Nasogastric and enterostomy feeding

Nasogastric and enterostomy feeds

Alison Morton, Sue Wolfe, Helen White and Kisten Tremlett. Jan, 2001. Nasogastric and enterostomy feeds [online]. Seacroft and St James's University Hospitals, Leeds, UK. Available from http://www.cysticfibrosismedicine.com

Some patients, usually those with more severe chest involvement, may be unable to achieve or maintain an adequate energy intake and normal growth even with a high fat diet and dietary supplements. If patients are failing to achieve an adequate weight gain over a period of 6 months, if their weight-for-height falls below 90% or their BMI to less than 19 in adults, or if there is a significant weight loss during an acute exacerbation, the need for more intensive supplementary feeding may be discussed. These patients can achieve an adequate energy intake by additional feeds given via a fine bore nasogastric tube (Holden et al, 1991). An alternative is to administer the extra feed via a gastrostomy directly into the stomach or, more rarely, via a jejunostomy into the upper small bowel (Levy et al, 1985; Boland et al, 1986; Dalzell et al, 1992; Steinkamp et al, 1994). The fine bore nasogastric tube may either be left in place or passed each time a feed is given (Holden et al, 1991). Nasogastric feeding has proved effective and acceptable to patients (Pencharz et al, 1984; Bellwood et al, 1991). However, the gastrostomy has become a more popular method of enteral feeding, due to the simplification of tube placement by the percutaneous endoscopic technique and the use of gastrostomy buttons. The need for nutritional support may be long term (Wicks et al,1992). The increasing experience in the placement of the gastrostomy devices and the management surrounding the operation in CF units has also been important in their increasing use and acceptability (Littlewood & Wolfe, 1994). In adults, enteral feeding by gastrostomy is more effective than by the nasogastric route (Morton & Conway, 1996). Enteral tube feeding usually takes place overnight, allowing the patient to eat normally through the day. Patients seem to tolerate lower volumes of more highly concentrated preparations such as the whole protein feeds (Ensure Plus, 2Cal HN [Abbott]) rather than more dilute feeds given at a higher rate, as is often necessary with elemental feeds. Whatever type of feed is used, careful monitoring of the patient's blood glucose is essential when feeds are first introduced. Hyperglycaemia (high blood glucose) requiring insulin therapy may occur in patients given night time enteral feeds (Smith et al, 1994) irrespective of the carbohydrate content (Kane et al, 1989). This tendency is exacerbated if the patient is also receiving corticosteroids. Orally administered pancreatic enzymes are necessary with all enteral feeds including elemental preparations and those containing medium chain triglyceride fat (Durie et al, 1980). However, as the feed is continuously administered over a long period of time, it is likely that the enzyme requirement is less than that calculated when comparing the fat content of the feed and the patient's usual enzyme dose with food. For this reason, an initial dose of 1 or 2 capsules of the patients usual enzyme preparation at the start and end of the feed is usually advised. This dose is then altered on an individual basis according to assessment of absorption. More research is needed to determine the best dose and time of administration of enzymes with enteral feeds.

References

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Littlewood JM, Wolfe SP. Nutrition in Cystic Fibrosis. In: Heatley RV, Green JH, Losowsky MS, editors. Consensus in Clinical Nutrition. Cambridge University Press, 1994, pp388-419

Morton A, Conway SP. Enteral feeding by gastrostomy is more effective than by nasogastric route in patients with cystic fibrosis. Israel J Med Sci 1996; 32 (suppl): S218

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Wicks C, Gimson A, Vlavianos P et al. Assessment of percutaneous endoscopic gastrostomy feeding tube as of an integrated approach to enteral feeding. Gut 1992; 33: 613-616

Kane RE, Black P. Glucose intolerance with low-, medium-, and high carbohydrate formulas during night time enteral feedings in cystic fibrosis patients. J Pediatr Gastroenterol Nutr 1989; 8: 321-326