Perspectives on Nasogastric Tube (NGT) Feeding in Eating Disorder Treatment: A Q&A With the Hidden River Team

In the Q&A below, members of Hidden River’s multidisciplinary team share their perspectives on when nasogastric tube (NGT) feeding may be considered, what patients and families can expect throughout the process, and how NGT feeding can support nutritional rehabilitation and comprehensive eating disorder treatment.

When might NFT feeding be considered in eating disorder treatment?

Jason Minion, MD, Medical Director: Primarily, the patient must not be eating sufficiently and consistently and must not improve with other interventions. We will first work with the patient to encourage better meal plan completion using a variety of coping skills. Next, we will have them have meals in a one-on-one setting with staff who can more directly explore the thoughts and emotions that come up and maybe even go bite-for-bite with them. 

When these are ineffective, an NGT becomes our next tool for providing a baseline level of medically sufficient nutrition. Often, these patients will show signs of medical instability from malnutrition, but sometimes, they don’t, and instead, it’s the duration of insufficient eating that we look for. 

Holly Greenburg, RD, CEDS & Kaeley Maltez, RD, CEDS: To initiate nasogastric feedings, the patient must demonstrate the inability to consume an adequate caloric intake orally to the point where it has negatively impacted their weight and their vital signs. Nasogastric tube feedings are administered to support both weight restoration and medical stability. 

James “Buck” Runyan, MS, LMFT, LPC, CEDSS, Executive Director: Another important consideration is whether psychological resistance to oral intake is interfering with a patient’s ability to restore adequate nutrition. Fear, shame, and a desire to maintain control can make meeting nutritional needs by mouth extraordinarily difficult, even when a patient understands the importance of weight restoration.

In these circumstances, NGT feeding can provide additional nutritional support while the patient continues working therapeutically toward more consistent oral intake.

How does the treatment team prepare a patient and family for NGT feeding?

Stacie Rokosny, RN, Nursing Director: A multidisciplinary approach is used to prepare patients and families for NGT feeding, typically involving the patient’s primary therapist, psychiatrist, and nurse on duty. Patients are informed in person about the intervention, while family members may be included by phone when needed.

Lynn Corey, LCSW, CEDSS, Clinical Director: Following discussions with the medical team about NGT feeding, the therapist provides additional support to the patient and family. This may include processing new information of NGT use, uncomfortable emotional responses, addressing psychological distress and body image concerns, and answering questions to promote a supportive engagement with the intervention.

Holly Greenburg RD, CEDS & Kaeley Maltez RD, CEDS: The Registered Dietitian may keep the patient’s identified support system, whether parents, a partner, a close friend, or another support person, informed about the NGT so they understand the purpose of its use and the intended goals and are aware of how to provide additional support. For adult patients, parental consent is not required.

What happens when an NGT is placed, and how is it monitored?

Jason Minion, MD, Medical Director: Before an NGT is placed, signed informed consent is obtained and witnessed to ensure the patient — or guardian, if the patient is a minor — understands the process and rationale. A physician’s order is then entered, and I coordinate with the nursing team to make sure everything is prepared for placement.

Stacie Rokosny, RN, Nursing Director: A Hidden River Registered Nurse places the NGT under physician supervision. Once the tube is in place, nursing staff are responsible for checking it every shift for placement and it remains open and unobstructed. The nursing team will also maintain the set-up of the NGT pumps and monitor feedings.

How is an NGT used as part of a patient’s overall nutrition plan?

Holly Greenburg RD, CEDS & Kaeley Maltez RD, CEDS: The NGT feedings typically are administered overnight, to not act as a barrier towards meal plan completion during the day. The NGT will remain in place but not be utilized during the day unless the Registered Dietitian deems daytime feedings to be more appropriate for that patient. 

Stacie Rokosny, RN, Nursing Director: During mealtime, the patient receives support from peers and Recovery Assistants to do their best even though it is difficult. Even if they have an NGT, patients are encouraged to complete the portion of their meal plan provided at the table.  

How does the team support the emotional experience of NGT feeding?

Lynn Corey, LCSW, CEDSS, Clinical Director: Prior to and following NGT placement, therapists use individual sessions to process the patient’s thoughts and emotions related to the intervention. This may include exploring themes such as perceived failure, loss of control, body image, uncomfortable emotions, social stigmas, family dynamics, or other conflictual interpretations. Therapists will validate and normalize ambivalence toward the intervention without reinforcing eating disorder-related cognitions, while also helping the patient identify personal goals for recovery and continued engagement in treatment.

James “Buck” Runyan, MS, LMFT, LPC, CEDS-S, Executive Director: At Hidden River, NGT feeding is approached with empathy, respect, and compassion. Importantly, participation is entirely voluntary, reflecting a commitment to respecting patient autonomy while providing the medical support needed for recovery.

Stacie Rokosny, RN, Nursing Director: The nursing team aims to provide the patient with emotional support before, during, and after the placement of the NGT. The patient is reassured that the NGT is meant to be used as a tool to aid in their continued recovery and that it is not a punishment or to be viewed as a failure. The patient is reminded that the NGT is meant to be a short-term intervention to assist in their meal plan completion while it may feel too overwhelming to complete a large quantity of food orally. 

How does the team determine when a patient is ready to transition away from the NGT?

Holly Greenburg RD, CEDS & Kaeley Maltez RD, CEDS: As patients demonstrate an ability to complete meals and snacks orally, the amount of food prescribed by mouth gradually increases while decreasing the amount of nutrition provided through the NGT. Once a patient is completing their meal plan adequately or is within their target weight range, NGT nutrition can continue to be reduced until the patient is receiving nutrition entirely by mouth. After demonstrating the ability to complete their meal plan orally for two to three days, the NGT may be removed.

Lynn Corey, LCSW, CEDSS, Clinical Director: The process of preparing a patient to discontinue NGT use may vary depending on individual presentation and clinical needs. Some patients may experience relief or excitement, while others may perceive themselves as betraying their eating disorder or no longer the “sickest” person in residential care or “sick enough” to need further treatment. Therapists support patients in processing these thoughts and difficult emotions while continuing to emphasize treatment goals, personal motivators, and the ongoing use of recovery focused coping skills.

What are the potential risks or challenges associated with NGT feeding?

Jason Minion, MD, Medical Director: There is a very small risk of the tube entering the lungs during placement. Before the supplement is administered through the tube, a chest X-ray to confirm that it is properly positioned within the stomach is obtained. There may also be some nasal bleeding or irritation following placement. These typically resolve quickly.

Once the tube is in use, patients may experience increased gastrointestinal discomfort or fullness in the mornings because feedings are typically provided overnight. Our team is always cognizant of the risk of refeeding syndrome particularly, when a patient has received very little nutrition for a significant period of time. When a patient begins taking in more calories than their body is accustomed to process, there may be some adverse symptoms that occur. With significant medical monitoring by the nurses and dietitians, adverse effects are promptly identified and addressed medically with NGT feeding.

Lynn Corey, LCSW, CEDSS, Clinical Director:  Potential clinical challenges may include cognitive withdrawal or uncomfortable emotional tension, which can promote resistance to the prescribed meal plan. The clinical team remains attentive to these responses and works with patients to address them as part of the ongoing therapeutic process.

What have been the outcomes of Hidden River’s NGT program? 

Jason Minion, MD, Medical Director: The NGT program has been very successful. For some patients, the medical recommendation for an NGT has served as their motivation to increase their meal completion and remain consistent with it while avoiding an NGT placement. For patients who have selected to receive the nutritional support of an NGT, it has allowed them to remain in Hidden River’s peaceful environment for consistency of treatment rather than interrupting their care with a hospital stay.

Patients have been able to medically stabilize in our setting and gradually transition into successfully managing their nutritional requirements. Even patients who arrived 100 percent dependent on the NGT for caloric intake for many weeks and some for several months, before coming to Hidden River, have courageously returned to autonomously managing their nutrition requirements orally. When this transition occurs, patients often become hopeful and learn that they can actually recover from their eating disorder.

James “Buck” Runyan, MS, LMFT, LPC, CEDS-S, Executive Director: The NGT program available at Hidden River through the expert care of our well-trained medical, nursing, clinical, and dietary team helps appropriate patients who seriously struggle to consume their necessary nutritional requirements to continue their therapy while receiving the additional support needed for medical stabilization. The benefit of remaining in the nurturing environment of Hidden River, without requiring a medical transfer to a higher level of care at another facility, allows the patient to have daily ongoing conversations with our highly skilled multidisciplinary team of providers in real time. With the success of the NGT program at Hidden River, other providers, including those of a higher level of care, commonly refer patients to our care who already have an NGT in place when they are not making progress to autonomous oral meal consumption. Hidden River has supported patients who arrive receiving 100% of their nutrition through an NGT who successfully transition into becoming fully autonomous with managing their daily nutritional requirements orally. 

The multidisciplinary treatment team finds great reward supporting the development of the patients’ physical and psychological restoration. When the day arrives for the patient to step from Hidden River into the next recommended level of care, the multidisciplinary team, current patients, and departing patient hold a congratulatory ceremony which often has many tears of joy celebrating her success while reinforcing her journey into recovery along with her developing strong hope of a bright future. 

Thank you to the following Hidden River team members for sharing their expertise and perspectives for this Q&A!

Medical: Jason Minion, MD, Medical Director
Nursing: Stacie Rokosny, RN; Beth Heath, RN; Julie Ryan, RN; Kayley Santos, RN
Nutrition: Holly Greenberg, MS, RDN, CEDS; Kaeley Maltez, MS, RDN, LMT, CEDS
Therapy: Lynn Corey, LCSW, CEDSS, Alexis Harper, LCSW, CEDS; Gabrielle Andolino, LPC, CEDS; Kelly Plue, LCSW; Paige Sklar, LCSW; Cara Becker, LAC; Fredelyne Lebrun, LAMFT
Leadership: James “Buck” Runyan, MS, LMFT, LPC, CEDSS, Executive Director