3.2 Use and Benefits Of Enteral Tube Feeding (ETF)

Summary

Enteral tube feeding (ETF) is a life-saving technique without which patients with a functioning gut, who are unable to consume sufficient food and drink via the oral route to meet their nutritional needs, would die due to dehydration and starvation. Enteral tube feeding is indicated if a patient has a functioning gut but is unable or unwilling to consume sufficient food or fluid orally to meet their nutritional requirements.

ETF is frequently used in patients of all age groups across all healthcare settings e.g. hospitals, nursing homes and in patients living in their own homes. The use of ETF in the community or home enteral tube feeding (HETF) has become more common globally as a result of developments in technology, the development of the percutaneous endoscopic gastrostomy (PEG) and as a result of the need for more community care as governments’ attempt to refocus the delivery of healthcare away from the costly acute healthcare setting and closer to patients at home. The prevalence of HETF is steadily growing year on year. HETF has gained popularity due to advancements in managing the aging population, progress in technology, such as the development of percutaneous endoscopic gastrostomy (PEG), and a shift towards community-based care as part of efforts to reduce healthcare costs.

The prevalence of HETF is steadily increasing, particularly as patients in the UK and other countries, especially younger individuals, manage their care independently at home.

ETF is used to support adult patients with a wide variety of conditions. In national surveys of HETF the main disease areas in which patients receive tube feeding are cancers, neurological disorders and non-malignant GI diseases.

Many patients receiving HETF live in their own homes. Data from national registers and retrospective studies shows that many people receiving HETF live independently and self- manage their daily care whilst also achieving normal activity levels. In the UK there is an increasing trend towards HETF patients living independently which may reflect the younger age groups in which HETF is initiated. Unsurprisingly, those HETF patients that live in nursing homes tend to require total care and are generally immobile.

HETF is used to support children of all ages in the community but particularly children under the age of 5 years. Most children on HETF live at home with their family. For children in the community, especially those under 5 years old, HETF serves as crucial support, emphasizing the significant role families play in managing their care.

From a clinical perspective it is clear that ETF is indicated for particular clinical conditions. Its value is generally undisputed in patients who are likely to recover from a period of unconsciousness or in those who have swallowing difficulties but otherwise are in good health or have a good quality of life. Because of the value of ETF in sustaining life it is often considered unethical to withhold treatment. This also means that undertaking randomised controlled trials, whereby one group of subjects are randomised to receive ETF whilst the other group don’t, would also be considered to be unethical. It is generally considered unethical to withhold ETF due to its critical role in sustaining life. Enteral feeding decisions should be made collaboratively with the patient, family, and healthcare team. The patient should be given appropriate support to maximize their ability to participate in the decision-making process.

Systematic reviews have shown a number of benefits of ETF such as improving nutritional intake in patients across healthcare settings; attenuating loss of body weight and lean tissue mass in hospital patients; improving body weight and lean tissue mass in patients in the community and improving growth in children in the community. ETF is associated with functional improvements (depending on patient group) such as improved wound healing and well-being in hospital patients; improved pulmonary function and well-being in community patients and improvements in some aspects of quality of life e.g. in patients with head and neck cancer who undergo prophylactic gastrostomy feeding (6-month data).

ETF is associated with reductions in mortality and complications in hospital patients, including patients who are critically ill. In one systematic review mortality rates were significantly reduced by ETF compared with routine care in some patient groups (11% vs. 23%). There is limited data available in the literature about the potential cost savings and cost-effectiveness of ETF across healthcare settings, from different countries and in particular in children. However, a small number of studies have been undertaken. In England, the potential savings from reduced length of hospital stay associated with use of ETF and PN combined have been estimated to be approximately £11 million. In Poland a study showed that after introduction of reimbursement for commercial ETF there was a reduction in the number of hospital admissions and length of stay with savings in annual hospitalisation costs.

Conclusion

ETF is an important life-saving technique used widely across all healthcare settings in patients of all ages with a variety of medical conditions. The use of ETF is increasing in the community, and many patients live independently and achieve normal activity levels. ETF has nutritional, functional and clinical benefits and data is emerging showing that it is cost- effective in adults and children.

Recommendations

On the issue of the benefits of ETF the MNI makes the following recommendation: