How to Choose a Tube-Feeding Formula: A Guide for Confused Parents

When your child's doctor recommends a feeding tube to avoid malnutrition and foster healthy growth, many possibilities opens up. With more than 100 varieties of formula on the market, figuring out which is best for your child feels a bit like rocket science.

Good news: It's more like a long division problem—confusing at first glance, but easily solvable if you break it down into smaller steps.

Tube-feeding is also referred to as enteral nutrition, or the delivery of nutrients directly into the gastrointestinal tract. Choosing the right formula is key to supporting your child's nutritional needs, as well as helping alleviate any medical issues, says David Suskind, M.D., director of clinical gastroenterology at Seattle Children's Hospital, professor of pediatrics at University of Washington School of Medicine, and a member of the Nutrition4Kids Medical Advisory Board.

"Sometimes we use formulas to make sure children are gaining weight and developing appropriately," he says. "Other times, we use them to help treat a medical condition."

Here are the five things your pediatric gastroenterologist and nutritionist will consider to find the right formula for your child.

Consideration #1: Your Child's Specific Issue

Your child's unique personal or medical issue will instantly trim the list of options. Your child's health care team will assess things like GI function, metabolic abnormalities, and medical history to help determine whether the formula will be used for complete nutrition or as a supplement, Dr. Suskind says.

There are four main types of formulas: standard, peptide, elemental, and specialized. If your child's digestive system is working normally, chances are your doctor will start with a standard formula.

If digestion is a problem, your doctor may suggest a peptide formula, in which the proteins are chopped into smaller pieces to make them easier to digest; or an elemental formula, where the proteins are completely broken down into their base molecules—amino acids.

Specialized formulas are designed for people with particular nutritional needs caused by specific disorders—diabetes or kidney failure, for example.

Consideration #2: Tube Type

There are many types of feeding tubes: Some originate from the nose and go down the esophagus and into the stomach; others start in the nose but bypass the stomach and connect into the small intestine. There are also tubes that connect directly to the stomach or small intestine from the abdomen.

Tube type influences formula choice, says Mel Heyman, M.D., professor of pediatrics, pediatric gastroenterology, hepatology, and nutrition at the University of California in San Francisco and a member of the Nutrition4Kids Medical Advisory Board.

"If you put a formula directly into the stomach, you can probably give a standard enteral formula that needs digestion," Dr. Heyman says. "But if you have a tube in the intestinal tract, bypassing the stomach, then you may need to use a formula that is more broken down and easier to absorb."

In the latter case, your child's doctor may recommend a peptide or elemental formula.

Consideration #3: Macro- and Micronutrient Breakdown

Every tube-feeding formula can be composed a little differently, as the makeup of each is dependent on what the formula is supposed to be used for, Dr. Suskind says. 

Even so, most are complete formulas that can give your child the nutrients they need to grow and develop healthily.

"That includes protein, carbohydrates and fats, as well as vitamins and minerals," Dr. Suskind says. "But again, needs vary depending on your child's unique situation."

Take food allergies, for example, which can occur in both very young and older children. That may require a hypoallergenic formula where the protein, which usually triggers allergies, is either broken down into smaller peptides or even into amino acids, to help avoid setting off that reaction, Dr. Suskind says.

So working with a medical team who really knows the condition and why a certain formula should be used—along with whether it's age-appropriate, as different parts of life require different nutrients, Dr. Heyman says—is key to selecting one with the correct nutrient breakdowns.

Consideration #4: Tolerance and Personal Preference

There's also the question of how well your child tolerates the formula, Dr. Suskind says. "There needs to be a dialogue," he says. "If a formula is not tolerated, then we need to figure out why. If it's the formula itself, then it's about trying to find another that's more appropriate for that patient."

Sometimes parents also have preferences around which formulas they're willing to give their child. Whole food and plant-based formulas are rising in popularity, for instance, as they're typically less processed and can be easier on the GI tract (though they can also be more expensive and not covered by health insurance).

But not all formulas are created equal, so regardless of preference, Dr. Heyman says it's important to make sure the formula is nutritionally complete and contains all the appropriate macro and micronutrients that a child needs to thrive.

Keep talking to your medical team about what works best for you and your family. After all, a formula is no good if your child isn't going to consume it regularly.

Consideration #5: Cost

The unfortunate reality of tube-feeding formulas is that, depending on which one is used and its insurance coverage, it can get quite expensive.

According to the Feeding Tube Awareness Foundation (FTAF), Medicaid must cover enteral formula if it's medically necessary, but that same mandate for private insurance doesn't currently exist. And while nearly half of U.S. states have laws or statutes in place that require coverage, FTAF says some of those laws are written more broadly than others, which could create loopholes for what's covered and what's not.

What's more: Self-funded insurance plans—like the ones midsize or large companies often offer—don't necessarily have to follow these state laws (though most do), FTAF says.

Bottom line: Make sure the tube-feeding formula your medical team selects is something you can afford, Dr. Suskind says.

Cost is one reason your child's nutritionist may start your child on a standard formula first, assuming there are no medical concerns. A case study on long-term tube feeding from Dietitians on Demand noted specialty formulas are often significantly more expensive, and are less likely to be covered by insurance.

Regardless, cost is another reason to maintain an open dialogue with your child's medical team. If it becomes too expensive, there may be other, more affordable options your child can try.

This story has been medically reviewed by Stan Cohen, M.D., a pediatric gastroenterologist at the Children's Center for Digestive Health Care in Atlanta and the director of Nutrtion4Kids Medical Advisory Board.