17 minute read
Adult tube feeding
ADULT TUBE FEEDING THEN, NOW AND IN THE FUTURE
Ever wondered what were the beginnings of enteral tube feeding? How did it emerge? What were tubes made of? How was nutritional formula made? This article presents the development of adult tube feeding throughout history.
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The earliest description of tube feeding was found on 3500-year-old papyrus, although it was not tube feeding as we know it. Due to issues with accessing the upper gastrointestinal tract, ancient Egyptians and Greeks, including Hippocrates, are reported to have performed rectal feeding. From then on, rectal alimentation was commonly used throughout history. Although nasogastric feeding was introduced in the 16th century, rectal feeding still gained popularity in the 19th century.1-3
FOOD ENEMAS In 1878, food enemas pushed into the rectum twice daily with a wooden syringe were claimed to provide an adequate provision of fluids and nutrients. One of the most famous reports of rectal alimentation was following President Garfield’s gunshot wound. For 79 days, every four hours he was rectally infused with peptonised beef broth, several drops of opium and whisky!1-3
Until 1940, the rectal route was still used to provide water, saline and glucose solutions. In 1941, it was a recommended form of nutrition in US military hospitals and infamously used as a method of torture by the Central Intelligence Agency (CIA). Solutions contained a combination of wheat or barley broth, milk, eggs, wine, brandy, tobacco and meat mixed with wax and starch. Defibrinated blood was also considered for that purpose but dismissed after reports of causing rectal irritation.1-3
Currently, in some wellness companies, the rectal route is used to provide colonic irrigation, also known as hydrotherapy. Its purpose? To flush waste materials out of the body using water, in order to ‘cleanse’ yourself. However, according to the NHS, there is no scientific evidence to suggest any health benefits of hydrotherapy, and the list of side effects remains extensive from irritation and dehydration to infection and bowel puncture.4
NASOGASTRIC BEGINNINGS The humble beginnings of nasogastric feeding date back to the 16th century, when nasogastric tubes were made out of silver or leather. An animal bladder served as an equivalent of the 20th century ‘formula bottle’.
The 18th century brought major advances when John Hunter used a catheter and syringe approach to deliver nasogastric feeding. Later, investment in device developments led to inventions including a tube made of spiral wire covered with gut and another consisting of an eel skin drawn over flexible whalebone for orogastric feeding. However, these tubes were very large in diameter, not flexible and difficult to insert.1,3,5,7,8
The early 19th century brought major advances in psychiatry, with tubes being widely used for forcibly feeding patients with mental health issues. It wasn’t until the late 19th century when medics started using softer rubber tubing. Only then did tube feeding stop being an extremely traumatic experience for patients.3,5,7,8
Bogna Nicinska RD
Dietitian by day, writer by night, Bogna has experience in research, community and acute care. Prior to Oviva, Bogna worked at Imperial College Healthcare NHS Trust as a Nutrition Support Dietitian.
REFERENCES Please visit: nhdmag.com/ references.html
GASTRIC FEEDING TECHNIQUES The stomach pump became the first form of gastric feeding. Liquid formulas comprised mixtures of jellies, eggs, milk, wine, beef tea, water with sugar beaten in, thick custards, mashed potatoes and predigested milk treated with acid or enzymes (brandy or whisky).5-7 In 1837, the purpose of potential gastrostomies was being raised. The procedure itself came to life eight years later; however, due to many associated infections, physicians were more inclined to sway towards the use of nasogastric tubes. That took a turn in the 1860s with Lister’s introduction of an aseptic surgical technique.3
The 20th century was the most fruitful in tube feeding developments. It brought the invention of a minimally invasive endoscopic method of placing percutaneous endoscopic gastrostomy (PEG). Studies of the benefits of early postoperative feeding were being published. In one of them, Polish-American gastroenterologist, Max Einhorn, stated that the rectum and colon are simply organs to absorb remaining fluids and for excreting faeces. The main focus then evolved around the duodenum, which was considered an organ that secreted digestive juices of great importance. Einhorn introduced small bowel feeding in 1910 using a rubber tube. Soon after, other physicians followed in his footsteps. That led to further developments, including the invention of the nasojejunal tube and a gastrojejunal dual lumen tube. Physicians experimented with surgical placement of jejunal tubes and nutritional formulas. Used solutions consisted of 200ml of milk, 15g of dextrose and 8ml of whisky at two-hour intervals. For patients who did not tolerate bolus feeding, continuous feeding was introduced.1,3,5
BLENDED DIETS Medical science advances led to a greater understanding of the absorption of nutrients and biochemistry of water-soluble vitamins. As we started discovering more about diseases, we also started developing more diets for certain conditions.5 For tube feeding, blended diets were more commonly used (infant foods + hospital food) to mimic the natural experience of eating. Enterally-fed formulas started being commercially available in the 1950s. Our understanding of human amino acid requirements contributed to the development of ‘space diets’ for astronauts, which were based on essential amino acids, glucose, vitamins and minerals. They maintained nitrogen balance while ensuring minimal faecal output. Although astronauts rejected ‘the elemental diets’ due to their strong and bitter taste, they did not go to waste. They found application in the local hospital, to tube-fed patients with gastrointestinal disorders. This was the beginning of elemental diets.1,2,3,5
CURRENTLY . . . Relentless technological advancements in the enteral feeding market translated into improvement of feeding devices and nutritional formulas. There are now multiple factors considered in tube development. The most important one is the biocompatibility, which encompasses:
• the body’s response to the material (inflammation, allergic reaction); • the material’s response to the body: – leaking due to gastric acid or feeding formulas, – swelling (due to medication, alcohol); • the body’s response to the material’s response (degradation might cause a release of small particles causing the body’s response).2, 5,8
We can already ensure patient-friendly portable pumps and tubes made from extensively tested materials to prevent cracking in highstress applications. Most pumps include a screen, multiple programming settings and several alarm options, eg, a pressure alarm. You can choose the preferred language, program flushing intervals, check the history of previous feed rates and program lock-out features to prevent manipulation. Tubes are smaller in diameter and made from softer polymers.5,9
WHAT DOES THE FUTURE HOLD? The rising adoption of enteral feeding has resulted in an increase in uptake of enteral feeding tubes across the globe. The enteral feeding devices market is projected to increase from USD 3.2 billion to USD 4.4 billion by 2025.9,10
In developing countries across the Asia Pacific, Latin America and the Middle East, reimbursements are insufficient. This poses a significant challenge to the widespread adoption of enteral feeding. This is now important more than ever. Why? Because these are expected to be the fastest-growing regional markets. There is an increasing incidence of preterm births
A collection of 19th century enema apparatus and syringes.
in the Asia Pacific, and older populations are increasing in number worldwide. Along with cancer being one of the most prevalent diseases in developing countries (India, China, Brazil), this means that demand for enteral feeding devices in these countries is expected to grow. In a nutshell: insufficient reimbursements, rapidly increasing demand and the unforeseen toll of the COVID-19 pandemic.9,10
In developed countries such as the US, Canada, Germany, France, the UK and Japan, enteral nutrition therapy is reimbursed (by insurers, governments, national health insurance, etc). Constantly changing requirements of healthcare providers, patients’ growing preference for low-profile tubes and a shift of healthcare provision from hospitals to community settings, are expected to propel the growth of the enteral feeding pumps market.9
CONCLUSION Based on archaeological findings and documentation, we can assume that, throughout history, people have always known that nutrition is essential for humans to thrive. Currently, we can observe a growing awareness of enteral nutrition due to an increasing number of preterm births, a rising geriatric population and rising incidents of cancers, all factors that are driving the growth of the enteral feeding healthcare market.
We can only speculate on what the future holds, but ongoing scientific investigations will likely lead to developing more sophisticated treatment techniques, with simultaneous improvement in quality of life for patients.1,9,10
Oana Oancea,RD
Oana works with Day Centre patients and outpatients. She also holds discussions about healthy eating and mental health at the Carers Support Centre in Dumfries. In the past, she led the CAMHS Addiction and Eating Disorder Unit in Priory Hospital, Chelmsford.
REFERENCES Please visit: nhdmag.com/ references.html
NASOGASTRIC FEEDING AND THE EATING DISORDERS PATIENT
Nasogastric feeding to support life in eating disorder patients is a last resort. This article considers the protocols involved and outlines a moving case study.
Specialised nutrition support, particularly enteral feeding, has been used for centuries. Feeding solutions, devices and placement techniques have evolved over the years.1
One such example in recent history was the force-feeding of suffragettes who went on hunger strike whilst in prison. The Government took action by forcibly feeding them, arguing that this “ordinary hospital treatment” was necessary to preserve the women’s lives.2
Forcible feeding as carried out on the hunger strikers was a brutal, lifethreatening and degrading procedure, undertaken by male doctors on struggling female bodies.3 Mary Leigh, a well-known suffragette, described her experience of the feeding in a muchcirculated pamphlet at the time:
“The sensation is most painful – the drums of the ear seem to be bursting, a horrible pain in the throat and the breast. The tube is pushed down 20 inches… I resist and am overcome by weight of numbers.”4
Lady Constance Lytton wrote:
“My jaws were fastened wide apart, far more than they could go naturally...
Then the food was poured in quickly; it made me sick a few seconds after it was down and the action of the sickness made my body and legs double up, but the wardresses instantly pressed back my head and the doctor leant on my knees.”5 with the Cat and Mouse Act of 1913, which released prisoners once they were weakened by hunger.6
Today we have clear guidelines and protocols. We use nasogastric feeding (NG) as a last resort to save a life, no longer to punish. Most published guidelines regarding nutrition support for the critically ill recommend the use of enteral nutrition (EN) rather than parenteral nutrition (PN), according to an accumulating body of evidence that suggests EN is associated with better clinical outcomes than PN.7
CONDITIONS TO INITIATE NG IN THE EATING DISORDER PATIENT
Feeding purposes
NICE guidelines state that NG tubes should only be used in people who are malnourished or at risk of malnutrition and: • the patient is less than or equal to 85% ideal body weight (IBW); • the patient has experienced greater than one month severe restriction (less than 500 calories per day) prior to admission; • a three-day calorie count reveals intake below maintenance/gain calories; • the patient is severely restricting fluid intake and needs the NG tube to maintain hydration status.
Medication delivery
• to deliver certain medications directly into the stomach of patients with the same stipulations as feeding.
Table 1: Contraindications of tube feeding
Absolute contraindications Relative contraindications Complications of NG placement
Mid-face trauma Coagulation abnormalities Gagging or vomiting
Recent nasal surgery Recent alkaline ingestion (due to risk of oesophageal rupture)
Tissue trauma along the nasal, oropharyngeal or upper gastrointestinal tract Oesophageal varices (untreated or recently banded/cauterised) Oesophageal perforation (rare) Oesophageal strictures
WHEN IS TUBE FEEDING COUNTERPRODUCTIVE OR CONTRAINDICATED? Tube feeding is not recommended in the following circumstances: 1 When there is an anatomical abnormality of the nose. 2 When a patient has anorexia and binge-purges, and the patient may be hypokalemic. 3 When the patient has refeeding syndrome or electrolyte disturbance needs to be corrected before the patient is aggressively refed. 4 When a patient inflicts self-injury that could be a limiting factor in considering an NG tube. 5 When the patient has a “need” to be sick and the NG tube can become a personal statement. See Table 1 for contraindications.
THE MENTAL HEALTH ACT The Code of Practice states that: ‘Any restrictions should be the minimum necessary to safely provide the care or treatment required having regard to whether the purpose for the restriction can be achieved in a way that is less restrictive of the person’s rights and freedom of action.’
Patients who receive an NG feed under restraint often describe the experience as being traumatic, especially for patients who were victims of physical abuse, which has an impact on establishing or maintaining a therapeutic and trusted relationship with staff members. The deterioration of the relationship between patient and healthcare professional can be due to the lack of support after a restraint. During restraint, patients experience a range of emotions,
including confusion, frustration, worry, a sense of isolation and powerlessness. The restraint comes with a high risk of emotional damage and can lead to negative consequences on wellbeing.
Social determinants are sometimes a factor related to admission and include psychosocial stressors, occupational and social backgrounds and histories of being survivors of abuse. The treatment from ED staff and the use of restraints has a range of effects on patients, including scepticism and distrust of the medical system, the worsening of existing psychiatric conditions, or healthcare avoidance.8 The therapeutic relationship with ED patients can be fractured due to coercion and physical restraint and this can impact the relationship with food. Before any restraint, we need to be absolutely certain that we did everything in our power to avoid this. We need to be 100% certain that we tried all the possibilities before proceeding with an NG feed under restraint. Without solid and ongoing psychological support, patients may begin a spiral of negative emotions with subsequent ED visits and instinctively escalating short-term agitation and aggression as a protective shield based on prior experiences.
Any decision that leads to the use of physical restraint as a last resort should be thoroughly thought through, balanced and well evidenced. It can be very helpful to reduce the number of feeds given over a 24-hour period to minimise the trauma caused and reduce the high levels of anxiety experienced by patients. A lower number of feeds allows patients to focus and use the time in a beneficial way to improve their wellbeing. We need to encourage patients to come out from their bedrooms and to engage positively in activities unrelated to their ED. It is also beneficial for the patient to receive psychological support between feeds.
Reducing the number of feeds conflicts with general practice, i.e. that feeds should be given after each meal and snack to promote normal eating patterns. Every healthcare professional has their own way to approach and assess the problem and every patient is different. Personally, I like to decide with the patient when it’s the right time to focus on normal eating patterns and discuss in advance the steps to achieve this. One of our main objectives is to work with the patient towards acceptance of feeding without physical intervention during these periods. Supervision and support of staff, as well as debriefing and motivational enhancement work with patients, are essential. We need to make clear to the patient at every opportunity that we work with them, not against them. Many of our patients identify very easily with the illness, so trying to externalise the ED is very useful.
LK is a 27-year-old woman who, over many years, has suffered from anorexia nervosa. She was first diagnosed when she was a teenager at 15 and now has a formal diagnosis of a Severe and Enduring Eating Disorder (SEED). The healthcare professionals who are treating her recognise that her illness is chronic and severe. LK is at serious risk of death because her weight is so low (26kg). She could die at any time from cardiac arrest. She also suffers from a number of different presenting conditions as a result of severe and chronic malnutrition. These include osteoporosis, oedema (painfully swollen legs), anaemia (low blood count leading to extreme fatigue and tiredness) and unstable blood salts (the result of low potassium levels which expose her to possible heart complications and the risk of a cardiac arrest as well as adding to her debilitating fatigue). The only form of life-sustaining treatment now available to her is in the form of tube feeding using physical restraint or chemical sedation. The NHS Trust and the team of treating clinicians who have been responsible for providing care for LK now apply to the court for declaratory relief pursuant to sections 4 and 15 of the Mental Capacity Act 2005 in these terms: i) It is in LK’s best interests not to receive any further active treatment for anorexia nervosa. ii) LK lacks capacity to make decisions about treatment relating to anorexia nervosa and there is only one treatment option available to LK given the significant deterioration in her health and that is to undergo forced nasogastric feeding through the insertion into her stomach of a tube through which liquid nutrients can be delivered. LK leads her life one day at a time and she makes the most of each day knowing that one day she may simply not wake up. Whilst much of her waking day is spent engaging with her treating team both as an outpatient and within the community, there are still activities that bring her much pleasure on a day-to-day basis. She places enormous value on the time she spends with her parents, even when they are doing simple activities such as watching favourite television programmes together. She has a number of pets with whom she continues to engage.
Court decision
The following is an extract from the court decision relating to the application by LK’s clinical team. It reads as a moving conclusion to this case study: “I would want LK to know that I have considered all that has been said on her behalf very carefully. I have read, and re-read, all that she has said to me through the two very personal statements which she has prepared. No one who heard (or reads in this judgment) her account of her experience of tube feeding could fail to be both moved and appalled by its graphic detail. I recognise fully the effects upon her of that experience. I understand completely why, even in the context of a life-critical decision, she does not wish to endure further treatment. I accept that she is aware of the options which are currently available to her and the likelihood that tube feeding is very unlikely now to produce any sustainable benefits. I acknowledge that she understands the risks of any attempt to restart tube feeding. In this context she has shown remarkable dignity in her contemplation of a very significantly shortened life expectancy. Despite all she has endured in the past 15 years (which is the majority of her life), there is still much which makes her life worthwhile. She has the love of a devoted family and it is abundantly clear to me from all the material I have read that the unstinting love and support they have provided over the years has been a very precious resource to this young woman in coping with all she has had to endure. “The issue at the heart of this case is the ability of this particular illness in its current presentation in LK’s case to so infect to such a significant extent the very nature of her decision-making processes which are engaged in relation to food, calories and weight gain that any decisions flowing from those processes cannot be considered as legally capacitous decisions. This is not to introduce any generalisations or circularity of argument into the decision which is now before the court. I am concerned only with LK, the powerful evidence which she has presented to the court, and the professional views of those charged with the responsibility of caring for her. I have weighed fully in the balance the fact that she is intelligent, articulate and demonstrates clear insight into some of the aspects of her illness. She is also a delightful young woman despite all that she has gone through. That she has managed to retain personal and emotional resilience to the extent she has is humbling to any reader of the chronology of interventions she has endured in the attempts of professionals to reverse the progress of her illness.”
