Feeding Management

Feeding Strategies

Consider changing from continuous to intermittent feeding if currently on continuous infusion, as intermittent feeding may help reduce diarrhea in some patients, according to the European Society of Parenteral and Enteral Nutrition 1
Gastrostomy tube management involves various aspects, including flushing and medication administration, tube selection, and prevention of complications, as recommended by the American Gastroenterological Association and the Clinical Nutrition society 2, 3, 4

When flushing a PEG tube, administer at least 30 mL of water before, between, and after each medication or feeding to prevent tube occlusion, as recommended by the Clinical Nutrition society 3, 4
Never shake syringes to remove medication, and never mix medications before administration through the tube due to risk of drug-drug interactions, as recommended by the Clinical Nutrition society 3, 4
Polyurethane PEGs may be preferable to silicone PEGs for medication administration due to better patency retention, as suggested by the Clinical Nutrition society 3, 4
Balloon-type tubes require weekly water volume checks and replacement every 3-4 months due to balloon degradation, as recommended by the Clinical Nutrition society 3

Peristomal infection occurs in up to 30% of cases, with risk factors including diabetes, obesity, poor nutritional status, and immunosuppressive therapy, according to the American Gastroenterological Association 2
Daily inspection and sterile dressing changes until granulation occurs, and applying antimicrobial agent topically to entry site and surrounding tissue, are recommended for managing peristomal infections, as suggested by the Clinical Nutrition society 4
Buried bumper syndrome occurs in 0.3-2.4% of gastrostomy patients, and prevention includes allowing approximately 1 cm of play between skin and external bolster, and weekly maintenance, as recommended by the American Gastroenterological Association 2
Accidental removal of tubes occurs in 1.6-4.4% of cases, and replacement through the existing tract or urgent replacement is necessary, as recommended by the Clinical Nutrition society 3
Mechanical failure, including clogging, cracking, and deterioration, can be managed by replacing the tube endoscopically, radiologically, surgically, or at bedside, as suggested by the Clinical Nutrition society 3

Aspiration pneumonia is a serious condition that requires prompt management, with guidelines from the American Thoracic Society and European Respiratory Society providing recommendations for treatment 5
Procedure-related aspiration occurs in 0.3-1.0% of cases, and post-procedure aspiration is more common, with risk factors including supine position, sedation, and neurologic impairment, as reported by the American Gastroenterological Association 2
Prevention of aspiration includes considering conversion to GJ tube for patients with recurrent aspiration, as recommended by the American Gastroenterological Association 2
Maintain head elevation at a minimum of 30° during and for 30 minutes after feeding to reduce reflux and aspiration risk, as recommended by the European Society for Clinical Nutrition and Metabolism and the Gut society 1

Monitor fluid status, electrolytes, and signs of aspiration in patients receiving tube feeds, according to the Gut society and the American Society for Parenteral and Enteral Nutrition 1, 4
Daily weight measurements, regular assessment of fluid balance, and weekly monitoring of electrolytes until stable are essential for managing patients with gastrostomy tubes, as recommended by the American Society for Parenteral and Enteral Nutrition 4
Monitor fluid status, electrolytes (glucose, sodium, potassium, magnesium, calcium, phosphate) closely in the first few days after starting enteral feeding, and be vigilant for refeeding syndrome, particularly in malnourished patients 1

Review all medications, particularly liquid formulations which often contain sorbitol, to identify potential causes of diarrhea, as recommended by the American Gastroenterological Association 2
Medications should be given in liquid form when possible to reduce the risk of clogs, and avoid hyperosmolar drugs, potassium supplements, iron supplements, and sucralfate as they are more likely to cause clogs 6
Consider switching to a lower osmolality or fiber-containing formula to manage diarrhea, as suggested by the European Society for Clinical Nutrition and Metabolism 4
Avoid rapid administration of formula; use continuous rather than bolus feeding to reduce the risk of diarrhea, according to the American Society for Parenteral and Enteral Nutrition 4

Patients and caregivers must demonstrate competency in feed administration, equipment handling, basic troubleshooting for tube/equipment failure, proper positioning during feeding, and medication administration through the tube 4, 3
Patients should be positioned at a minimum 30° elevation during nebulizer treatments to reduce aspiration risk, and nebulizer treatments should be scheduled away from G-tube feeding times to reduce aspiration risk 5, 7
When patients are discharged to the community on continuing enteral tube feeding, ensure all community carers are fully informed and continuing prescription of feed and relevant equipment is in place 1
A formal dysphagia screening must be completed before any oral intake, as recommended by the American Heart Association 8
Oral intake should be avoided if the patient shows signs of severe dysphagia, frequent aspiration, impaired consciousness, or recent acute variceal bleeding (within 3 days), according to the American Gastroenterological Association 1