Naso-gastric Tubes Image Credit : Royal Children's Hospital, Melbourne
When the problem is seen to be a temporary one (a crisis brought on by an acute illness like pneumonia), a naso-gastric tube may be the best solution. This is a very thin tube which is inserted through the nose directly into the stomach. A liquid feed is then run through the tube by fitting a syringe into the top end and pouring the feed down – a feed can be plain milk, a commercial preparation (expensive! One feed costs approximately 50 rupees) or a homemade formula.
Putting the tube in is an awkward procedure, which even a cooperative person – one who understands the necessity and has agreed to it – instinctively fights against. The gag reflex is highly developed and most people find the insertion of the tube very unpleasant. When the person is a child, particularly if the child has a mental handicap and cannot understand what is happening, several people may be required to hold him down. The process takes less than a minute when an experienced doctor is doing it, however, so the suffering is minimal. It is upsetting, but remind yourself that it will save your child’s life.
A Naso-gastric tube is, by nature, a temporary solution to a crisis. It is designed to be used for only a few weeks (and even during that time, the tube must be switched from one nostril to the other periodically – otherwise, the nostril itself begins to be cut into by the constant pressure of the tube) – that said, there are people who have continued on it for months.
While doctors often treat the decision matter-of-factly, as the only logical step to take in a crisis, it is important for parents to be prepared for the emotional toll the decision to tube feed brings. There is something final-feeling about a tube to provide nourishment, as if an important milestone has been crossed. Parents often break down in tears after the procedure is over and may need much reassurance from friends and family. The child, of course, will also need tremendous emotional support.
Once the tube is in and the child is settled, however, the benefits almost immediately become apparent. With proper nourishment, the child’s natural healing abilities suddenly kick in and she begins to get better. It is almost miraculous to watch a child who had been hovering on the brink of starvation make the turn back to life and good health.
Another advantage of the tube is that you can administer medicines through it too. Try to stick to liquid meds. Crushed pills often clog the tube and contribute to its breakdown more rapidly than liquids. If pills are all you have available, try to soak them in water till they are completely dissolved. Overnight usually works well.
Putting in a G-tube is a momentous decision for most parents. A naso-gastric tube, while difficult to decide upon, is still temporary and there are many children who have needed one once or twice and then returned to normal eating. But a G-tube, while also reversible, is seen as a more permanent decision. The whole landscape changes. The social act of sharing food is so central to our human existence that to be nourished in any other way seems alien and bizarre.
A G-tube involves making a surgical opening in the abdomen and threading the tube through. It is held in place by a small balloon like protrusion which is inflated from the outside. The method of choice is to put the tube in via endoscopy – which means that the tube goes through the mouth, down the esophagus and out through the opening the surgeon has made in the abdomen. The old method was to make a much larger opening in the abdomen and put the tube in from there. This new approach minimizes the extent of the incision and promotes faster healing and less of a scar.
In India, most G-tubes Image Credit : All Refer are around a foot long and trail from the abdomen. The outside end has a little stopper, which you open when it is time for a feed. You push a tiny funnel (available in medical supply or laboratory equipment shops) into the opening and pour the feed down.
Take your time while pouring. You don’t want to overload the tummy by shoving it all in at one go.
Sometimes, when the tube is opened first thing in the morning, some gastric fluids may spurt out. The same thing will happen if the child coughs or laughs during a feed. You can pinch the tube when this happens to avoid having everything come right out.
Sometimes the tube may get clogged. Flush it gently with a syringe of warm water. The best size is 50ml, but this can be difficult to find in India. If you do locate a shop that stocks them, buy several to have on hand.
A recipe for tube-feeding
Note: Tube feedings should not be warmed before use. A cold formula can be fed without problems if administered slowly. Warming the mixture may result in destruction of water soluble vitamins, coagulation of proteins, clogging of tubes, coagulation of formula or more rapid growth of bacteria. Raw eggs should never be used as part of the diet because of the danger of a salmonella infection
Nutan’s Recipe for A Good, Nutritionally-Complete Tube Feed in India
For approximately 1000 kcal per 1 litre
- Cooked Instant Dalia 115 gm 3⁄4 cup*
- 1⁄4 cup sieved yellow mung dal** no salt
- 120 ml (3⁄4 cup) thick orange juice
- Salt free strained carrots 50 gm 1⁄4 cup sieved carrots***no salt
- Instant Milk powder 23 gm 1⁄2 cup
- 1⁄2 cup cooked rice put thru sieve
- Corn syrup 70 gm < 1⁄4 cup
- Oil 40 gm 1⁄4 cup
- Water is added to reach the desired volume 2 3⁄4 cup ( 600 ml)
A commercial formula (Ensure) is simple to prepare and easy for many people to digest. It is, however, very expensive at Rs 350 per tin (seven feeds).
Be careful about making sure the stopper on the tube stays closed. The gastric juices the stomach produces to break down food are like acid and burn when in contact with the skin. My daughter managed to open her tube one night and when I got her up in the morning she was drenched in the highly corrosive fluid and her skin was burnt in several places. Because she has an abnormally high pain threshold, she didn’t cry and I have no idea how long she was in this condition. The scars are still on her body however.
We now cover the top of the tube with a small pouch which we tie in a tight knot before she goes to sleep at night. She is unable to remove it and cannot accidentally open the tube again.