Why Do Babies on Feeding Tubes Smell Like Formula

 Types of Enteral Feeding
 Assistants of Tube Feeding: Bolus and Continuous Drip
 Equipment for Continuous Drip Feeding
 Nutritional Considerations
 Administration of Tube Feedings
 Medication and Tube Feedings
 Social Concerns with Tube Feeding
 Transition to Oral Feeding

Types of Enteral Feeding

• Nasogastric Tube Feeding
• Gastrostomy Tube Feeding
• Jejunal Tube Feeding

The types of enteral feeding, or tube feeding, are named according to the feeding route used, i.e., the site where the feeding tube enters the body and the point at which the formula is delivered: nasogastric, nasoduodenal, nasojejunal, gastrostomy, and jejunostomy. The decision of which type of feeding to use is based on the expected elapsing of tube feeding likewise equally physiologic and patient-related factors. The types of tube feeding most commonly used are nasogastric feeding and gastrostomy feeding.

Nasogastric Tube Feeding

The nasogastric (NG) tube commonly is used when tube feeding will be required for a short time (i.e., less than 3 months) although in some cases it can be used for several years. The major advantage of nasogastric, nasoduodenal, and nasojejunal feedings over gastrostomy or jejunostomy feeding is they exercise not crave surgery. Therefore, they can be started apace and they tin be used either for brusque periods or intermittently with relatively low risk.

The disadvantages of NG feeding include nasal or esophageal irritation and discomfort (especially if used long-term); increased fungus secretion; and partial blockage of the nasal airways. Nasogastric feeding may contribute to recurrent otitis media and sinusitis. With infants, NG feeding can decrease the suck/swallow mechanism. Two additional disadvantages are the possibility that the tube will perforate the esophagus or the tummy and the possibility that the tube will enter the trachea, delivering formula into the lungs. If formula enters the lungs, astringent or fatal pneumonitis can result; therefore, it is essential to confirm that the NG tube is in the stomach before feeding begins

Gastrostomy Tube Feeding

Gastrostomy tubes are well suited for long-term enteral feeding. Patient condolement with gastrostomies is an advantage over NG tubes. Gastrostomies practise non irritate nasal passage, esophagus, or trachea, cause facial pare irritation, nor interfere with breathing. Gastrostomies are stable and more than physiologic, allowing continued oral eating. In that location are button gastrostomies and other skin level feeding tubes that are hands hidden under a child'south clothing. These require less daily care and interfere less with a kid'due south motion. Gastrostomies use a large-diameter tube, which allows a more viscous feedings and decreased risk of tube apoplexy.

Disadvantages of gastrostomy feeding include the surgery required to place the tube, possible skin irritation or infection effectually the gastrostomy site, and a slight risk of intra-abdominal leakage resulting in peritonitis. Of special business organisation is the child with poor gastric elimination and/or severe reflux or intractable vomiting. These children have increased gamble of aspiration. Please encounter department on aspiration.

Jejunal Tube Feeding

Tube feeding straight into the jejunum (i.e., the middle department of the small intestines) is used for children who cannot use their upper gastrointestinal (GI) tract considering of congenital anomalies, GI surgery, young or inadequate gastric motion, severe gastric reflux, or a loftier adventure of aspiration. The jejunal tube bypasses the breadbasket decreasing the adventure of gastric reflux and aspiration.

All the same, fifty-fifty for children with gastric retention and a high risk of aspiration, there are disadvantages to jejunal feeding. First, nasojejunal tubes and jejunal tubes passed from a gastrostomy to the jejunum are difficult to position and may dislodge or relocate; their position must be checked frequently by X-ray. A jejunostomy reduces problems of tube position. Second, jejunal feedings bypass the digestive and anti-ineffective mechanisms of the breadbasket. Third, they crave continuous drip feeding which results in limited patient mobility and decreased ability to lead a "normal" life. Finally, when compared to gastric feedings, they behave a greater take chances of formula intolerance, which may lead to nausea, diarrhea, and cramps. Intact nutrients may exist given if the feeding is given in the proximal intestine, but elemental or semi-elemental feeding are required if the feeding is delivered more distally. These formulas are more expensive.

Administration of Tube Feeding: Bolus and Continuous Baste

• Bolus Feeding
• Continuous Baste Feeding

Tube feedings can be administered past bolus feedings, continuous drip feedings or a combination of the two. The best is a combination of oral and tube feeding that fits into a child and family's schedule. Many of the complications of tube feeding arise from improper assistants of formula.

Bolus Feeding

Bolus feedings are delivered four to eight times per day; each feeding lasting well-nigh xv to 30 minutes. The advantages of bolus feedings over continuous drip feeding are that bolus feedings are more similar to a normal feeding pattern, more than convenient, and less expensive if a pump is not needed. Furthermore, bolus feedings allow freedom of movement for the patient, and so the child is not tethered to a feeding bag.

The disadvantages of bolus feedings are that they are aspirated more easily than continuous baste feedings, and in some children, they may cause bloating, cramping, nausea, and diarrhea. It may not be practical to bolus feed a child when the volume of formula a kid needs is large or requires that the child needs to be fed around the clock.

Continuous Baste Feeding

Continuous drip feeding may be delivered without intermission for an unlimited flow of time each day. However, it is best to limit feeding to 18 hours or less. Feeding around the clock is not recommended every bit this limits a child's mobility and may elevate insulin levels contributing to hypoglycemia. Commonly, it is used for 8 to 10 hours during the night for book-sensitive patients then that smaller bolus feedings or oral feeding may be used during the day. Continuous baste feeding is delivered by either gravity drip or infusion pump. The infusion pump is a better method of delivery than gravity baste. The menstruation rate of gravity drip may be inconsistent and, therefore, needs to be checked frequently.

I reward of continuous feeding over bolus feeding is that it may be tolerated amend by children who are sensitive to volume, are at high hazard for aspiration, or have gastroesophageal reflux. Continuous feeding tin can be administered at night, so it will not interfere with daytime activities. Continuous feeding increases free energy efficiency, allowing more calories to be used for growth. This tin be important for severely malnourished children. When feedings are delivered continuously, stool output is reduced, a consideration for the child with chronic diarrhea. Continuous infusions of elemental formula have been successful in managing infants with curt bowel syndrome, intractable diarrhea, necrotizing enterocolitis, and Crohn'south affliction.

A disadvantage of continuous feeding is that the child is "tied" to the feeding equipment during the infusion, although feedings can exist scheduled for dark time and naptime feedings. Additionally, continuous feeding is more expensive because of the toll of the pump and additional feeding supplies which may be necessary. A kid'south medication needs to be considered as continuous feeding may interfere with serum concentration of some drugs.

Equipment for Continuous Drip Feeding

• Feeding Tubes
• Pumps
• Feeding Sets
• Boosted Equipment

Feeding Tubes

When choosing a feeding tube, the following factors should be considered: the patient's age and size, the viscosity of the formula to be used, and the possible need for a pump. For nasogastric feeding, the smallest bore tube in a soft material volition minimize patient discomfort. Large-diameter tubes partially cake the airways, may interfere with the function of the gastroesophageal sphincter, and may irritate the nose and pharynx. Tubes size eight French or smaller are usually used for children. The size refers to the outside diameter of the tube; one French unit of measurement equals 0.33 mm. Tubes this pocket-sized cannot accommodate thick or viscous feedings (eastward.g., homemade blenderized formula or commercial formula containing fiber).

Most of the tubes now available are made of polyurethane or silicone, both of which remain soft and flexible over time; these tubes are usually weighted at the finish for easier nasogastric insertion. The more flexible tubes are difficult to place without using a stylet. Nonweighted tubes may exist displaced during gagging, vomiting, or coughing spells; however, they are used regularly and without difficulty for intermittent feedings in newborns.

Skin level gastrostomy feeding devices such as the Baard button gastrostomy or MIC-Central are available. They let feeding tubes to be attached only when the child is being fed. These devices are easily hidden nether a child's wearing apparel without tubing extending from stomach. They may be placed surgically in the tummy wall or after a gastrostomy tube has been placed.

Pumps

At that place are many different enteral infusion pumps, varying in complexity, menses charge per unit, and cost. Pumps can be rented from suppliers of medical equipment; however, for long-term apply, it is less expensive to buy a pump. When deciding which blazon of pump to apply, there are various considerations: availability, accuracy, cost, and ease of maintenance. The portable, battery-operated Kangaroo Pet Enteral Feeding Pump allows the child to attend schoolhouse or go on outings. The Kangaroo pump fits neatly into a backpack.

Feeding Sets

Many of the pumps crave their own feeding sets, including a container for the formula and tubing to connect the formula container to the feeding tube. Reuse of feeding sets tin can assist minimize the cost. After use, the formula container, drip chamber, and tubing should be carefully cleaned with hot soapy water and rinsed thoroughly to remove the formula residue, which tin cause bacterial contamination. It is all-time to have two feeding sets so that one tin can dry while the other is being used.

Boosted Equipment

To give the child more than mobility during continuous feeding, the feeding set can be hung on an IV pole and connected to a long length of tubing. Alternatives are to hang the feeding set on a establish hook above the bed or crib, on a nail in the wall or bedpost, or on a sturdy lamp or apparel tree. When traveling past car, the pump can be placed on the dorsum seat with the feeding set hanging from the clotheshook. Miscellaneous supplies include syringes, gauze, catheter adapters, and tape.

Nutritional Considerations

• Energy
• Fluid and Electrolytes
• Vitamins and Minerals
• Feedings

In order to make up one's mind free energy and nutrient needs, nutritional status should exist assessed earlier tube feeding is started. The following table outlines the requirements of normal infants and children for water. For energy, protein and other nutrient needs refer to the DRIs. Accommodate equally needed for individual patient and status.

H2o Requirements for Infants and Children

Weight	H2o
	cc/kg	cc/lb
Stride 1
For offset 10 kg or 22 lbs., provide	100-120	45
STEP ii
For second ten kg or 22 lbs., provide	fifty	24
STEP 3
For weight over 22 kg or 44 lb., add to the amount above an additional:	20	x

These requirements are useful in formulating tube feedings for children with disabilities as long as whatever weather that may alter the child'due south nutritional needs are taken into account. For example, cardiopulmonary stress may increase calorie needs, while decreasing tolerance to fluid book; infection or the stress from surgery may increase both calorie and protein needs, and certain drugs may increase the requirement for specific vitamins or minerals. On the other hand, immobility tends to decrease calorie needs.

Energy

The merely style to accurately evaluate an individual'southward caloric needs is to regularly monitor weight gain, growth, and actual caloric intake. If a child'southward caloric intake is inadequate, weight gain will be poor. If caloric intake is excessive, weight gain will be higher than that desired for linear growth. Factors that may change caloric needs include illness, increased seizure activity, surgery, increase in therapy or return to school, or changes in medication.

Children who have been chronically underweight while on oral feedings often gain excessive weight when put on tube feedings, sometimes to the point of obesity. In these children, 2 factors may exist coming into play: oral-motor problems that interfere with acceptable caloric intake past means of oral feeding, and caloric needs that are lower than expected. Cases such as these illustrate the necessity of routinely monitoring weight and caloric intake in tube-fed children.

Older children with delayed growth due to inadequate calories may have delayed puberty. With adequate calories provided enterally they may begin to experience puberty and its body changes into their 20s. These changes need to be assessed when determining calorie needs so weight gain is advisable.

Fluid and Electrolytes

H2o must exist provided in sufficient quantities to replace fluid losses and permit for normal metabolism. Fluid requirements depend on the following variables: urine output, sweating, airsickness, fever, stool pattern, environment, renal disease, cardiac anomalies, tracheotomies and medications. Constant drooling as well contributes to fluid losses. H2o requirements can exist estimated using the table above, as long as the above variables are considered. Signs of dehydration requiring additional fluid include: constipation, decreased urine output, strong smelling or nighttime urine, crying without tears, dry lips and skin, or sunken eyes.

Patients who rely on tube feedings every bit their sole source of nutrients are at risk for electrolyte imbalances, which may event in serious medical complications (due east.chiliad. hyponatremia, hypernatremia, hypokalemia, hyperkalemia, dehydration and cardiac arrythmias). These patients should be evaluated regularly for sodium, potassium, and chloride status. The post-obit Dietary Reference Intakes (DRIs) provide guidelines for a condom and acceptable intake of electrolytes.

Dietary Reference Intakes (DRIs) for Sodium, Potassium, and Chloride

Age	Sodium (g/d)	Chloride (k/d)	Potassium (g/d)
0-half-dozen months	0.12	0.18	0.4
7-12 months	0.37	0.57	0.7
1-3 years	i.0	1.5	3

Vitamins and Minerals

To determine vitamin and mineral needs, the DRIs for age tin can be used every bit a base, unless the child's growth is markedly delayed. For the child with growth delay, the DRIs for height age can be used. The value of "height historic period" is obtained by finding the age at which the child'south actual superlative would be at the 50^th percentile on the CDC charts (See Growth Charts section). Children with inadequate caloric intakes, decreased assimilation, and increased caloric needs should be considered for supplemental vitamins and minerals.

Vitamin and mineral requirements can exist altered past medications (Run across Nutritional Impact of Medications). Other variables to consider are disease, previous medical and dietary history, and biochemical parameters.

In general, supplement needs of VLBW infants on enteral feedings are the same as those fed orally, please see section on Supplements.

For older children or those who crave special attending to calcium, phosphorus, and atomic number 26, supplemental vitamins and iron can be given with feedings in the form of multivitamin-with-iron drops or crushed chewable tablets. Calcium can be provided by crushed antacid tablets of calcium carbonate (e.g., Tums - ane regular Tums provides 200 mg Ca) or liquid calcium preparation (east.m., Titralac - one tsp. provides 400 mg Ca). Phosphorus can be provided by liquid Neutra-phos; 1 capsule provides 250 mg P. Note: This may take a laxative consequence.

Trace elements should be evaluated for the patient on long-term enteral support. The risk of developing food deficiencies increases with frequent vomiting or gastrointestinal disturbances. Children on long-term tube feedings demand to be evaluated for fluoride intake, and may need to be supplemented. This volition require a prescription from the child'south md or dentist. Children with cystic fibrosis or anomalies of the distal ileum and ileocecal valve may fail to blot fat-soluble vitamins or to reabsorb bile salts.

All children who are receiving enteral feedings should be monitored routinely past a dietitian who has experience in pediatrics.

Feedings

Please come across section on Babe Formulas and Breastfeeding for information that applies to infants less than 12 months corrected historic period. For data about products for enteral feeding for all children, please see section on Enteral Feeding Products for Children.

Administration of Tube Feedings

Infants who are commencement tube feedings with isotonic formulas or breast milk may be started at small volumes. Book is gradually increased every bit the baby demonstrates tolerance. In the infirmary, fluid needs are usually assured by IV fluid assistants during this procedure.

Children showtime tube feedings may be started at full strength isotonic formulas or breast milk, given in depression volumes. See recommendations below. Hypertonic formulas should be started at one-half force. Children who have had no oral feedings for a long menstruum of time or have a history of formula intolerance such as premature infants or children with short-gut, may require half-strength formula initially with gradual increases to full strength. In general, if a kid needs diluted feedings, it is best to increase volume to brand sure the child meets fluid needs then gradually increment concentration as the child can tolerate. Practice non increment concentration and volume at the same time. Frequent adjustments may be necessary to help child and family adjust. It is all-time for feeding schedule to circumduct effectually family schedule than the other manner around.

Schedule to initiate enteral feeds:

Age	Volume
Infants	ten ml/hour
Child ane-5 twelvemonth	xx ml/hr
Child 5-x years	30 ml/60 minutes
Child >ten years	fifty ml/hour

Advance rate as tolerated to goal rate to meet kid's nutritional needs. Increment volume every 4-12 hours, and monitor advisedly for tolerance. Tolerance is defined as absence of diarrhea, abdominal amplification, vomiting or gagging.

The doctor may require residuals to exist checked on new tube feeding patients or when the kid switches formula or medicine. To check residuals, attach syringe to feeding tube and pull back stomach contents. If residuals are >25-fifty% of previous bolus feeding or 2 times the hourly book for continuous drip feeding, reduce the feeding to the previous volume and advance at a slower rate. Return stomach contents.

Medication and Tube Feedings

Many tube-fed children require extensive drug regimens. Although the feeding tube is a convenient artery for administering medicine, some medications are incompatible with the enteral products, interacting with specific nutrients, or causing the feeding tube to clog.

Elixirs and suspensions can unremarkably exist delivered through the feeding tube without a problem. Too, simple compressed tablets can be crushed and mixed with water or the formula. In dissimilarity, syrups are incompatible with tube feedings because they tend to clog the tube unless diluted with water. Solid medicines such as sustained-action tablets or capsules or enteric-coated tablets should not be crushed and delivered through the tube; once crushed, their activeness may be contradistinct or they may cause gastrointestinal distress.

Earlier a drug is given through the tube, the residual gastric book should be checked. If the residuum volume is greater than l% of the volume of the last bolus feeding or 50% of the book delivered during 1 hr of continuous feeding, the drug may not be absorbed effectively.

A benefit of tube feeding is delivery of medication by tube. The child does not turn down to swallow medication, drool, or vomit medication. Medications need to be given separately, with water flushes in between to forbid bottleneck the feeding tube. Check to see if medications can be given together without changing drug absorption. Feedings may decrease the absorption of a drug like phenytoin (Dilantin). Medications should non be mixed with feedings. If the child is on continuous drip feedings, stop the feeding. If the medication needs to be given on an empty tum, finish feeding and expect xv-30 minutes before administering the drug. Then wait one hour before resuming feeding.

Social Concerns with Tube Feeding

An of import consideration in tube feeding is the family's ability and willingness to carry out the tube feeding program. Concerns include the availability and cost of equipment and formula, habitation sanitation and family hygiene, family support systems, and other psychosocial factors.

Before the kid is discharged from the hospital, the caregiver(s) must be prepared for tube feeding. They should be thoroughly instructed on the following aspects of tube feeding: breast milk storage and handling, formula preparation, utilise and intendance of equipment, insertion of the tube, stoma care and emergency procedures. The caregivers should be encouraged to keep the post-obit records in a notebook, which they should bring to each clinic visit: formula intake, stooling pattern, action, beliefs, medications, and instructions from medical staff. Earlier discharge, families should accept a program for expressing breast milk or obtaining and paying for formula, for obtaining and paying for enteral feeding supplies and for nutritional follow-upwardly.

The caregiver(s) should be contacted daily for the first week the kid is dwelling, or until they feel secure with the tube feeding regimen. The follow-up can be provided by home visit, clinic visit, or telephone. The caregiver(s) should be given a telephone number for 24-hour assistance regarding problems with tube feeding.

More than than one family member or caregiver should be taught almost the tube feeding to ensure continuity of the child's feeding programme and to prevent isolation of the primary caregiver.

Family meals offering of import learning experiences for children who are tube fed. It is of import for the child to associate the satisfying feeling of fullness with the pleasant time of family meals, including social interactions, good smells and appearance of food. Even though the tube fed kid may non experience the tastes and textures of oral feeding, he or she can benefit from the social experience. This is of import if the kid is to eventually transition from enteral to oral feeding.

When families are asked about enteral feeding their concerns include: finding a caretaker to tube feed their child; public ignorance well-nigh tube feeding; planning their social life around feeding schedule, and sadness over depriving a kid of the pleasure of eating.

Feeding behaviors are often present before a kid is tube fed and additional behaviors may develop while the child is tube fed. Patience is the key word. See section on Behavioral Problems Related to Feeding.

Transition to Oral Feeding

Transition to eating by oral cavity starts when the tube is first placed. It is important to follow an oral motor stimulation program with child who is tube fed. This is important and so that the kid can resume eating by rima oris. The kid needs to associate feeling in the mouth with a full stomach. For case: if you are hungry, you swallow by rima oris and feel satisfied.

Transition to oral feeding requires a team approach. Teams may include a md, nutritionist, therapist, lactation consultant for breastfeeding and nurse. The initial step is to accost readiness. The post-obit questions are considered:

1. Is the child safe to feed? How are their oral skills?
2. Has the kid shown appropriate growth on enteral feeds? Often a child will non testify hunger until they have reached an appropriate weight for meridian. We need to know now many calories the kid needs to eat to proceed growing.
3. Has the medical condition for which the child had tube placed been corrected?
4. Are the parent and kid ready to transition? Do they accept the time to devote to transitioning?

One of the first steps in transitioning is to promote hunger. The feeding schedule needs to be normalized into meals and snacks. After the feeding schedule is changed, calories are decreased by 25% and book replaced with water to meet fluid needs. Information technology takes time to modify feeding behaviors. The longer the fourth dimension a child goes without eating the longer it volition take to transition to oral feeding. It is important to take modest steps, letting the child feel that they are in control. The child has the benefit of using the enteral tube to run into nutritional requirements.

When do you remove tube? When the child demonstrates that she tin can eat acceptable amounts of food to go on growth. It may be prudent to wait until the child demonstrates that they practice not lose excessive weight with illness or during the wintertime cold and virus season.

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Source: https://depts.washington.edu/growing/Nourish/Tubetech.htm

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