A feeding tube is a

medical device A medical device is any device intended to be used for medical purposes. Significant potential for hazards are inherent when using a device for medical purposes and thus medical devices must be proved safe and effective with reasonable assura ...

used to provide

nutrition Nutrition is the biochemistry, biochemical and physiology, physiological process by which an organism uses food and water to support its life. The intake of these substances provides organisms with nutrients (divided into Macronutrient, macro- ...

to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation. The state of being fed by a feeding tube is called gavage, enteral feeding or tube feeding. Placement may be temporary for the treatment of acute conditions or lifelong in the case of chronic disabilities. A variety of feeding tubes are used in medical practice. They are usually made of

polyurethane Polyurethane (; often abbreviated PUR and PU) is a class of polymers composed of organic chemistry, organic units joined by carbamate (urethane) links. In contrast to other common polymers such as polyethylene and polystyrene, polyurethane term ...

or silicone. The outer diameter of a feeding tube is measured in French units (each French unit equals mm). They are classified by the site of insertion and intended use.

Medical uses

There are dozens of conditions that may require tube feeding (enteral nutrition) to prevent or treat malnutrition. Conditions that necessitate feeding tubes include prematurity,

failure to thrive Failure to thrive (FTT), also known as weight faltering or faltering growth, indicates insufficient weight gain or absence of appropriate physical growth in children. FTT is usually defined in terms of weight, and can be evaluated either by a low ...

(or malnutrition), neurologic and neuromuscular disorders, inability to swallow, anatomical and post-surgical malformations of the mouth and esophagus, cancer, Sanfilippo syndrome, and digestive disorders.

Children

Feeding tubes are used widely in children with excellent success for a wide variety of conditions. Some children use them temporarily until they are able to eat on their own, while other children require them for a longer time. Some children only use feeding tubes to supplement their oral diet, while others rely on them exclusively.

Dementia

People with advanced

dementia Dementia is a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform activities of daily living, everyday activities. This typically invo ...

who get feeding assistance rather than feeding tubes have better outcomes. Feeding tubes do not increase

life expectancy Human life expectancy is a statistical measure of the estimate of the average remaining years of life at a given age. The most commonly used measure is ''life expectancy at birth'' (LEB, or in demographic notation ''e''0, where '' ...

for such people, or protect them from aspiration pneumonia. Feeding tubes can also increase the risk of

pressure ulcers Pressure ulcers, also known as pressure sores, bed sores or pressure injuries, are localised damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in comb ...

, require pharmacological or physical restraints, and lead to distress. In the final stages of dementia, assisted feeding may still be preferred over a feeding tube to bring benefits of

palliative care Palliative care (from Latin root "to cloak") is an interdisciplinary medical care-giving approach aimed at optimizing quality of life and mitigating or reducing suffering among people with serious, complex, and often terminal illnesses. Man ...

and human interaction even when nutritional goals are not being met.

ICU

Feeding tubes are often used in the

intensive care unit An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensive care medicine. An inten ...

(ICU) to provide nutrition to people who are critically ill while their medical conditions are addressed; as of 2016, there was no consensus as to whether nasogastric or gastric tubes led to better outcomes.

Mechanical obstruction and dysmotility

There is at least moderate evidence for feeding tubes improving outcomes for chronic malnutrition in people with cancers of the head and neck that obstruct the esophagus and would limit oral intake, people with advanced

gastroparesis Gastroparesis (gastro- from Ancient Greek – gaster, "stomach"; and -paresis, πάρεσις – "partial paralysis") is a medical disorder of ineffective neuromuscular contractions (peristalsis) of the stomach, resulting in food and l ...

, and

ALS Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease (MND) or—in the United States—Lou Gehrig's disease (LGD), is a rare, terminal neurodegenerative disorder that results in the progressive loss of both upper and low ...

. For long term use, gastric tubes appear to have better outcomes than nasogastric tubes.

GI surgery

People who have surgery on their throat or stomach often have a feeding tube while recovering from surgery; a tube leading through the nose and down to the middle part of the small intestine is used, or a tube is directly placed through the abdomen to the small intestine. There is some evidence to suggest that people with a tube through the nose were able to start eating normally sooner.

Product types

Medical nutrition companies make flavored products for drinking and unflavored for tube feeding. In the USA these are regulated as

medical food Medical food is food that is specially formulated and intended for the dietary management of a disease that has distinctive nutritional needs that cannot be met by normal diet alone. In the United States, it was defined in the Food and Drug Admin ...

s, which are defined in section 5(b) of the Orphan Drug Act (21 U.S.C. 360ee (b) (3)) as "a food which is formulated to be consumed or administered enterally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation."

Types

The most common types of tubes include those placed through the nose, including nasogastric, nasoduodenal, and nasojejunal tubes, and those placed directly into the abdomen, such as a gastrostomy, gastrojejunostomy, or jejunostomy feeding tube.

Nasogastric feeding tube

Man_with_NG_feeding_tube_wearing_a_zebra_baseball_cap

A nasogastric feeding tube or NG-tube is passed through the nares (nostril), down the esophagus and into the stomach. This type of feeding tube is generally used for short term feeding, usually less than a month, though some infants and children may use an NG-tube longterm. Individuals who need tube feeding for a longer period of time are typically transitioned to a more permanent gastric feeding tube. The primary advantage of the NG-tube is that it is temporary and relatively non-invasive to place, meaning it can be removed or replaced at any time without surgery. NG-tubes can have complications, particularly related to accidental removal of the tube and nasal irritation. More specifically, when nasogastric or nasoenteric tubes are placed incorrectly, they can damage patients'

vocal cords In humans, the vocal cords, also known as vocal folds, are folds of throat tissues that are key in creating sounds through Speech, vocalization. The length of the vocal cords affects the pitch of voice, similar to a violin string. Open when brea ...

lungs The lungs are the primary organs of the respiratory system in many animals, including humans. In mammals and most other tetrapods, two lungs are located near the backbone on either side of the heart. Their function in the respiratory syste ...

, or

trachea The trachea (: tracheae or tracheas), also known as the windpipe, is a cartilaginous tube that connects the larynx to the bronchi of the lungs, allowing the passage of air, and so is present in almost all animals' lungs. The trachea extends from ...

, resulting in serious injuries or even death. In March 2022,

Avanos Medical Avanos Medical, Inc. is a medical technology company making clinical medical devices. The company consists of two franchises – Pain Management and Chronic Care – that address reducing the use of opioids while helping patients recover faster ...

's ''Cortrak2 EAS recall'', for instance, has been classified as a Class I recall by the

FDA The United States Food and Drug Administration (FDA or US FDA) is a federal agency of the Department of Health and Human Services. The FDA is responsible for protecting and promoting public health through the control and supervision of food ...

, following reports of injuries and patient deaths caused by misplaced nasoenteric or nasogastric tubes.

Nasojejunal feeding tube

A nasojejunal or NJ-tube is similar to an NG-tube except that it is threaded through the stomach and into the

jejunum The jejunum is the second part of the small intestine in humans and most higher vertebrates, including mammals, reptiles, and birds. Its lining is specialized for the absorption by enterocytes of small nutrient molecules which have been pr ...

, the middle section of the

small intestine The small intestine or small bowel is an organ (anatomy), organ in the human gastrointestinal tract, gastrointestinal tract where most of the #Absorption, absorption of nutrients from food takes place. It lies between the stomach and large intes ...

. In some cases, a nasoduodenal or ND-tube may be placed into the duodenum, the first part of the small intestine. These types of tube are used for individuals who are unable to tolerate feeding into the stomach, due to dysfunction of the stomach, impaired gastric motility, severe reflux or vomiting. These types of tubes must be placed in a hospital setting.

Gastrostomy or gastric feeding tube

A gastric feeding tube (G-tube or "button") is a tube inserted through a small incision in the abdomen into the

stomach The stomach is a muscular, hollow organ in the upper gastrointestinal tract of Human, humans and many other animals, including several invertebrates. The Ancient Greek name for the stomach is ''gaster'' which is used as ''gastric'' in medical t ...

and is used for long-term enteral nutrition. One type is the

percutaneous endoscopic gastrostomy Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate ...

(PEG) tube which is placed endoscopically. The position of the endoscope can be visualized on the outside of the person's abdomen because it contains a powerful light source. A needle is inserted through the abdomen, visualized within the stomach by the endoscope, and a suture passed through the needle is grasped by the endoscope and pulled up through the esophagus. The suture is then tied to the end of the PEG tube that will be external, and pulled back down through the esophagus, stomach, and out through the abdominal wall. The insertion takes about 20 minutes. The tube is kept within the stomach either by a balloon on its tip (which can be deflated) or by a retention dome which is wider than the tract of the tube. G-tubes may also be placed surgically, using either an open or laparoscopic technique. Gastric feeding tubes are suitable for long-term use, though they sometimes need to be replaced if used long-term. The G-tube can be useful where there is difficulty with swallowing because of neurologic or anatomic disorders (

stroke Stroke is a medical condition in which poor cerebral circulation, blood flow to a part of the brain causes cell death. There are two main types of stroke: brain ischemia, ischemic, due to lack of blood flow, and intracranial hemorrhage, hemor ...

, esophageal atresia, tracheoesophageal fistula,

radiotherapy Radiation therapy or radiotherapy (RT, RTx, or XRT) is a treatment using ionizing radiation, generally provided as part of cancer therapy to either kill or control the growth of malignant cells. It is normally delivered by a linear particle ...

for

head and neck cancer Head and neck cancer is a general term encompassing multiple cancers that can develop in the head and neck region. These include cancers of the mouth, tongue, gums and lips (oral cancer), voice box ( laryngeal), throat ( nasopharyngeal, orophary ...

, etc.), and to decrease the risk of

aspiration pneumonia Aspiration pneumonia is a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs. Signs and symptoms often include fever and cough of relatively rapid onset. Complications may incl ...

. However, in people with advanced

or adult

, it does not decrease the risk of pneumonia. There is moderate quality evidence suggesting that the risk of aspiration pneumonia may be reduced by inserting the feeding tube into the duodenum or the jejunum (post-pyloric feeding), when compared to inserting the feeding tube into the stomach. People with dementia may attempt to remove the PEG, which causes complications.

Gastric drainage tube

A G-tube may instead be used for gastric drainage as a longer-term solution to the condition where blockage in the proximal small intestine causes bile and acid to accumulate in the stomach, typically leading to periodic vomiting, or if the

vagus nerve The vagus nerve, also known as the tenth cranial nerve (CN X), plays a crucial role in the autonomic nervous system, which is responsible for regulating involuntary functions within the human body. This nerve carries both sensory and motor fibe ...

is damaged. Where such conditions are only short term, as in a hospital setting, a nasal tube connected to suction is usually used. A blockage lower in the intestinal tract may be addressed with a surgical procedure known as a colostomy, and either type of blockage may be corrected with a

bowel resection A bowel resection or enterectomy (''wikt:entero-#Prefix, enter-'' + ''wikt:-ectomy#Suffix, -ectomy'') is a surgery, surgical procedure in which a part of an intestine (bowel) is removed, from either the small intestine or large intestine. Often t ...

under appropriate circumstances. If such correction is not possible or practical, nutrition may be supplied by

parenteral nutrition Parenteral nutrition (PN), or intravenous feeding, is the feeding of nutritional products to a person intravenously, bypassing the usual process of eating and digestion. The products are made by pharmaceutical compounding entities or standard ph ...

Gastrojejunal feeding tube

A gastrojejunal tube (GJ-tube, gastrojejunostomy tube) is a combination device that includes access to both the stomach and the jejunum, or middle part of the small intestine. Typical tubes are placed in a G-tube site or

stoma In botany, a stoma (: stomata, from Greek language, Greek ''στόμα'', "mouth"), also called a stomate (: stomates), is a pore found in the Epidermis (botany), epidermis of leaves, stems, and other organs, that controls the rate of gas exc ...

, with a narrower long tube continuing through the stomach and into the small intestine. The GJ-tube is used widely in individuals with severely impaired gastric motility, high risk of aspiration, or an inability to feed into the stomach. It allows the stomach to be continually vented or drained while simultaneously feeding into the small intestine. GJ-tubes are typically placed by an interventional radiologist in a hospital setting (a gastrojejunostomy. The primary complication of a GJ-tube is migration of the long portion of the tube out of the intestine and back into the stomach.

Jejunal feeding tube

A jejunostomy feeding tube (J-tube) is a tube surgically or endoscopically inserted through the abdomen and into the

(the second part of the

Complications

Nasogastric and nasojejeunal tubes are meant to convey liquid food to the stomach or intestines. When inserted incorrectly, the tip may rest in the respiratory system instead of the stomach or intestines; in this case, the liquid food will enter the lungs, resulting in pneumonia and can, in rare cases, lead to death. Complications associated with gastrostomy tubes (inserted through the abdomen and into the stomach or intestines) include leakage of gastric contents (containing

hydrochloric acid Hydrochloric acid, also known as muriatic acid or spirits of salt, is an aqueous solution of hydrogen chloride (HCl). It is a colorless solution with a distinctive pungency, pungent smell. It is classified as a acid strength, strong acid. It is ...

) around the tube into the abdominal (peritoneal) cavity resulting in

peritonitis Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and covering of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One pa ...

, a serious complication which will cause death if it is not properly treated.

Septic shock Septic shock is a potentially fatal medical condition that occurs when sepsis, which is organ injury or damage in response to infection, leads to dangerously low blood pressure and abnormalities in cellular metabolism. The Third International C ...

is another possible complication. Minor leakage may cause irritation of the skin around the gastrostomy site or stoma. Barrier creams, to protect the skin from the corrosive acid, are used to manage this. A phenomenon called "tube dependency" has been discussed in the medical literature, in which a child refuses to eat after being on a feeding tube, but it is not recognized as a disorder in the ICD or DSM, and its epidemiology is unknown.

Oral and dental complications

Guidelines for dental care for children fed by tube are poorly established. Many dental complications arise due to poor

oral health The word oral may refer to: Relating to the mouth * Relating to the mouth, the first portion of the alimentary canal that primarily receives food and liquid **Oral administration of medicines ** Oral examination (also known as an oral exam or oral ...

that may result from reluctance or intolerance towards

oral hygiene Oral hygiene is the practice of keeping one's oral cavity clean and free of disease and other problems (e.g. bad breath) by regular brushing of the teeth (dental hygiene) and adopting good hygiene habits. It is important that oral hygiene be carr ...

practices by patients and caregivers, abundance of dental plaque and/or tooth decay, and lack of oral stimulation. Although many studies on this topic involve a relatively small sample size, the findings are important as they are associated with the development of various oral conditions, dental diseases and even systemic diseases such as

Calculus

Adults fed by tube have previously shown a significantly higher rate and quantity of

calculus Calculus is the mathematics, mathematical study of continuous change, in the same way that geometry is the study of shape, and algebra is the study of generalizations of arithmetic operations. Originally called infinitesimal calculus or "the ...

deposition than adults fed orally. Even with an intensive oral hygiene program in place, adults fed by tube still demonstrate a greater quantity of supra- gingival calculus accumulation, which can be a risk factor for several oral diseases including

periodontal disease Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main c ...

s and

. Although calculus removal may be difficult for caregivers to perform and provide an unpleasant experience for patients with a feeding tube, the implications of calculus in the initiation of aspiration pneumonia make it clear that it poses a serious health risk. Research suggests that the best course of treatment for patients with a gastric tube is periodic professional cleaning, maintained with routine home use of a non-foaming anti-calculus dentifrice (

toothpaste Toothpaste is a paste or gel dentifrice that is used with a toothbrush to clean and maintain the aesthetics of Human tooth, teeth. Toothpaste is used to promote oral hygiene: it is an abrasive that aids in removing dental plaque and food from th ...

Caries

Dental caries Tooth decay, also known as caries,The word 'caries' is a mass noun, and is not a plural of 'carie'.'' is the breakdown of teeth due to acids produced by bacteria. The resulting cavities may be a number of different colors, from yellow to black ...

is a localized disease in which susceptible tooth structure is broken down by bacteria that are able to ferment carbohydrates into acid. Although it has not been extensively studied, researchers speculate that individuals fed by tube may be less prone to the development of caries as they are not exposed to carbohydrates orally. Examination of

dental plaque Dental plaque is a biofilm of microorganisms (mostly bacteria, but also fungi) that grows on surfaces within the mouth. It is a sticky colorless deposit at first, but when it forms Calculus (dental), tartar, it is often brown or pale yellow. It is ...

from tube-fed individuals found that it contained fewer caries-associated microorganisms ( lactobacilli and

streptococcus ''Streptococcus'' is a genus of gram-positive spherical bacteria that belongs to the family Streptococcaceae, within the order Lactobacillales (lactic acid bacteria), in the phylum Bacillota. Cell division in streptococci occurs along a sing ...

) and had reduced ability to produce acids, suggesting an overall weaker ability to cause caries. Further, studies with animal subjects found that tube-feeding was not associated with tooth decay, even when combined with reduced

saliva Saliva (commonly referred as spit or drool) is an extracellular fluid produced and secreted by salivary glands in the mouth. In humans, saliva is around 99% water, plus electrolytes, mucus, white blood cells, epithelial cells (from which ...

tion. Thus, tube-feeding alone does not necessarily directly promote the development of caries.

Periodontal diseases

To date, no published studies have been conducted on

indicators (including clinical attachment loss, pocket depth, or periodontal indices) among tube-fed individuals. However, since tube feeding is correlated with calculus build-up, which is known to be a risk factor in the development of periodontal diseases, further investigation is critical to determine what role tube feeding might have in the development of periodontal disease.

Dental erosion

Dental erosion is the dissolution of the

tooth A tooth (: teeth) is a hard, calcified structure found in the jaws (or mouths) of many vertebrates and used to break down food. Some animals, particularly carnivores and omnivores, also use teeth to help with capturing or wounding prey, tea ...

's hard structures ( enamel,

dentin Dentin ( ) (American English) or dentine ( or ) (British English) () is a calcified tissue (biology), tissue of the body and, along with tooth enamel, enamel, cementum, and pulp (tooth), pulp, is one of the four major components of teeth. It i ...

cementum Cementum is a specialized calcified substance covering the root of a tooth. The cementum is the part of the periodontium that attaches the teeth to the alveolar bone by anchoring the periodontal ligament. Structure The cells of cementum are ...

) by exposure to acids not caused by

bacteria Bacteria (; : bacterium) are ubiquitous, mostly free-living organisms often consisting of one Cell (biology), biological cell. They constitute a large domain (biology), domain of Prokaryote, prokaryotic microorganisms. Typically a few micr ...

. In the case of individuals fed by gastric tube, acid may enter the oral cavity through reflux of gastric contents.

Gastroesophageal reflux disease Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is a chronic upper gastrointestinal disease in which stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/or ...

(GERD) affects up to 67% of children and young adults with central nervous system dysfunction, a condition which in itself is normally an indicator for tube feeding. The effects of gastric acid on the teeth may sometimes be masked or minimized by the abundance of calculus. Tube feeding may either resolve, exacerbate or introduce the issue of GERD in individuals.

Aspiration pneumonia

Individuals fed by tube are susceptible to aspiration through a multitude of factors. Firstly, undisturbed plaque is known to shift towards the type of

(

Gram-negative Gram-negative bacteria are bacteria that, unlike gram-positive bacteria, do not retain the crystal violet stain used in the Gram staining method of bacterial differentiation. Their defining characteristic is that their cell envelope consists ...

anaerobic) implicated in aspiration pneumonia. Additionally, tube-fed patients are commonly affected by gastroesophageal reflux and a breakdown in the airway protection reflex (breathing while swallowing). This results in the inadvertent inhalation of bacteria-containing gastric juices as they are re-swallowed, leading to the development of aspiration pneumonia.

Oral hypersensitivity

While a child undergoes a period of tube-feeding, there is a lack of oral stimulation that can lead to the development of oral

hypersensitivity Hypersensitivity (also called hypersensitivity reaction or intolerance) is an abnormal physiological condition in which there is an undesirable and adverse immune response to an antigen. It is an abnormality in the immune system that causes Imm ...

. This can complicate the delivery of dental care and serve as a barrier for the child's return to oral feeding. This can also lead to

dysphagia Dysphagia is difficulty in swallowing. Although classified under " symptoms and signs" in ICD-10, in some contexts it is classified as a condition in its own right. It may be a sensation that suggests difficulty in the passage of solids or l ...

(difficulty swallowing), muscle weakness and improper airway protection, resulting in longer periods of tube-feeding and increased risk of dental complications. A dentist may prescribe a "desensitization program", which involves routine stimulation of intra-oral and extra-oral structures, and encourage

procedures to be performed at home.

History

While enemas were previously used for supplemental enteral nutrition, the practice of surgically inserting feeding tubes emerged in the mid to late 1800s. Initially, these procedures were largely unsuccessful, but they quickly improved with advancements in technique. Originally, the

nasogastric tube Nasogastric intubation is a medical process involving the insertion of a plastic tube (nasogastric tube or NG tube) through the nose, down the esophagus, and down into the stomach. Orogastric intubation is a similar process involving the insertion ...

(NGT) was described by John Hunter in the 18th century as a combination of eelskin and

whalebone Baleen is a filter-feeding system inside the mouths of baleen whales. To use baleen, the whale first opens its mouth underwater to take in water. The whale then pushes the water out, and animals such as krill are filtered by the baleen and ...

. It was initially utilized to provide liquid nutrition to the ill.

References

{{reflist, 30em

External links

American Society for Parenteral and Enteral Nutrition
Medical equipment Enteral feeding