Enteral (NG/PEG) Nutrition
Enteral vs Parenteral Nutrition
While Enteral Nutrition (EN), or tube feeding, is considered safer than Parenteral Nutrition (PN), or IV nutrition, in women with HG, EN is contraindicated for patients actively vomiting, especially by nasogastric (NG) tubes. Jejunal tubes, especially those surgically placed, may be better tolerated.
The metabolic complications of parenteral nutrition may not be avoided by use of enteral nutrition, nor is EN without risk. The most common risks of EN include tube displacement, pulmonary aspiration and poor patient tolerance. Many women with HG have delayed gastric emptying, gastroesophageal reflux, extremely sensitive gag reflexes, and frequent vomiting which decrease tolerance and increase the risk of aspiration.
The benefits of EN include maintaining normal digestion and absorption capabilities and gastrointestinal structure, but these may not outweigh the risks in this patient population, especially during the acute phase of illness. Further, many women benefit greatly from a period of gut rest yet require nutritional support after weeks of vomiting and limited intake.
When using nasal tubes, a small-bore, flexible tube is imperative to reduce stimulation of gag reflex and pain. Jejunal placement reduces risk of aspiration and distention, as well as tube displacement. Alternatively, percutaneous jejunostomy or gastrojejunostomy tubes may be placed and have the benefit of longer placement, less patient discomfort, and are more discreet than nasal tubes. Women have reported benefit from dual ports to allow for gastric drainage and jejunal feeding.
Considerations for EN in HG
- Intravenous nutrition may be the preferred option for nutrition initially.
- Simultaneous use of peripheral parenteral nutrition when trialing EN helps prevent onset of complications related to nutritional depletion.
- Women with HG given EN require continued antiemetics and may need additional fluid boluses.
- Women who vomit on EN need more aggressive antiemetic therapy and/or an alternative mode of nutritional support (surgically placed jejunal tube or parenteral nutrition).
- Monitor for Refeeding Syndrome and aspiration for at least the first week.
Research & Risks
Studies find EN is poorly tolerated, and maternal and fetal outcomes are similar among those given EN and those not given EN.
Offsite Resources on EN and HG
Risk Factors and Potential Complications
A few research studies have found that enteral nutrition may be a safe and effective alternative to TPN in some pregnant women with HG who have failed conventional treatment, but a more recent study with a larger number of participants found it is not an ideal treatment and not well-tolerated. Lack of benefit may be due in part to standard tube feeding formulas not being exactly high quality foods. (Review possible alternatives to discuss with your OB.)
It is not yet clear as to which women with HG are the best candidates. If your health professional suggests this therapy, be informed of the risks and discuss them. Also, make sure you are educated in the care of a gastric tube and able to identify signs of complications. A second opinion may be needed if this therapy is not tolerated or desired and the mother continues to become more nutritionally depleted. See our Referral Network for assistance in finding a doctor.
Remember, chronic dehydration and nutrient depletion make vomiting and nausea worse. So assist her in getting the help she needs so she will improve and recover faster.
Risk Factors for Aspiration:
Risk Factors for Refeeding Syndrome:
|Electrolyte imbalances (K+, Na+)||Due to fluid imbalance, renal impairment, diarrhea, Refeeding syndrome. Lab samples taken when dehydrated may show normal levels although they are low due to concentration of the urine.|
|Hyperglycemia||Too many calories or lack of adequate insulin.|
|Dehydration||Inadequate intake and fluids.|
|Tube clogging||Avoid inputting other foods, fluids without advice from the feeding team to avoid clogging. Boluses to clear the tube may trigger vomiting if large volumes or forceful fluids are given.|
|Aspiration||Use medications to minimize vomiting and retching.|
|Nausea and vomiting||Slowly advance feeding rate, flush with small volumes, and use a small bore tubing to minimize nausea/vomiting.|
|Constipation||Additional fluid or fiber may be needed.|
|Refeeding syndrome||The metabolic cascade of events that takes place when a malnourished patient is refed.|