same class be used instead?
• Can the medication be given safely orally instead?
• What is the site and size of feeding tube?

Formulations administered through feeding tubes

1. Liquid – this is easy to measure and administer and ready to use. However, excipients may cause side effects (eg sorbitol), large volumes may be needed, and some may cause GI side effects if hyperosmolar. Preferred formulation.
2. Liquid suspension – this is easy to measure and administer and ready to use. However, granules in the suspension may block tubes, they can be expensive special prescriptions, and adequate mixing is needed.
3. Soluble tablets (in water) – drug is in solution/liquid form, easy to administer, relatively cheap, dosing accurate. However, the drugs may take a while to disperse.
4. Effervescent tablets – Convenient and accurate dosing, but may have high salt content, need a large volume of water and take a while to disperse.
5. Opening capsules – cheap, readily available, convenient. However, they may not disperse in water, may cause contact skin allergies and can be tricky to manage. Last resort.

Do not crush:

• Modified release preparations
• Enteric coated tablets
• Cytotoxics
• Hormones

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)

Psychological impact

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:

• Taking away the pleasure of eating and drinking
• Feeling trapped by the equipment, with a restriction of their social milieu due to fear of damaging the NG tube or PEG. This can include exercise, physical activities/work, taking public transport. The time needed for feeds and maintenance of the tube is also restrictive for some.
• Impact on socialising with others – some struggle with meals out with others. Family members and friends may not understand their changed situation with eating and drinking. Some are reluctant to initiate new relationships or struggle with physical intimacy with existing partners due to concerns about the equipment.
• Social stigma. The NG tube may be commented on by others when out in public or make the individual themselves feel different to others.

Possible strategies that may help

• Choosing the best way to administer the feed that gives them the most control and allows them to integrate it into their life – eg syringe feeding for speed or backpack for others.
• Arranging their activities around their feeding routine so they can live a full life.
• PEG feeding is less visible and allows patients to feel more confident in undertaking their daily routine and socialising with others. (209)