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This information is to help you understand more about nutritional support, which may also be called artificial feeding.
Malnutrition is when the body isn't getting enough vitamins, minerals and other nutrients to keep it healthy. Cancer or the effects of cancer treatments can sometimes result in malnutrition and also weight loss. You may 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 or have difficulty swallowing.
If you aren't able to eat or drink enough to maintain your weight your doctors may advise that you have nutritional support (artificial feeding). This can seem overwhelming at first but the advantages usually help overcome this.
Nutritional support is used to help people who are not able to eat or drink in the usual way. It can:
Generally, nutritional support is needed:
Two main types of feeding systems are used.
The type of nutritional support you will have depends on a number of factors.
Parenteral nutrition (nutrition into the vein) is usually used if people are unable to have EN – for example, if you have had major surgery on the small bowel, have a bowel obstruction, or if the insertion of the tubes used for EN would be difficult, such as after some types of surgery to the head, neck or stomach.
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 are likely to need to be given 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 due to 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 is important that the person inserting the NG tube checks that it is correctly positioned in your stomach.
Position of NG tube
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 are at home, the liquid food can be prescribed by your GP, who will ask your local pharmacy to supply it for you.
Other fluids, such as liquid medicines, can be given through the tube. Your dietitian, doctor, nurses or pharmacist can advise you about which medicines can be given through the tube. They will show you how to give them properly. Medicines can block the tube if they are not diluted properly and flushed through with plenty of liquid.
There can be drawbacks and possible complications with any type of nutritional support. With NG feeding the main drawbacks are as follows:
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. It may be used for people whose cancer is blocking the gullet and so nasogastric feeding cannot be used.
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 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 (known as the tube site) is cleaned. A dressing is not 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 30mls 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 do not get the area wet. It is fine to shower as long as the exit site is protected. It is also fine to wash, but bathing should be avoided.
Position of PEG/RIG tube
Your dietitian will discuss with you how much liquid food you need to have through the tube each day.
A radiologically-inserted gastrostomy is done in a similar way to a PEG, but using x-ray scanning equipment to position it.
An NG tube is inserted (see earlier). 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 which helps to position the 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 ten days later.
PEG and RIGs enable people who can't eat in the usual way to take in enough liquid food and fluids.
The most common complications with a PEG or RIG tube include:
Some people may have a sensation of stomach contents flowing back up the gullet (known as reflux), or nausea, if the feed is given too quickly. Let your doctor know if this happens, as medicines can be given 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 are at home, you should be given the name of a health 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 (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). 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 may be inserted at the same time as surgery to the gullet or the 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.
Parenteral Nutrition (PN) means giving necessary nutrients and fluid directly into the blood stream. Total parenteral nutrition (TPN) aims to give complete nutrition into the bloodstream – in other words, to give every nutrient that the body needs. It is very difficult to achieve total parenteral nutrition.
PN allows nutrition to be given even when the digestive tract is not working.
It can allow the digestive tract to rest so that it can heal; for example, after surgery to the stomach or bowel.
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 which 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 ten days) and if you are not on restricted fluids, as fluids need to be more diluted if an arm vein is used. An arm vein may be used for children who need nutritional support.
The doctors will decide which is the best type of feeding for your particular situation, taking into account your individual circumstances.
Your central line or your PICC line will be put in at the hospital by a specially trained nurse or doctor. A PICC line is put in using a local anaesthetic. A central line is usually put in under a general anaesthetic, but sometimes a local anaesthetic may be used. You will have an x-ray to make sure that the tube is in the right place.
You should not 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 to ease this.
Position of TPN/PN central line
First, your chest is cleaned with an antiseptic solution. A small cut is made in the skin near your collarbone and the tip of the tube is threaded into a large vein. This is called the insertion site. The tube is then tunnelled under the skin to reach the exit site. The exit site is the place where the end of the tube comes out of your body. You will have an x-ray to make sure that the tube is in the right place.
The position of the exit site will vary from person to person. You can ask the doctor who is going to put the line in where the exit site is likely to be.
When the tube has been put in you will have dressings covering the insertion and exit sites. You may have some pain or discomfort where the tube has been tunnelled under the skin. A mild painkiller such as paracetamol will help to ease this.
The line is kept in place with a stitch.
It is 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 may be more difficult to deal with than nasogastric feeding 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 very anxious. Before you are discharged home from hospital, you and your carers will be given training in how to manage your particular feeding system. Home nutritional support will not start until everyone involved feels confident in dealing with the tube and the feeds.
A team of health 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 that is needed.
This section has been compiled using information from a number of reliable sources including:
For further references, please see the general bibliography|.
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