Enteral Nutrition (Tube Feeding)

Enteral nutrition or tube feeding is when a tube is used to provide liquid formula for some or all of your child’s nutrition. It also can be used to provide fluids and medications. 

There are many reasons why your child may need tube feeds. Some reasons may include:

• To improve feeding and/or swallowing difficulties that limit what your child can eat by mouth
• To increase nutrition to promote weight gain or growth

Different types of feeding tubes can be used for enteral nutrition. These may differ in where the feeding is delivered from and into the body. For example, a nasogastric tube starts in the nose and ends in the stomach.  

Some types of tubes are:

• Nasogastric tubes (NG-tubes): nose to stomach
• Gastrostomy tubes (G-tubes): directly into stomach
• Jejunostomy tubes (J-tubes): directly into small intestine

Tubes differ in how they are placed in your child’s body. For example, a nasogastric tube is initially placed in a medical facility with proper instruction; afterwards, the tube can be placed at home by the patient or parent. Other tubes such as gastrostomy tubes are placed surgically.  

Tubes also come in different sizes. The size is based on two factors: 1) diameter or “French” and 2) length of the tube. The smaller the tube diameter, the smaller the “French” number. Nasogastric tubes are smallest in size. As a child grows and gets older, the tube gradually must be increased in size. The length of the tube will also need to be increased as the child grows and gets older. For gastrostomy tubes, typical lengths are 1.2–4.0 centimeters (cm).

Tube feeds can vary based on the tube type, medical condition, tolerance to tube feedings, formula type, and desired schedule. Tube feeds require various equipment and supplies including syringes, pumps to help deliver the formula, bags to hold the formula, and extension tubing to deliver the formula from the pump to the tube. Some common ways to give tube feeds are:

• Bolus: tube feeds given using a syringe and pushed in over a short amount of time

• Pump: tube feeds given using a pump and can be run over a longer period of time 

• Gravity: tube feeds given using a syringe or formula bag and allowed to flow through the tubing by gravity

Tube feeds can also be given using a combination of these ways.

There are many types of formulas used for tube feeds. Formulas can be grouped based on age, medical conditions, or ingredient type. For example, some formulas contain cow’s milk protein while others contain plant-based protein. Formulas may or may not contain fiber, generally are lactose-free, and may or may not be flavored. Formulas also can differ in how easily they are digested and may include ingredients that are broken down or “hydrolyzed”. Hypoallergenic formulas are also available if needed. 

Generally, formulas are considered nutritionally complete, meaning they contain all the nutrients needed to support a child’s nutrition and growth in a specific amount. If your child does not tolerate a specific formula, there are usually many other options than can be tried.

Food-based formula, often referred to as “blended formula” or “blenderized tube feeding”, has become popular. Food-based formula is composed of blended food that is smooth enough to flow through a feeding tube. The formula can be homemade or commercially prepared. 

Blended formula can help decrease reflux, retching, constipation, and respiratory illnesses and to improve overall health. Homemade blended formula can be tailored to fit the individual needs of a child, such as food allergies or intolerances. Commercially prepared blended formulas may be more convenient for those who prefer not to make their own or may be used in addition to homemade blended formula. 

Blended formulas tend to be thicker than regular tube feeding formula. This may change how the formula is given. Using a syringe with a plunger to push the feeding in is a common method. Giving the blended formula using a feeding pump also is possible. 

It is important to note the amount of time a formula can safely stay at room temperature (called hang time) differs depending on the type of blended formula. Homemade blended formula has a hang time of no more than 2 hours, whereas some commercially prepared blended formulas have a hang time of 8 hours, making longer pump-delivered feeds possible.

Choosing a homemade blended formula requires a good understanding of your child’s nutrition needs. It is recommended that you work with a dietitian to ensure that your child receives adequate nutrients to grow.

Your child’s doctor or dietitian will be able to recommend how much formula and water to give through the feeding tube. The amount will depend on things like how much your child is able to eat by mouth and how well they are growing. 

Often, a tube feeding prescription will include a recommended amount of formula and extra water to make sure your child is getting enough nutrition as well as fluids to stay hydrated. It also may be recommended that your child receive additional vitamins and/or minerals.

Some children only need tube feedings for a few weeks or months, while others need it for a few years or even for life. Talk to your doctor about how long your child will need tube feeding. The time required is due to your child’s health, their ability to safely eat enough by mouth, their weight, and their growth.

Being tube fed does not always mean that your child cannot eat by mouth. Some children are able to continue to eat what they can by mouth and use the tube as a “second mouth” to provide extra nutrition and/or fluids. Ask your doctor if your child will still be able to eat by mouth if they have a feeding tube.

Talk to your child’s pediatrician, gastroenterologist, or dietitian about your questions regarding tube feeds. In addition, some helpful resources include the following:

• The Oley Foundation

Authors: Katherine Bennett RD MPH CLEC and Sharon Weston MS RD CSP LDN
Editor: Christine Waasdorp MD, MSCS, FAAP
October 2021