Tube feeding refers to a surgical procedure whereby a feeding tube is placed directly into the stomach or small intestine, bypassing the mouth and esophagus. Liquid formula is transported through the tube for feeding.
Percutaneous Endoscopic Gastrostomy (PEG) is a surgical procedure to install a feeding tube directly into the stomach. The wall of the stomach and abdomen are penetrated with a tube that is capped with internal and external bumpers which prevent movement of the tube.
Percutaneous Endoscopic Jejunostomy (PEJ) is a surgical procedure just like PEG, with the tube placed in the small intestine after the stomach instead of directly into the stomach.
Nasogastric (NG) tubes are inserted through the nose and down the throat to the stomach. NG tubes are used by some individuals with ALS, though typically only for a short time while they wait for the surgical insertion of a PEG or PEJ tube.
An individual with ALS may undergo PEG or PEJ when feeding via the mouth becomes too difficult or unsafe. Tube feeding surgeries prolong survival in individuals that would not otherwise be able to receive adequate nutrition.
Tube feeding is indicated (suitable and recommended) for individuals with ALS that lack the ability to safely consume food orally due to swallowing impairment; however, it may also be indicated earlier on if eating causes too much fatigue for the individual to meet their daily nutritional requirements through oral nutrition alone. In such a case, the individual may continue to consume small amounts of food by mouth for as long as they have the energy and physical ability to do so.
Formulae come in a wide variety of ingredients and levels of nutrition.
Brand | Indications for use |
---|---|
Resource 2.0 | One of the most commonly used feed formula. 2cal/ml. Designed to meet basic nutritional needs. Gluten and lactose free however, does contain galactose. |
Resource 1.05 | 1.05cal/ml. Diabetic formula. Designed for individuals with diabetes, impaired glucose tolerance or stress induced hyperglycemia. Modified carbohydrate profile. Gluten and lactose free however does contain galactose. |
Compleat 1.06 | 1.06cal/ml. Designed to meet basic nutritional needs for individuals 14 and older. Contains milk, chicken and pea protein. Gluten free. |
Compleat 1.5 | higher calorie concentration than compleat 1.06. This formula has 1.5cal/ml and is lactose and gluten free. Contains hydrolyzed pea protein. |
Isosource 1.0 | 1.0 cal/ml. This feed formula is recommended for individuals with fibre restrictions or contraindications due to issues such as a tumour or inflammatory disease (Chrons or colitis) or if they have recently undergone bowel surgery. This feed contains no fibre or soy products and is lactose and gluten free. Individuals getting their nutrition exclusively from this formula will need close monitoring of bowel movements to ensure no issues with constipation. |
Isosource 1.0 Fibre | This formula contains the same caloric density as Isosource 1.0 but is made with soy protein isolate and and blend of soluble and insoluble fibre. It is also lactose and gluten free however does contain some milk ingredients and cannot be digested by individuals with galactosemia (Inability to digest Galactose, a sugar contained in milk). |
Isosource 2.0 | higher caloric density at 2cals/ml, this formula is meant for individuals with higher caloric needs who are also on fibre restrictions. This formula has a combination of soy protein and modified milk ingredients. It does not contain any fibre and is gluten and lactose free however, does contain galactose. |
Novasource Renal | This formula has 2cal/ml and meant for individuals with renal impairment. This formula has a lower amount of potassium and phosphorus and is recommended for individuals with acute or chronic kidney failure and/or fluid and electrolyte restrictions |
Peptamen 1.0 | This formula contains 1cal/ml and is designed for individuals who have issues with feed tolerance (digestive upset, vomiting or diarrhea with feeds). This formula partially hydrolyzed whey protein and is gluten free |
Peptamen AF 1.2 | This formula contains 1.2cal/ml. Similarly to Peptamen 1.0, this formula is recommended for individuals who have issues with feed tolerance however, it also contains a higher amount of protein and Omega 3 fatty acids. This feed is a good option for someone initiating tube feeds, someone with frequent diarrhea or someone with elevated protein needs due to other health conditions such as a wound. |
Other traditional meal replacement shakes such as Ensure or Boost can be administered via feeding tube however, they are not a complete nutritional replacement. Due to the higher amount of vitamins and minerals in these formulae, they can cause an individual to exceed their upper tolerable intake level for those vitamins and minerals. Use of shakes such as Boost or Ensure should be limited to no more than 2-3 times per day. In order to ensure daily calorie requirements are being met, they can be used in tandem with feed formulae.
Some individuals with ALS may wish to continue consuming regular food or supplements despite not being able to consume them orally. Medical experts do not recommend doing so; food that is not able to pass through the feeding tube easily may clog the feeding tube, which can lead to complications. Any substance that passes through a feeding tube must do so readily, and not build up residue which cannot be flushed out.
Tube feedings may be given around the clock using a sustained rate of flow through the tube, or over the span of several hours during the day, or relatively quickly in multiple occasions during the day.
Formulae are typically administered when at room temperature; refrigerated formulae must be gradually brought up to room temperature before administering.
Residual liquid from a previous feeding may be present in the stomach; caregivers are required to check for residue before initiating a subsequent feeding.
Tube feedings require that the head be significantly higher than the stomach to prevent liquid from entering the esophagus and eventually into the lungs. The individual receiving the feeding should be sat entirely upright if possible, or have their head and shoulders elevated upward at least 30° from flat.
Bottles containing formula are hung in an elevated position to promote gravity feeding into the PEG tube.