What are the indications for feeding tube placement?

Indications for Feeding Tube Placement

Feeding tubes should be placed when patients cannot consume or absorb adequate amounts orally and are at high risk of malnutrition, with the specific route and timing determined by the expected duration of need and underlying pathology. 1

General Indications for Enteral Tube Feeding

Primary indication: Tube feeding must be considered when a patient cannot consume or absorb adequate amounts orally to maintain nutritional status, and oral intake is expected to remain below 50% of energy requirements for more than 10 days despite adequate support and oral supplements. 1

Specific Clinical Conditions Warranting Tube Feeding:

Neurological disorders:

• Dysphagia following cerebrovascular stroke or craniocerebral trauma 1
• Bulbar paralysis, Parkinson's disease, amyotrophic lateral sclerosis 1
• Cerebral palsy, cerebral tumors 1
• Prolonged coma or persistent vegetative state 1

Oncological conditions:

• Stenosing tumors in the ear, nose, throat region or upper gastrointestinal tract 1
• Patients undergoing chemotherapy or radiotherapy who cannot maintain adequate oral intake 1
• Reconstructive facial surgery 1

Other medical conditions:

• Severe burns, polytrauma 1, 2
• Short bowel syndrome, Crohn's disease 1
• Cystic fibrosis, chronic renal failure 1
• AIDS-related wasting 1
• Congenital abnormalities such as tracheo-esophageal fistula 1

Timing and Route Selection Algorithm

For Short-Term Feeding (< 4-6 weeks):

Use nasogastric (NG) tubes for gastrointestinal access up to 4-6 weeks, as they can be easily placed at bedside without invasive procedures. 1, 3

Switch to nasojejunal (NJ) tubes if:

• Problems with gastric reflux or delayed gastric emptying exist 1
• Unconscious patients must be nursed flat 1
• Documented aspiration occurs despite prokinetic therapy 4

For Long-Term Feeding (> 4-6 weeks):

Percutaneous gastrostomy (PEG) should be considered if enteral feeding is likely to be needed for periods exceeding 4-6 weeks, as gastrostomy tubes provide feeding without the inconvenience, discomfort, and embarrassment of nasal access. 1

Percutaneous jejunostomy (PEJ) is preferred when:

• Severe gastroparesis is present and gastric feeding has failed 5, 6
• Gastric outlet obstruction exists 4
• Long-term jejunal feeding is required 1

Specific Quantitative Thresholds

Initiate nasogastric feeding when:

• Intake falls below approximately 50% of energy requirements for more than 10 days despite adequate support and oral supplements 1

Convert to PEG when:

• The period of markedly low intake is expected to last longer than 4 weeks 1
• Nasogastric feeding is not tolerated or accepted by the patient 1

For gastroparesis specifically:

• Tube feeding via jejunostomy should be initiated if oral intake remains below 50-60% of energy requirements for more than 10 days despite dietary modifications and medical therapy 5

Critical Contraindications and Special Populations

Absolute Contraindications:

• Intestinal obstruction or ileus 5
• Severe shock 5
• Intestinal ischemia 5

Severe Dementia - Special Consideration:

Tube feeding is NOT recommended in patients with severe/advanced dementia. There is high-grade evidence showing no survival benefit, no improvement in quality of life, no reduction in pressure ulcers, and no improvement in physical or mental function. 1

Exception for mild-moderate dementia: Tube feeding may be used for a limited period to overcome a crisis situation with markedly insufficient oral intake if the low nutritional intake is predominantly caused by a potentially reversible condition (e.g., anorexia during infection, dysphagia from acute stroke, delirium with reduced intake). 1

Terminal Illness Considerations:

If an illness is in a terminal phase and the plan is to provide only compassionate and palliative care, tube feeding need only be given to relieve symptoms, not necessarily to prolong survival. 1

Monitoring Requirements After Tube Placement

For temporary tube feeding in reversible conditions:

• Reassess indication weekly during the first month 1
• Reassess monthly thereafter 1
• Attempt weaning from tube feeding when nutritional demands are again partly covered orally 1

Common Pitfalls to Avoid

Do not place gastrostomy tubes in gastroparesis patients - they deliver nutrition into the dysfunctional stomach and will not bypass the emptying problem; jejunostomy is required instead. 5

Do not delay tube feeding beyond 10 days of inadequate intake in patients with documented need, as malnutrition significantly worsens outcomes. 5

Avoid placing PEG tubes in patients with severe dementia unless there is an exceptional, individualized circumstance with clear reversible pathology, as evidence shows no mortality or quality of life benefit. 1

Do not place feeding tubes for administrative convenience (saving time, money, or manpower) or as a substitute for good nursing care - placement must always be for valid medical reasons. 1