PEG Tube Feedings: Navigating Hospital Standards
By Michelle Hamburger
Transitioning from eating-by-mouth to PEG tube feedings can be a difficult process, especially if patients or family members desire healthier alternatives to what hospitals and home care programs typically offer. The following paragraphs will highlight how to navigate hospital systems so you and your patient/loved-one can receive the best care possible.
What is a PEG Tube?
A PEG tube (Percutaneous Endoscopic Gastronomy Tube) is a flexible feeding tube placed through the abdominal wall and directly into the stomach, allowing nutrition, fluids, medications and supplements to bypass the mouth and esophagus. This procedure benefits people who have difficulty swallowing or an inability to take nutrition through the mouth. At Conners Clinic this is common for patients with cancer of the mouth, throat or esophagus, or for toddlers or young children who are less likely to eat a variety of nutrient-dense foods to maintain their health and bodyweight.
Standard PEG formulas focus primarily on macronutrients – carbohydrates, proteins and fats – without much consideration for the source or quality of those nutrients.
Below is a list of ingredients in PEG formula TwoCal-HN, commonly used in hospital settings. All ingredients listed in italics are those which Conners Clinic typically contraindicates for patients dealing with cancer. Many of these ingredients are also contraindicated for patients with any form of auto-immune or chronic dis-ease, due to these foods’ propensity to increase inflammation, hormone imbalances and GI issues.
Conners Clinic contraindicates the ingestion of:
- Sugar because of its ability to be a rapid fuel source for cancer.
Conners Clinic Video: https://www.youtube.com/watch?v=lekYtGygMd8
- Dairy (from both from cows and goats) because of its ability to stimulate growth factor, also known as IGF1. Growth factor increases the rapid replication of cells, which is why baby calfs drink their mother’s milk and develop into a 1,500 pound adult cow.
Conners Clinic Video: https://www.youtube.com/watch?v=ZtUUE8F1VYA
- Corn (GMO) because unless corn-based products are labeled non-GMO or organic, corn is typically genetically modified (also known as “Bio Enhanced”). GMO foods act as a form of antibiotic and can damage the healthy bacteria sick patients desperately need.
Conners Clinic Video: https://www.youtube.com/watch?v=o5c1PRnkB0A&t=1s
- Soy because it mimics estrogen in the body and creates complications for patients whose cancers are hormonally driven. Soy is also one of the most common GMO foods, thereby acting as an antibiotic on the human biome.
Conners Clinic Video: https://www.youtube.com/watch?v=2CzbZcx70j0&t=2s
One of the trickiest aspects of DIY/Alternative PEG formulas are collaborating with hospital staff, respecting their policies and effectively communicating your ability to meet caloric and macronutrient standards.
Below is a list of 5 common concerns a caretaker/loved-one may need to address with hospital/facility staff.
1. Maintaining a High Caloric Intake.
Before bringing your DIY plans to the hospital’s attention it is helpful to get a general idea of the total daily calories needed by the patient, as well as macronutrient breakdowns. Putting in the work ahead-of-time will show hospital staff you’ve done your research and are capable of providing for the patient.
A great online resource for calculating individual enteral nutrition needs is www.ClinCalc.com. Enter the necessary Patient Parameters and, if desired, your Formulation-of-choice, then press calculate.
Below are images of an example enteral nutrition calculation and the results provided.
Calculator ClinCalc Results
The results are thorough and provide recommended hourly caloric requirements, instructions for dosing both water and food, breakdowns of formula macronutrients and how to manage both feed water and water flushes. Most hospitals should have no problems accepting this level of preparedness.
2. Liability and Gaining Permission.
When it comes feeding tubes, gaining permission before administration is very important. It allows hospitals to knowingly participate in feeding schedules that align with both personal values and hospital standards, and it will ensure the patient isn’t fed inappropriate foods during non-visiting hours.
It’s possible hospitals will request the patient’s family/caretakers sign a liability waiver, releasing the hospital of responsibility if the alternate or DIY formulas cause issues for the patient or the physical feeding tubes. This is fairly standard procedure.
Ultimately developing good communication channels between caretakers and hospital staff sets a trustworthy foundation that, in the long-run, will benefit the patient.
3. The Use of “Non-Verified” Products
If the hospital hasn’t previously worked with patients making homemade formulas, several steps may need to be taken.
- All outside ingredients/formulas may need to be sent to Dietary for approval and special labeling. Hospitals track each patient’s dietary needs/restrictions so it’s common practice for special requests to be recorded in the patient’s chart. This allows the hospital to know what the patient is being fed and prevents the delivery of undesired foods.
- Filtered water should not need special approval/labeling, however it will still be important to make sure hospital staff is aware that tube flushing and water feedings are to be done with filtered water only. Ask hospital staff where they would like the water to be stored for easy accessibility.
- It some instances it may be up to the family/caretakers to handle all feedings (and possibly all water feedings/flushings). This may mean taking turns “staffing” the room on a 24-hour loop to make sure PEG food is mixed properly and that the patient doesn’t miss a feeding or become dehydrated.
4. Preventing Clogging of the PEG Tube
Clogging a patient’s feeding tube is often a hospital’s #1 concern. It’s vital that the consistency of the formula be compatible with the patient’s specific feeding tube and that formulas be mixed thoroughly to prevent caking and clotting, otherwise hospitals are faced with needing to take corrective action to unclog or replace the tube.
The diameter of a PEG tube may vary from patient-to-patient and will influence the ease-of-administration. Some patients may receive a larger diameter tube which accommodates thicker formulas and won’t need to be watered-down. In these instances, the patient is able to receive higher caloric feedings within smaller fluid quantities.
If the patient cannot tolerate a larger diameter tube, a smaller tube will be installed. Smaller feeding tubes don’t work for viscous formulas and feedings will need to be watered-down until they reach an appropriate consistency. The more liquid the formula, the higher quantity of food – or higher quantity of total feedings – may be necessary to fully fuel that patient.
Bringing a blender/mixer into the hospital may ensure the formula doesn’t contain/develop any clots. Common protein shaker bottles are likely not sufficient-enough for this. Should a powdered clot enter a small diameter feeding tube, the tube could clog and prevent future feedings. If bringing a blender isn’t an option then pre-blend the formula at home, pour through a strainer to remove excess clumping, then shake the mixture vigorously before administration to redistribute any particulate.
5. Respecting Necessary Procedures/Boundaries
Special requests may be met with mild resistance simply because of the possible extra work to hospital staff. Understanding that doctors/nurses are trying to do the best they can for all patients, and supplying requests in a respectful and calm manner, goes a long way to establish a healthy relationship.
Some hospitals may initially refuse to accommodate certain dietary adjustments, but don’t lose hope. Slowly and respectfully work your way up the chain-of-command until you reach somebody who can help move your requests forward. You may have to make minor adjustments to meet the hospital halfway, but by following the above guidelines there shouldn’t be many issues.
Michelle Hamburger was a former patient at Conners Clinic, and is currently the lead Clinical Kinesiologist and distance program director. For more information on Conners Clinic, please visit www.ConnersClinic.com.