Tube feeding and intravenous (IV) nutrition

If you can't eat or drink by mouth, tube feeding and intravenous (IV) nutrition can help your body get the nutrition it needs during and after cancer treatment. Tube feeding and IV nutrition can help you maintain or gain weight and keep your body strong by preventing your muscles from breaking down.

Tube feeding and IV nutrition may be used if you:

• can't absorb nutrients properly or need extra nutrition such as higher amounts of protein and calories
• aren't receiving enough nutrition from food
• are having problems with swallowing
• can't eat or drink during or after cancer treatment
• have an extremely sore mouth or throat

Tube feeding is a way of getting nutrition directly into your stomach or small intestine. Some people with feeding tubes continue to eat food and drink liquids by mouth. You may also receive medicines through the feeding tube.

Tube feeding is preferred over IV nutrition because it uses the gastrointestinal (GI) tract and is less likely to lead to infection. You can only be fed through a tube into your stomach or small intestine if your GI tract is working well.

Tube feeding is also called enteral nutrition.

There are different types of feeding tubes. The one used will depend on:

• how long you will need the feeding tube
• your overall health
• your risk of accidentally sucking or breathing food or fluid into the lungs (called aspiration)
• the location in your GI tract where food can be given safely

Nasogastric, nasoduodenal and nasojejunal feeding tubes are long, thin, flexible tubes that are inserted into a nostril. They go down the throat and into the stomach (nasogastric), into the first part of the small intestine (nasoduodenal) or into the second part of the small intestine (nasojejunal). You won't need surgery to put these feeding tubes in place. Once a nasogastric, nasoduodenal or nasojejunal tube is in the correct position, it is taped to your nose or cheek to keep it in place. Placement of the tube will be checked with an x-ray before the first feeding is given. Nasogastric, nasoduodenal and nasojejunal feeding tubes are usually used if you need nutrition support for less than 4 to 6 weeks

Percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ) tubes are passed through the skin directly into your stomach (PEG) or into the small intestine (PEJ). They do not go through the nose. You will need surgery to make an opening (stoma) through the abdomen wall where the feeding tube enters the body. The feeding tube is held in place with either a stitch or a small inflated balloon around the tube just under the skin. An endoscope is inserted through the mouth, down the throat and into the stomach or small intestine to help guide the tube in place.

PEG and PEJ tubes are usually put in place when you're having another planned surgery. They may also be placed before treatment if you are unlikely to get the nutrition and fluids you need (for example, when you have a head and neck cancer).

PEG and PEJ tubes are used if you:

• will need nutrition support for a long time (more than 4 to 6 weeks)
• can't have a tube pass through your mouth or throat
• vomit frequently

There are different types of feeding schedules:

Intermittent tube feedings are given over short periods several times throughout the day, often at regular meal times. This feeding schedule is usually used for tubes that feed into the stomach. It can also be called bolus tube feeding.

Continuous tube feedings are given at a steady rate for usually 24 hours.

Cyclic tube feeding is an alternative to continuous tube feeding. It is given at a faster rate over a shorter period of time. It's given at the same time each day for the same amount of time. Cyclic feeding may also be called nocturnal feeding when the tube feeding is done overnight (for example, for 8 to 12 hours at night while you are resting or sleeping). This feeding schedule is usually used for tubes that feed into the small intestine.

• Cyclic tube feeding is helpful for people adjusting to eating food by mouth.
• It can be used along with eating food by mouth if you cannot eat enough.
• It's convenient if you can't do tube feeding during the day (for example, because of your treatment schedule).

If you are still able to eat some food, you can eat food by mouth with any type of schedule.

If you can't swallow medicines, some medicines can be crushed and given through the feeding tubes. Your healthcare team will work with you to make sure you receive your medicines in a safe way.

The feeding tube and the skin around it need special care. A nurse will show you how to manage this before leaving the hospital. They will show you how to do the feeding and flush the tube with water. The skin around the tube will need to be cleaned.

Your healthcare team, including a registered dietitian, will help decrease the risks of tube feeding and help you manage side effects.

Side effects and risks of tube feeding include:

• aspiration
• food from the stomach coming back into the feeding tube (called regurgitation)
• nausea and vomiting
• gas, bloating or cramping
• dehydration
• constipation
• dry mouth
• a blocked feeding tube
• a feeding tube that falls out or moves
• skin infection or irritation where the tube enters the body
• bleeding
• diarrhea
• fluid leaking around the tube
• dumping syndrome

Intravenous (IV) nutrition provides fluids and nutrients directly into the blood through a catheter inserted into a vein. IV nutrition does not use the stomach or intestines to digest food. IV nutrition is used if:

• your GI tract is not working well
• your bowel needs a rest (no food can go into your GI tract)
• you can't be tube fed for some reason

IV nutrition is also called parenteral nutrition.

IV nutrition provides:

• carbohydrates (glucose and dextrose)
• protein (amino acids)
• fats (lipids)
• vitamins (A, B, C, D and E) and minerals (zinc, copper, chromium, manganese, iodide and selenium)
• electrolytes (calcium, magnesium, phosphorus, sodium, potassium, acetate and chloride)
• vitamin K, if you are not taking blood thinners
• fluids

IV nutrition is prepared by a pharmacist. A dietitian works closely with the pharmacist to make sure the IV solution meets your specific nutrition needs. Blood tests are done to check the levels of potassium, sugar, sodium and other substances in your blood. The tests help determine how much of each nutrient is needed to make up the proper IV nutrition solution.

The catheter can be inserted into a vein in the chest or in the arm. The route depends on whether you will need IV nutrition for a long or short time.

Total parenteral nutrition (TPN) is when a central venous catheter (specifically a peripherally inserted central catheter, or a PICC line) is placed under the skin into a large vein in the chest by a surgeon. TPN is used when you will need IV nutrition for longer than a week.

Peripheral parenteral nutrition (PPN) is when a catheter is placed into a vein in the arm. You do not need surgery to have this done. PPN is used when you will need IV nutrition for less than a week and you do not have a central venous catheter already in place.

IV nutrition is usually started in the hospital as a non-stop infusion over a 24-hour period. You are weighed every morning at about the same time to monitor your fluid balance. Blood is taken every day to measure your electrolyte levels and see how well your liver and kidneys are working. This helps the healthcare team decide if the IV nutrition solution is meeting your nutrition needs. Once your body can handle IV nutrition, it can be done at home for 10 to 14 hours per day. Your healthcare team will give you instructions on how to give IV nutrition at home.

Your healthcare team, including a registered dietitian, will help decrease the risks of IV nutrition and help you manage side effects.

Side effects and risks of IV nutrition include:

• infection
• low blood sugar (hypoglycemia)
• high blood sugar (hyperglycemia)
• fluid overload
• bleeding
• an IV tube that comes out or moves
• blood clots
• an air embolism
• a buildup of air in the space between the lung and the chest wall (called a pneumothorax)
• IV nutrition–induced liver disease or liver failure
• weakening of gastrointestinal cells (called gastrointestinal atrophy)