1. Nasoenteric - Used for short term feedings (< 1 month).

a. Tungsten weighted feeding tube (Dobhoff Tube) - Small caliber nasoenteric tube well tolerated by patients. Preferred placement is through the pylorus confirmed by X-ray. For continuous or intermittent feedings. Must be flushed regularly to prevent clogging.

b. Nasogastric tube - Not preferred route for long term feedings. Must have a normal gag reflex because feeds can reflux and aspirate into lungs.

2. Tube enterostomies - Used for long term feedings (>4 weeks). Are surgically placed in part of GI tract.

a. Gastrostomy tube - Larger caliber tube placed in stomach via endoscopy or via open surgical technique. May give bolus feedings. If dislodged usually can be reinserted easily. Requires return of bowel function prior to use.

b. Jejunostomy tube - Surgically placed medium caliber catheter placed in lumen of small bowel. Requires continuous or intermittent feedings. Requires radiographic confirmation of location if replacement is necessary. May be used for immediate postoperative feeding.

c. Needle catheter jejunostomy - Very small caliber tube surgically placed into the small bowel. Requires continuous feedings of thin consistency to prevent clogging. Difficult to reinsert if dislodged or clogged. May be used for immediate postoperative feeding.

1. Fat - Use MCT (Medium chain triglyceride) oil. Requires less bile acid for digestion, not dependent on chylo-micron formation or lymphatic transport. Does not provide essential fatty acids. Use in patient who cannot efficiently digest or absorb long chain food fats. Contains:115 calories/15 ml Normal dose: 15 ml po 3-4x/day. Mix w/fruit juices, on salads/vegetables or use in cooking.

2. Protein and carbohydrate - Contact dietitian for information.

1. Continuous feeding - Infusion of feeding at a steady constant rate over 24 hours. Pump recommended.

2. Bolus feeding - Rapid administration of 300-400 ml of formula. Not recommended because of the higher risk of aspiration and intestinal side effects. Use only with gastric feedings as the stomach can better tolerate sudden changes in rate of formula delivery.

3. Intermittent feeding - Administration of 4-8 feedings, each over 20-40 minutes period. Better tolerance if each feeding consists of no more than 250 ml over approximately 30 minutes (maximum 400 ml) and given as gastric feeding.

4. Cyclic feeding - When more freedom and mobility are desirable, the continuous feedings can be consolidated into 10-12 hour cyclic infusions.

When patients are transitioned from TPN to enteral feedings, the following steps are recommended.

1. Place the feeding tube and verify position.

2. Order enteral feedings (Call the dietitian for feeding recommendations).

3. Check residuals after 4 hours:

a. If the residual is greater than two times the hourly rate, hold feeding for 4 hours then restart cycle.

b. If the residual is less than two times the hourly rate, then decrease the TPN rate by 25 ml/hr and increase the enteral feeding by 25 ml/hr. Continue decreasing the TPN rate as the enteral feeding is increased every 4 hours until the enteral feeding is at goal rate. Then discontinue the TPN. TPN needs to be ordered before 12:00 noon. If the enteral feeding is at one half of goal, write TPN for only 1/2 of caloric and protein needs.

Administration rate (continuous feedings)

Most patients will tolerate administration of isotonic or even moderately hypertonic formula (Osm < 500 mOsm) at full strength if initiated at a slow rate of usually 25-50 ml/hr. Then increase the rate every 8-12 hours by 25 ml/hr to the final rate as tolerated.

Osmolar feedings between 500 and 600 mOsm should be started at half strength and then increased to full strength once the desired rate is reached. Very hyperosmolar feedings (Osm >600 mOsm) may be diluted initially and gradually increased in concentration and rate. Concentration and rate should not be changed at the same time. For duodenal and jujunal feeding advance the rate of delivery before increasing concentration. When the desired volume is reached then increase strength (1/4 to 1/2 to 3/4 to Full) every 12 hours as tolerated. For gastric feedings, make changes in formula concentration before increasing the rate of administration.

Patients can usually tolerate advancement of feedings to the needed amount within 48 hours. Intestinal atrophy will require a slower progession.