Background   Medically administered nutrition and hydration (MANH) via a naso-, gastric-, or jejunal- tube is colloquially referred to as tube feeding. It is frequently used in patients who are chronically ill or dying.  The evidence for much of this use is weak.  The Fast Fact reviews data on the use of tube feeding in advanced illness. 

For prevention of aspiration pneumonia 

• Numerous observational studies have demonstrated a high incidence of aspiration pneumonia in those who have been tube fed.  Reduction in the chance of pneumonia has been suggested for non-bed-ridden post-stroke patients in one prospective, non-randomized study.  For bedridden post-stroke patients, no reduction was observed.
• Three retrospective cohort studies comparing patients with and without tube feeding demonstrated no advantage to tube feeding for this purpose.
• Swallowing studies, such as videofluoroscopy, lack both sensitivity and specificity in predicting who will develop aspiration pneumonia.  Croghan’s study of 22 patients undergoing videofluoroscopy demonstrated a sensitivity of 65% and specificity of 67% in predicting who would develop aspiration pneumonia within one year.  In this study no reduction in the incidence of pneumonia was demonstrated in those tube fed.
• Swallowing studies may be helpful in providing guidance regarding swallowing techniques and optimal food consistencies for populations amenable to instruction. See Fast Fact #128 for discussion of the role of swallowing studies. 

For life prolongation via caloric support 

• Data is strongest for patients with reversible illness in a catabolic state (such as acute sepsis or a reversible cause of delirium).
• Data is weakest in advanced cancer.  No improvement in survival has been found (see exceptions noted below).
• Individual patients may have weight stabilization or gain with tube feeding.  However, when larger cohorts are studied, no clear survival advantage between tube fed and carefully hand-fed cohorts have been consistently demonstrated.
• Tube feeding may be life-prolonging in select circumstances:
  • Patients with good functional status and proximal GI obstruction due to cancer.
  • Patients receiving chemotherapy/XRT involving the proximal GI tract.
  • Selected HIV patients.
  • Patients with amyotrophic lateral sclerosis.
  • Reversible dysphagia after a stroke. 

For enhancing quality of life 

• Where true hunger and thirst exist, quality of life may be enhanced (such as in very proximal GI obstruction from treatable tumor).
• Most actively dying patients (see Fast Fact #3) however do not experience hunger or thirst.  Although dry mouth is a common problem, there is no clear relation to hydration status and the symptom of dry mouth – see Fast Fact #133.
• No studies demonstrate improved quality of life through tube feeding.
• Conversely, tube feeding may adversely affect quality of life if patients are denied the pleasure of eating.  Additionally, tube feeding has been associated with an erosion in quality of life for patients with advanced dementia by increasing the risk of physical and chemical restraints, pressure ulcers, and maybe even aspiration pneumonia.

Summary: Although often used, current data does not provide much sort for the use of medically administered enteral nutrition in patients with advanced dementia or in patients in a dying trajectory from an underlying progressive illness.  A recommendation to use, or not use, tube feeding should be made only after first establishing the overall Goals of Care (see Fast Fact #16).

References 

1. Loeb MB, Becker M, Eady A, Walker-Dilks C. Interventions to prevent aspiration pneumonia in older adults: a systematic review. J Am Geriatr Soc. 2003;51(7):1018-1022.
2. Meier DE, Ahronheim JC, Morris J, Baskin-Lyons S, Morrison RS. High Short-term Mortality in Hospitalized Patients With Advanced Dementia: Lack of Benefit of Tube Feeding. Arch Intern Med. 2001; 161(4):594-599.
3. Nakajoh, K., T. Nakagawa, et al.  Relation between incidence of pneumonia and protective reflexes in post- stroke patients with oral or tube feeding. J Intern Med .  2000; 247: 39-42.
4. Finucane T, Christmas C, Travis K. Tube feeding in patients with advanced dementia. JAMA. 1999; 282:1365-1369.
5. Finucane T, Bynum J. Use of tube feeding to prevent aspiration pneumonia. Lancet. 1996; 348:1421-1424.
6. Lee Y-F, Hsu T-W, Liang C-S, et al.  The efficacy and safety of tube feeding in advanced dementia patients: a systematic review and meta-analysis study.  Journal of American Medical Directors Association 2021; 22(2):357-363.
7. Croghan J, Burke E, Caplan S, Denman S. Pilot study of 12-month outcomes of nursing home patients with aspiration on videofluroscopy. Dysphagia. 1994; 9:141-146.
8. Duff C. Dementia: assessment, management and support for people living with dementia and their carers. National Institute for Health and Care Excellence, London, UK 2018.

Version History:  Originally edited by David Weissman MD; 2nd Edition published August 2005; 3rd Edition May 2015; 4th Edition in May 2025.
Conflicts of Interests: None to report.