INTRODUCTION Enteral feeding is defined as the administration of nutrients directly into the gastrointestinal (GI) tract. If the patient is unable to meet his/her nutritional requirements with oral diet/nutritional supplements, then enteral feeding is indicated. If the gastrointestinal tract is functional, enteral feeding is the optimal method of nutritional support. Indications for Enteral Feeding: anorexia associated with illness chewing or swallowing disorders acute metabolic states (e.g. trauma, burns) failure to thrive inflammatory bowel diseases (e.g. Crohn's disease) neuromuscular handicaps (e.g. cerebral palsy) prematurity Short Bowel Syndrome with adequate absorptive capacity head injury, coma metabolic disorders where overnight catabolism must be avoided metabolic or endocrine disorders where continuous feeding is needed to maintain glucose homeostasis Contraindications to enteral feeding: necrotizing enterocolitis bowel obstruction or ileus hemodynamic instability Short Bowel Syndrome with insufficient absorptive capacity Possible contraindications that should be evaluated on an individual basis: persistent vomiting and diarrhea acute abdominal distention gastric, small- or large-bowel fistula upper gastrointestinal bleeding severe mucositis Types of Enteral Feeding Tubes and Feeding Schedules: Nasogastric (NG): continuous, intermittent (bolus) or combination Nasojejunal (NJ): continuous only Gastrostomy (G-tube): continuous, intermittent (bolus) or combination Jejunostomy (J-tube) or Gastrojejunal/Transgastric Jejunal (GJ-tube): continuous only Bolus feeds should not be given through a jejunostomy tube as the diameter of the small bowel will not tolerate the volume and can lead to diarrhea. GUIDELINES 1. Use aseptic technique when preparing or administering enteral feeds or handling the feeding tube/system: a. Perform hand hygiene, using soap and water or alcohol-based hand rub before and after handling formula/breast milk, feeding tube or feeding system. b. Wipe surface area used for setting up feeds with disinfectant wipes. c. Maintain aseptic technique and contact precautions throughout set-up or when adding Rationale Many clinical investigations have linked GI colonization by microbes from contaminated tube feedings to the development of infection and sepsis. Contamination of enteral nutrition formula with microorganisms can occur at any point throughout the production, preparation, storage, or administration process. Hospital-acquired infections associated with contaminated substances occur predominantly in patient care areas, especially when basic hygiene CC.12.10 BC Children s Hospital Child & Youth Health Policy and Procedure Manual Page 1 of 6
formula/breast milk to container. d. Wipe can lid with alcohol/chg swab and allow it to dry before opening and then pour formula into feed container. e. Use disposable gloves when handling human breast milk (body fluid precautions). f. Clean the hub of the feeding tube with alcohol/chg swab when accessing tube. g. Do not allow any part of the delivery system and formula/breast milk to come into contact with hands, skin, clothes or any other nondisinfected surface (i.e. sink, patient bed). h. Keep reconstituted formulas or opened formula containers covered and refrigerated and discard them within 24 hours if not used. Store expressed breast milk (EBM) as per EBM: safe handling, storage, administration and transport guideline on document management system. i. Minimize the number of times a prepared bottle of formula is accessed. 2. Formula/breast milk hang times: Maximum feeding volume to be hung is that required for the hang time indicated. Empty bag before adding more formula. (e.g. for sterile formula at a rate of 40 ml/hr, hang time is 8 hours, so can add up to 320 ml formula to the container). Sterile formula in an open system for neonates and immunocompromised or critically ill patients Powdered reconstituted formula Formula with additives 4 hours 8 hours 12 hours Sterile formula Sterile formula in an open in an open system in system at hospital home (Not applicable to the NICU) measures are not followed. Setting up and manipulating the enteral nutrition feeding systems in patient care areas account for much of the contamination with potential pathogens. Performing hand hygiene and maintaining aseptic technique during setup and delivery of feeds helps maintain microbial quality of tube feeding during hang time. For enteral nutrition formulas not used immediately after preparation, refrigeration may reduce bacterial growth potential. The handling and portioning of formula increases the risk of contamination. When possible, order a volume of formula that is a single feed or hang time volume. In circumstances when this is not possible (metabolic, ketogenic or some renal formulas) ensure formula is portioned using aseptic techniques with clean workspace, clean hands, etc. Research has looked at contamination of enteral nutrition formulas along a continuum of time, with longer hang times being associated with increasing and unacceptable levels of bacteria. It is not possible to commercially sterilize powdered formulas so to reduce bacterial contamination and growth of micro-organisms; they should be reconstituted with sterile water and hung for maximum of 4 hours. Human breast milk (HBM) is not sterile. A sterile formula would be any Ready to Feed infant or enteral formula. Any formula prepared or modified by formula room, or any formula containing breast milk is not sterile. Human breast milk (HBM) 3. Feeding container changes: feeding bags or Studies have concluded that enteral feeding sets used syringes: for more than 24 hours in hospitalized patients result in a. In the NICU change feeding containers/sets unacceptably high levels of bacteria. every 4 hours and discard other items (e.g. syringes, sterile water) used for feeding after 24 hours. b. Pediatric patients: Change sets used for HBM every 4 hours. CC.12.10 BC Children s Hospital Child & Youth Health Policy and Procedure Manual Page 2 of 6
c. Change sets used for other enteral feedings at least every 24 hours. d. Discard any other items used for feeding (e.g. sterile water bottles, flush syringes, containers) after 24 hours. 4. Bag rinsing: a. Not recommended for NICU patients. b. Not recommended for continuous feeds. Every 4 or 8 hours (depending on recommended hang times as per above) empty container and "topup" with fresh formula using aseptic technique. c. Rinse bag following intermittent feeds with warm running tap water to clean bag and tubing and follow with cold water rinse. Use sterile water for neonates, infants under 1 year and critically ill and immunocompromised patients. d. Allow bag to drain and hang to dry away from sinks. Do not let the tubing or bag drop or hang touching into the sink, garbage container, floor, or any other unclean area. Cover tubing end with clean cap and hang set at patient bedside or other designated clean supply area. 5. Tubing flushes: a. Flush feeding tube during continuous feeds every 4 hours and before/after each intermittent feed and medication administration. b. Use sterile water for neonates, infants under 1 year of age and in critically ill or immunocompromised patients. Clean, running tap water may be used for all other patients. c. Use 3-5 ml water in infants and children and 5-10 ml in adolescents or with an appropriate volume to clear tube. 7-10 ml (for infants and children) and 10-15 ml (for adolescents) is recommended when flushing J-tubes due to their larger bore and longer length. d. Flush tube using a brisk technique, with a 30-60 ml syringe. Change the syringe every 24 hours. e. Do not use distilled water, cranberry juice or carbonated beverages to flush tubes. 6. Medication Administration: a. Confirm tube placement before administering medications via the nasoenteric route. b. Do not add medications directly to an enteral feeding formula if medications are ordered to be added, consult with pharmacist for compatibility information. If medication to be added, use aseptic technique to add medication to formula. The value of rinsing emptied containers with water before adding a fresh supply of formula is questionable because it is impossible to clean them sufficiently for reuse. Sterile water is recommended for use in the hospital environment as there is less chance of potential introduction of pathogens from tap water that may be harmless to most people, but possibly harmful to those at risk. Routine flushing of feeding tubes helps prevent occlusions and retrograde contamination from microbes ascending through the feeding tube from the patient. Administration of distilled water into the intestine may injure the intestinal epithelium. Sterile water or tap water have been found to be superior to both cranberry juice and carbonated beverages in maintaining tube patency. Cranberry juice and carbonated beverages are acidic and may actually contribute to tube occlusion by denaturing proteins in the enteral formulas. Adding medications directly to the enteral nutrition formula or combining medications requires knowledge of the drug's compatibility with the formula or with the other drug(s), and the stability of each component of the final formula. Dilution of each medication prior to administration is associated with improved delivery of the drug dose to the distal end of the tube. CC.12.10 BC Children s Hospital Child & Youth Health Policy and Procedure Manual Page 3 of 6
c. Do not mix medications together. Flushing the feeding tube between medications d. Use liquid forms of drugs whenever possible. If decreases the incidence of tube occlusions. a drug must be crushed, make sure it's crushed finely and dispersed well in water. Do not crush enteric-coated, sustained-release, or timerelease tablets or capsules. If you're unsure whether a drug may be crushed, check with the pharmacist. e. Dilute medications as needed with an appropriate liquid. f. Flush the feeding tube between medications with appropriate volume as in #5 above. g. Only use sterile water to flush tube before/after medication administration (metals in tap water may interact with the large surface area of crushed medications ingredients and reduce bioavailability). h. Hold feeding as per drug dosage handbook when separation is indicated to avoid altered drug bioavailability (e.g. phenytoin, theophylline, biphosphonates, and ciprofloxacin). Consult with pharmacist if unsure. i. Use only enteral/oral or catheter tip syringes. 7. Patient positioning: a. Neonates & Infants less than 1 year corrected age are to be positioned with the head of bed (H.O.B) flat unless medically contraindicated or otherwise ordered. b. Pediatric patients are to have the H.O.B elevated 30-45 unless medically contraindicated (unstable spine, hemodynamic instability, prone positioning, and during certain medical procedures such as central line insertion, lumbar puncture, etc.). c. Use reverse Trendelenburg position to elevate HOB when patient cannot tolerate a backrest elevated position. d. If necessary to lower the HOB for a procedure, return patient to an elevated position as soon as feasible. 8. Do not routinely check Gastric Residuals to assess tolerance to feeds. 9. Monitoring for tolerance: Once enteral nutrition support has been initiated, close monitoring of tolerance is essential. There are several criteria that can help assess tolerance including: It is recommended to place infants supine with the HOB flat after feeds. When infants display gastroesophageal reflux (GER) symptoms, elevating the HOB makes no difference. It is recommended to place infants prone or left side-lying after feeding, with a doctor s order, while cardio-respiratory monitoring is attached when GER is a concern. Infants preparing for discharge, should be transitioned to supine with HOB flat to demonstrate safe sleeping practices and prepare for home. As per American Society for Parenteral and Enteral Nutrition guidelines pediatric patients should have HOB elevated as it prevents gastroesophageal reflux, aspiration and pneumonia. Gastric Residual Volume is not correlated with gastrointestinal motility, feed tolerance (as measured by abdominal distention, vomiting, or weight gain), and risk of aspiration. Clinical signs of feeding intolerance include coughing, abdominal distention or pain, signs of discomfort, restlessness, vomiting and diarrhea. If any of these signs are observed, STOP the feed and assess the CC.12.10 BC Children s Hospital Child & Youth Health Policy and Procedure Manual Page 4 of 6
Aspiration Nausea and vomiting Abdominal distention Anthropometrics Fluid and electrolyte imbalance Gastrointestinal bleeding Constipation and diarrhea There are some criteria that are not evidence-based nor accurate methods of assessing tolerance to feeds including: Bowel sounds Gastric residual volumes Abdominal girth 10. Enteral Misconnections - Safety Precautions: Use only pumps that are specifically designated as enteral feeding pumps. Use tubing that is specifically designed to connect to enteral feeding tubes - DO NOT modify or adapt non-enteral devices to fit. Use oral/enteral syringes or catheter tip syringes to access the enteral feeding tube. DO NOT use parenteral syringes as these are intended solely for IV connections. When initiating a feed or delivering a medication always perform a site to source check to ensure correct line is being used. When arriving at a new setting or as part of a hand-off process, recheck connections and trace all tubes. REFERENCES patient's status, tube placement, rate and method of delivery, strength and choice of formula. Also review medications patient is taking as some can affect feeding tolerance. Enteral misconnections are inadvertent connections between an enteral feeding system and a non-enteral system such as an IV catheter, peritoneal dialysis catheter, tracheostomy, medical gas tubing, etc. In each case, serious patient harm, including death, can occur if fluid, medication, or nutritional formula intended for administration into the GI tract, are administered via the wrong route. American Dietetic Association. Infant Feeding: Guidelines for Preparation of Formula and Breast Milk in Health Care Facilities. Second Edition. Chicago: American Dietetic Association 2011. ASPEN Enteral Nutrition Practice Recommendations Task Force. (2009) Enteral Nutrition Practice Recommendations. Journal of Parenteral and Enteral Nutrition. 33(2):122-167. Retrieved April 26, 2013 from http://pen.sagepub.com/content/early/2009/01/27/0148607108330314.full.pdf. Beckwith, M.C., Feddema, S.S., Barton, R.G. and Graves, C. (2004). A Guide to Drug Therapy in Patients with Enteral Feeding Tubes: Dosage Form Selection and Administration Methods. Hospital Pharmacy. 39(3):225 237. Best, C. (2008). Enteral tube feeding and infection control: how safe is our practice? British Journal of Nursing, 17(16):1036-1041. Best, C and Wilson, N. (2011). Advice on Safe Administration of Medications via Enteral Feeding Tubes. Nutrition Supplement: S6-S10. Boullata, J.I. (2009). Drug Administration Through an Enteral Feeding Tube. American Journal of Nursing, 109(10):34-42. Joint Commission Sentinel Event Alert. Tubing Misconnections - a Persistent and Potentially Deadly Occurrence, Issue 36, April 3, 2006. Accessed April 26, 2013 from CC.12.10 BC Children s Hospital Child & Youth Health Policy and Procedure Manual Page 5 of 6
http://www.jointcommission.org/sentinel_event_alert_issue_36_tubing_misconnections a_persistent_and_potentially_deadly_occurrence/. Knox, T. and Davie, J. (2009). Nasogastric Tube Feeding -- which syringe size produces lower pressure and is safest to use? Nursing Times, 105(27). Mathus-Vliegen, E.M.H., Bredius, M.W.J. and Binnekade, J.M. (2006). Analysis of Sites of Bacterial Contamination in an Enteral Feeding System. Journal of Parenteral and Enteral Nutrition,30(6):519-525. Robbins, ST and Meyers, R. American Dietetic Association Pediatric Nutrition Practice Group. Infant Feedings: Guidelines for Preparation of Human milk and Formula in Health Care Facilities. 2 nd ed. Chicago. 2011. Vandenplas, Y., Rudolph, C. D., Di Lorenzo, C., Hassall, E., Liptak, G., Mazur, L., & Wenzl, T. G. (2009). Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). Journal of pediatric gastroenterology and nutrition, 49(4), 498-547. Williams, N.T. (2008). Medication Administration through Enteral Feeding Tubes. American Journal of Health- System Pharmacy, 65(24): 2347-57. CC.12.10 BC Children s Hospital Child & Youth Health Policy and Procedure Manual Page 6 of 6