This morning I talked a student nurse through the process of tube feeding our sons. I'm beginning to have the script memorized (this is a teaching hospital and students from Mount Royal's nursing program come through every day).
We always start by giving the boys a chance to eat as much as they can from their bottle. This is important as tube fed babies can quickly regress and stop taking any food orally, something we certainly want to avoid. So we offer the boys the bottle each time and give them up to 30 min to eat as much as they can. Never forcing and stopping as soon as they give sings that eating is becoming uncomfortable. They never last a full 30 min, between discomfort from reflux, an uncoordinated suck swallow pattern which results in a lot of air being swallowed, and being active babies who are easily distracted, bottle feeds usually last anywhere between 1 and 15 minutes.
I constantly have to remind myself that as long as those minutes were quality, happy eating, then it's a win, regardless of the volume consumed. This morning Alex quickly slugged back 60 of his 100 ml bottle, then had a burp/spit-up that discouraged further eating. So the other 40 ml were going down the tube.
As for the tube, the boys have Nasogastric Feeding Tubes, or NG tubes, which are inserted through the nose, and run down the back of the throat and into the stomach. In theory, the polyurethane tube, once placed, needs only be changed every 30 days. In practice, the boys will probably, pull, cough or vomit it out before then. Or the tube may become blocked. Or it may migrate up and out of the stomach and find its way somewhere else, like into the lungs.
As you can imagine, you really don't want the tube to be in their lungs, so before sending any food (formula or expressed breast milk) down the tube, it's best to be sure it's in their stomachs. Theoretically you can do this by sending some air down the tube and using a stethoscope, listening for bubbles in their tummies. In practice, this is a subjective test, and considering or boys quite often have tummies full of air, not a certain test. So we opt for a second testing method.
We begin our tube feeds by drawing up some of the stomach contents. Simply attach a small syringe to the end of the tube and draw back gently. If you're in the stomach you'll get some of their last meal, seeing the white milk flow up through the tube indicates, yes you're in the stomach and good to go. To be extra certain, you can check the pH of the fluid you draw out, acidic pH's of 6 or lower, and you're in the stomach and good to go. If you have resistance, draw up nothing but air, or draw a neutral or slightly basic fluid, the tube needs to be pulled out and replaced.
With our air gulping boys, we often draw considerable volumes of air before getting to the milk. It seems like you can never burp these boys enough. However since you can physically removing the air through the tube, it saves the boys the uncomfortable effort of passing ass that air out the other end, and as a result, they are less bloated and more comfortable.
Now we know we're in the stomach, time to feed, or gavage the boys (gavage is a gentler name for what is essentially force feeding). Swipe out the small syringe for a large 60 ml one, with the plunger removed and pour the milk in. In the future for larger feeds we may use a pump to very slowly feed the boys (this is a strategy often used to run overnight feeds will the little ones sleep) but for now, Gravity is enough. The milk should run freely down the tube and into their bellies, you can adjust the flow by moving the syringe up (faster) or down (slower). The key is to find a flow rate that doesn't take too long, but also doesn't make the boys uncomfortable.
Once all the milk is in, the tube needs to be cleaned or flushed. A second small syringe with 3 to 5 mls of sterile water is connected and pushed down the tube. Now we just cap off the tube, coil it up and tape it to the back of their shirts to hopefully keep it out of reach of little hands.
Finally, since our boys aren't yet used to eating bigger volumes (for the last month we were lunch if they ate 2 ounces in one go), we try to keep the upright for 20 or so minutes after each feed. And still we cant always avoid post feed spit ups. They are just a part of babies, and tube feeding in particular, all you can do is try to aim it away from their clothes, and ours too. Tile floors are easier to clean up than people.
And that's it. Not so brief I guess. Well it's not quick for us either. All and all it takes between 40 minutes and an hour and a half to feed one baby this way. And we have twins, and they need to eat 6 times a day. So you imagine I'm apprehensive to see how we can manage this when we are discharged from hospital and don't have helpful nurses and student nurses around all the time. But who said twins would be easy?
