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This information aims to help you understand more about nutritional support, which may also be called artificial feeding.
Cancer, or the effects of cancer treatments, can sometimes result in malnutrition and weight loss|.
Malnutrition is when the body isn't getting enough vitamins, minerals and other nutrients to keep it healthy. This may be because you have a reduced appetite| or difficulty swallowing|.
These problems may only happen for a short time. Changes to your diet or supplementing it with nutritious drinks| is sometimes all that's needed. However, for some people this won't be enough to keep their weight up, or they may be unable to swallow or have difficulty doing so.
If you aren't able to eat or drink enough to maintain your weight, your doctors or dietitian may advise that you have nutritional support (artificial feeding). This can seem overwhelming at first, but there are many advantages to having nutritional support, which usually helps people overcome their worries.
Nutritional support is used to help people who aren't able to eat or drink in the usual way. It can:
Generally, nutritional support is needed if a person:
Two main types of feeding system are used, known as enteral nutrition (EN) and parenteral nutrition (PN). The type of nutritional support you have depends on a number of factors.
This is where the nutritional fluid is given into the gut through a tube going into the stomach or small intestine. There are different ways of giving EN.
EN is best for you if your digestive system is working normally but you aren't able to eat enough - for example, because of a cancer in the head or neck| area.
This is where the nutritional fluid is given through a tube that is put into a vein (intravenously). PN is sometimes called TPN (total parenteral nutrition) as it aims to give total nutritional support, although this isn't always possible.
PN is usually used if people are unable to have EN. This may happen if you've had major surgery on the small bowel|, have a bowel obstruction or if the insertion of the tubes used for EN would be difficult, which may happen after some types of surgery to the head, neck or stomach|.
We have a section on diet after stomach surgery|, which you may find helpful.
There are several ways of giving EN. The most common methods used are:
Nutritional support through a nasogastric tube or a gastrostomy is often used after surgery to the head, neck, stomach or gullet (oesophagus).
Nasogastric feeding is usually recommended if you’re likely to need nutritional support for only a short time. NG feeding may also be used for people having radiotherapy to the mouth, throat or gullet| if swallowing becomes difficult because of swelling from the radiotherapy.
You will need to be in a comfortable position, sitting upright. A thin, flexible tube is gently inserted into your nostril, down the back of the throat, down the gullet (oesophagus) and into your stomach. It's important that the person inserting the NG tube checks it is correctly positioned in your stomach.
This is done by drawing some fluid out from the tube using a syringe. As stomach fluid is very acidic, fluid drawn out from the tube is tested for acidity with a pH indicator to show whether or not the tube is in the stomach. Sometimes an x-ray may be necessary to make sure that the tube is correctly placed in the stomach.
Once the tube is correctly positioned, it will be taped to your nose or cheek to keep it in place.
Your dietitian will work out how much liquid food you need to have each day and you can be given this through the tube by the hospital staff. If you’re at home, the liquid food can be prescribed by your GP, who will ask your local pharmacy to supply it for you. You or your carer will be shown how to give the liquid food and a district nurse will also visit you.
Other fluids, such as liquid medicines, can be given through the tube. Medicines can block the tube if they aren't diluted properly and flushed through with plenty of liquid. Your dietitian, doctor, nurses or pharmacist can advise you about which medicines can be given through the tube and can show you how to give them properly.
Position of a nasogastric (NG) tube
View a large copy of the position of the nasogastric (NG) tube diagram|
There can be drawbacks and possible complications with any type of nutritional support. With NG feeding the main disadvantages are:
Gastrostomy feeding is recommended if your digestive system is still working well but nutritional support is likely to be needed for more than a few weeks.
Gastrostomy feeding involves surgically creating an opening, known as a fistula, through the abdominal wall. A feeding tube can then be passed through the opening and into the stomach.
The feeding tube is held in place with either a stitch, a small inflated balloon around the tube just under the skin or a flange around the tube just under the skin.
Before a PEG is put in, the procedure will be explained to you by a doctor or specialist nurse. You will be asked to sign a consent form to say that you agree to having the PEG put in and that you understand why it is being done.
You will need to have nothing to eat or drink for several hours before the procedure to make sure that your stomach is empty. Your doctor will also give you antibiotics to reduce your risk of getting an infection.
You'll be given a sedative to make you feel sleepy. A flexible tube with a light at the end (an endoscope) is passed into your mouth, down your gullet and then into the stomach. The stomach is inflated with air, and the endoscope is positioned so that the light at the end shines through the abdominal wall to show the position of the stomach.
The skin of the abdominal wall is then cleaned and a local anaesthetic is used to numb the area. A small cut is made through the skin and muscle through which a feeding tube is inserted into the stomach.
Following the procedure, the area around the tube (the tube site) is cleaned. A dressing isn't usually necessary unless there is leakage of fluid from the site. The area around the tube needs to be cleaned daily with soap and water and thoroughly dried. The tube needs to be flushed with 30ml of water before and after each feed.
It takes approximately three weeks for the skin to heal around the tube, and during this time it is recommended that you don't get the area wet. It's fine to shower as long as the exit site is protected. It's also fine to wash, but you should avoid having a bath.
Your dietitian will discuss with you how much liquid food you need to have through the tube each day.
A RIG is inserted in a similar way to a PEG, but x-ray scanning equipment is used to position it. An NG tube is inserted (as above). You will then have some local anaesthetic injected to numb an area on your abdomen before a small cut (incision) is made.
Some air is pumped down the NG tube and into the stomach that helps position the RIG tube accurately. The gastrostomy tube is then put directly into the stomach using x-ray guidance.
Once the gastrostomy tube is in place, some dye is flushed into it and an x-ray is taken to make sure it's in the right place. After this the NG tube can be removed. The RIG is held in place with stitches, which are removed about 10 days later.
Position of a PEG/RIG tube
View a large copy of the position of a PEG/RIG tube diagram|
PEGs and RIGs enable people who can't eat in the usual way to take in enough liquid food and fluids. The tubes can't be seen when people are wearing clothes, whereas a nasogastric (NG) tube can be seen.
The most common complications with a PEG or RIG tube include:
It is important to tell your doctor as soon as possible if:
Some people may have a sensation of stomach contents flowing back up the gullet (reflux) or nausea if the feed is given too quickly. Let your doctor know if this happens, as they can give you medicines to help.
As with NG feeding, the feed needs to be given slowly and this can restrict you from being able to move around freely. For this reason, many people prefer to have their feed overnight. Your dietitian can discuss your feeding with you, so that you can minimise the disruption to your daily life.
If you’re at home, you should be given the name of a healthcare professional at the hospital so that you can contact them if you develop any problem with your PEG/RIG tube.
PEG/RIG tubes can remain in place for up to two years, but many people have them for much shorter periods. After this they can be replaced if they are still needed.
Some people may have a percutaneous endoscopic jejunostomy (PEJ), also called a jejunostomy tube. This procedure is similar to a PEG/RIG, but a feeding tube is passed into the middle part of the small bowel (the jejunum) instead of the stomach. A jejunostomy tube may be inserted at the same time as surgery to the gullet or stomach.
The care and issues are the same as for PEG/RIG tubes, but a PEJ feed needs to
be given more slowly, and any water put into the PEJ needs to be sterile, or boiled then cooled.
Parenteral nutrition (PN) means giving necessary nutrients and fluid directly into the bloodstream. Total parenteral nutrition (TPN) aims to give complete nutrition into the bloodstream – in other words, to provide every nutrient that the body needs. It is very difficult to achieve total parenteral nutrition.
PN is usually given through a thin tube, which is inserted into a large vein in your neck or chest. The tube is known as a central line|. Sometimes it is given through a thin tube in your arm that goes up into a vein in your chest. This is called a PICC line| (peripherally inserted central catheter).
Occasionally, a vein in the arm may be used (like having an ordinary drip), but this is less common. It tends to be used if feeding is only necessary for a short period of time (fewer than 10 days) and if you’re not on restricted fluids, as fluids need to be more diluted if an arm vein is used.
The doctors will decide which is the best type of feeding for your particular situation, taking into account your individual circumstances.
Your central or PICC line will be put in at the hospital by a specially-trained nurse or doctor. A central line is usually put in under a general anaesthetic, but sometimes a local anaesthetic may be used. A PICC line is put in using a local anaesthetic.
You will have an x-ray to make sure that the tube is in the right place.
You shouldn't feel any pain when the tube is being put in, but you may feel a bit sore for a few days afterwards. A mild painkiller such as paracetamol will help ease this.
PN allows nutrition to be given even when the digestive tract isn't working. It can allow the digestive tract to rest so that it can heal – for example, after surgery to the stomach or bowel.
It's possible for an infection to develop either inside the line or around the exit site. You should tell your doctor if:
You may be given antibiotics or, if the infection is serious, the tube may have to be removed.
It is possible for a blood clot (thrombosis) to form in your vein at the tip of the central line. If this happens the tube may have to be removed. You may be given some anti-clotting medicines to prevent this from happening. The medicines are usually added to the feed.
Your dietitian and pharmacist will create a feeding plan that, as far as possible, contains the nutrients in a normal diet and takes into account your individual needs.
Many people can have their nutritional support at home. Having parenteral nutrition is more difficult to deal with than NG or PEG feeding. You may need to be referred to a specialist hospital to be shown how to manage the parenteral feeds at home.
The thought of having nutritional support at home may make you feel anxious. Before you’re discharged from hospital, you will be given training in how to manage your particular feeding system. If you have a carer, or carers, they will be given training too.
Home nutritional support will not start until you, and your carer(s) if you have one, feel confident in dealing with the tube and the feeds.
A team of healthcare professionals will also help to support you at home. The support offered to people may vary, but your GP, district nurse and dietitian can help you.
Some NHS trusts work in partnership with specialist home-care companies to ensure that people who go from hospital care to home care receive the support and expertise they need.
PINNT |aims to support patients who need artificial nutrition therapy, and their carers, via the website and regional groups. It gives information on nutritional therapies, parenteral and enteral feeding, and has specific information for younger people.
This fact sheet has been compiled using information from a number of reliable sources, including:
With thanks to Dr Clare Shaw, Consultant Dietitian, and the people affected by cancer who reviewed this edition. Reviewing information is just one of the ways you could help when you join our Cancer Voices network|.
Content last reviewed: 1 January 2013
Next planned review: 2015
For answers, support or just a chat, call the Macmillan Support Line free (Monday to Friday, 9am-8pm)
If you have any questions about cancer, need support or just want someone to talk to, ask Macmillan.
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© Macmillan Cancer Support 2013
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