Feeding 2: Enteral feeding

Chapter 40 Feeding 2


Enteral feeding



Christopher Bunford



CHAPTER CONTENTS


Introduction 388
Learning outcomes 388

Rationale 388

Factors to note 388

Guidelines 392

Passing a nasogastric (NG) tube 392
Equipment 392

Method 392

Feeding via a nasogastric or gastrostomy tube 395
Equipment 395

Method 396

Observations and complications 397

Dos and don’ts 399


INTRODUCTION


Enteral feeding is an artificial method of supplying the child with nutrition via a nasogastric tube or gastrostomy.



LEARNING OUTCOMES


By the end of this section you should be able to:


• Identify some typical situations in which a child may require enteral feeding

• Describe the techniques of providing enteral nutrition and hydration to the child who is unable to feed orally

• Understand the possible risks and side-effects associated with some feeding techniques.


RATIONALE


A children’s nurse should be able to undertake enteral feeding, teach children and their families the different techniques and be aware of possible positive and negative effects of enteral feeding.



FACTORS TO NOTE


See also Factors to note in Feeding 1 (Ch. 39).


Hambridge et al (1995) give reasons why some children are unable to feed orally:


• The child has cancer and the treatment causes anorexia and vomiting

• The child is unable to take in sufficient nutrition for growth and development in an acute or chronic illness, e.g. severe bronchiolitis, gross reflux, renal failure or liver disease, particularly when the child has increased calorific and nutrient requirements

• The child is unable to absorb the food, e.g. short bowel syndrome and severe, acute diarrhoea

• The premature infant may not yet have developed a swallowing reflex.

These children can be fed enterally via nasogastric (NG) tube or gastrostomy.


The multidisciplinary team is essential when a sick child has special dietary requirements:


• A children’s dietitian and/or paediatrician may be required to prescribe a feed or extra calories (Maxijul) or additives, e.g. a thickening agent (Nestergel and Thixo D).

• A doctor may need to prescribe drugs, e.g. anti-reflux treatment, electrolyte supplements or intestinal motility regulators (domperidone, loperamide, ranitidine and omeprazole).

• Nutritional care nurse specialists may be available in some hospitals to help advise on practical aspects of feeding children.

• It is essential that a speech therapist conducts an assessment of the child’s oral motor function if long-term NG feeding is required, and is a source of valuable advice with regard to the child’s developmental needs associated with feeding (Langley 1994, NHS QIS 2007).

• Testing for acidity of gastric secretions to ensure correct positioning is essential to ensure safety. The pH of gastric secretions should be between 0–5 (NHS QIS 2007, Medical Devices Agency 2004, NPSA 2005).

• The use of pH indicator paper in neonates has been questioned by practitioners as their gastric secretions may not be sufficiently acidic to entail a change. Similarly, gastric acid pH response may be altered when infants/children are taking antacids. In these children, the pH reference range for testing with pH paper may be altered. Refer to local guidelines regarding type of pH paper and acceptable readings (Nutritional Care 2004, NPSA 2005). If there is any doubt that the tube may not be correctly positioned, it should not be used until its correct position in the stomach has been confirmed by senior nursing/medical staff.

• It used to be common practice to check the position of a NG tube by listening with a stethoscope for the sound of air injected into the stomach via the NG tube. Research has shown this to be an inaccurate and dangerous practice and should no longer be used (Hendry et al 1986, Metheny et al 1990, NPSA 2005).


Nasogastric tubes


There are two main types of NG tube commonly used. (1) Short-term tubes, which can be used for up to 7 days and (2) long-term tubes, which can last up to 30 days (refer to manufacturer’s guidelines). The tubes are sized according to the width of their internal lumen; 6, 8 and very occasionally 10 French gauge (Fg) are most commonly used in children. If a thickening agent has been added to the child’s feed, the small 6 Fg diameter tube may be too narrow to facilitate instillation of the feed. Tubes can come in various lengths which range from 50–85 cm in both short term and long term tubes. The length used will depend on how big the child is. The tube must be long enough to cover the length from the outer edge of the child’s face, through the nasopharynx and down into the stomach (Fig. 40.1). Short-term tubes should be changed every 5–7 days and long-term tubes monthly, to prevent increased risk of bacterial contamination and the material of the tube being eroded by gastric secretions (Taylor & Goodison-McLaren 1992, Skipper et al 2003).


image

Figure 40.1 The length and position of a nasogastric tube in situ.


Gastrostomy tubes are made of silicone. There are three main types: skin-level ‘button’, percutaneous endoscopic tubes and surgically placed tubes. The skin around a gastrostomy site should be washed daily to prevent the skin around the site becoming sore (Coldicutt 1994). Frequency and timing of tube changes vary according to the device used and the child’s condition.


The gastrostomy button is a device in which the exterior of the tube sits flush with the skin and, when not in use, resembles a button on the surface of the skin (Fig. 40.2). It is usually changed once every 3–6 months. However, in some areas, when the gastrostomy tract has been formed via a Stamm procedure (full surgical procedure), tubes are placed directly.


image image image

Figure 40.2 Types of gastrostomy tube: (A) Skin-level ‘button’ or ‘key’ device; sits a coin’s depth (2 mm) above the skin. (B) Percutaneous endoscopic tube; disc/crossbar to prevent tube becoming dislodged and migration of tube past stomach into duodenum. (C) Surgically placed tube, e.g. Foley catheter; held in place by suture depending on type of tube and surgeon’s preference.


The percutaneous endoscopic tube (PEG) is a gastrostomy tube that is inserted through the skin into the stomach under endoscopic control, therefore avoiding the need for a full, laparoscopic surgical procedure (Booth 1991). It can stay in situ usually for up to 2 years.


A surgically placed tube is usually much shorter term in use and should only be changed by a surgeon or nurse who has received training in the procedure. If it becomes displaced in the first 2 weeks postoperatively, before the tract has properly formed, it must be re-inserted as a matter of urgency or the skin and tissues will close over. Gastrostomy tubes are most commonly sized between 9 and 15 Fg, although smaller or larger tubes may be used in small babies or older children (Bowling 2003).



Research-based practice relating to the risks of enteral feeding


Research has highlighted the risks of nasogastric feeding, in particular the risk of aspiration of feed because of misplaced tubes, blocked tubes, infection transmission and the excessive vacuum pressure caused by using smaller-volume syringes (Taylor & Goodison-McLaren 1992, Lord 1997, Anderton & Nivgough 1991, Skipper et al 2003).



Maintaining patency of nasogastric and gastrostomy tubes


NG and gastrostomy tubes must be flushed before and after a feed. During continuous feeding, or when not in use, NG tubes should be flushed regularly to maintain patency, e.g. every 4 h during the daytime (Lifshitz et al 1991, Paul et al 1993).



Preventing infection transmission via enteral feeding


Whenever an NG or gastrostomy tube is flushed, it should be done with cooled, boiled water, or Tap, depending on the age and condition of the child (Coldicutt 1994, Anderton 1995, Paul et al 1994, Skipper et al 2003). In addition, feeds should be prepared only on surfaces which have been cleaned thoroughly with soap and water, dried and then wiped with 70% isopropyl alcohol-impregnated wipes (Anderton & Nivgough 1991). Any feed delivery systems should be single-use only, and feed containers (the visible external part of NG and gastrostomy tubes) should also be cleaned with alcohol-impregnated wipes prior to use (Paul et al 1994, Anderton 1995, Skipper et al 2003).



Size of enteral syringe used when administering feed/flush via nasogastric tube


A long-term tube is softer and more prone to damage. The smaller the syringe, the smaller is the bore (the hole in the middle) and the greater the pressure created when injecting with it; 1–5 mL syringes produce the highest pressure for a given force. Using a larger-sized syringe – 50 or 100 mL – reduces the pressure on the tube, thus minimising the risk of damage (Taylor & Goodison-McLaren 1992, Paul et al 1993, Sidey 1995).



GUIDELINES


Parents and older children should be encouraged to be involved with enteral feeding. This can include being involved in or even being trained to pass the NG or gastrostomy tube if they so wish. Involvement can help them to feel in control of the procedure and help their acceptance of the problem (Holden et al 1997).



PASSING A NASOGASTRIC (NG) TUBE



EQUIPMENT



• Plastic apron

• Disposable latex-free gloves

• Cooled, boiled water or sterile water for flushing tube

• Two sterile gallipots

• pH paper/strips capable of indicating an acid range of pH 0–5 (Metheney et al 1993)

• Two syringes – 5/10 mL for short-term NG tube or 50/60 mL for long-term NG tube (Lord 1997, Skipper et al 2003)

• 70% isopropyl alcohol-impregnated wipes

• Tape to secure the tube to the child’s cheek (check that the child is not allergic to the tape)

• Scissors

• If the child has especially sensitive skin, you may need a hydrocolloid dressing such as extra-thin Granuflex to provide a protective layer between the child’s skin and the adhesive tape holding the tube in place

• Dummy if the child uses it

• Drink of water if the child is older.


METHOD


Note: Generally, two people are needed to pass a NG tube; one to comfort and support the child and one to pass the tube.


1. Wherever possible, the child and family should have had psychological preparation to reduce the distress caused by the procedure (Holden et al 1997).

2. Wash hands thoroughly, dry them and put on a plastic apron to prevent cross-infection (Anderton 1995).

3. Clean the work surface/trolley on which equipment is to be placed as local policy, and wipe with alcohol (Anderton 1995). Allow alcohol to dry (it sterilises as it dries).

4. If using a hydrocolloid dressing, cut a piece and place it within easy reach. It should be wide enough to be at least three times the diameter of the NG tube and long enough to cover at least two-thirds of the child’s cheek from the side of the nostril towards the ear (Fig. 40.3). Normally, a piece 1.5 × 5 cm would be adequate for most children except for a very tiny neonate who would need less.

5. Cut a piece of adhesive tape and place it in easy reach. It should be wide enough to cover the NG tube with overlap at each side sufficient to hold it securely in place, and long enough to secure at least 3 cm of tube. If a hydrocolloid dressing is used, the adhesive tape should not extend beyond the boundary of the hydrocolloid.

6. Draw up 2–5 mL of the water into one of the syringes. Place on one side, in easy reach.

7. Put approximately 10 mL of water into a gallipot in easy reach.

8. Open up the second syringe and place it in easy reach.

9. Take a strip of pH paper/strip and place it in the second gallipot.

10. Wash hands thoroughly, dry them and put on disposable gloves to prevent bacterial contamination of the tube (Anderton 1995).

11. Take the NG tube out of its sterile packaging. Ensure that it is not damaged in any way. If the tube has a guide wire, check that the wire is not bent and is correctly inserted down the middle of the tube. Measure what length of tube is to be passed. With the fingers of your dominant hand, hold the distal end of the tube (the end which will sit in the stomach) by the child’s nostril. Measure the first length of tubing from the nostril to the edge of the cheek, by the ear (Fig. 40.4A). Then, measure the second length of tubing from the edge of the ear down to the child’s stomach and then two fingers below the xiphoid process (Fig. 40.4B). Mark this point on the tube by using a piece of surgical tape or a permanent marker pen (Nutritional Care 2004). Some tubes have black markings on the tubing at 10 cm intervals to give you a visual guide as to what length of tubing needs to be passed.

12. Ask the person assisting to position the child so that you can access the nostril. An older child should be encouraged to sit upright.

13. Maintain your hold on the proximal end of the tube (the end of which will remain on the exterior) at the end of the pre-measured length. Lubricate the distal end of the NG tube by dipping it in the gallipot containing water.

14. Gently pass the distal end of the tube into the child’s nostril. Angle it slightly upwards and gently guide it over the back of the nose and into the nasopharynx.

15. Continue to pass the tube downwards. As it gets to the back of the throat, the child will gag. To ease the passage of the tube, encourage a baby to suck on a dummy and try to persuade an older child to have a sip of water. Advance the tube as the child swallows. This will help ease discomfort and reduce the risk of the tube passing into the trachea, as the epiglottis will cover the trachea when swallowing.

16. Continue to advance the tube. You may have to pause in order for the tube to pass through the cardiac sphincter into the stomach. When the place you have marked on the tube is at the opening of the child’s nostril, the distal end should now be in the stomach.

17. Ask the person comforting the child, or the child personally, to place two fingers against the tube to prevent it slipping.

18. Check that the NG tube is in the correct position.

19. Connect a syringe 5/10 mL or 50/60 mL depending on type of tube and manufacturer’s guidelines to the end of the NG tube and withdraw the plunger until fluid appears in the syringe – only a very small amount (0.5–1 mL) of fluid is required. Disconnect the syringe and close off the end of the tube.

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Mar 7, 2017 | Posted by in NURSING | Comments Off on Feeding 2: Enteral feeding

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