Feeding, Enteral

CLINICAL GUIDELINES

Enteral feeding may be administered by a registered nurse (RN), licensed practical nurse (LPN), physician, or appropriately trained child or family member.
A healthcare prescriber must order enteral tube feeding.
Enteral feedings may be given by a number of routes, including nasogastric or orogastric tube placement, gastrostomy tube, PEG, skin-level G-tube devices (e.g., MIC-KEY®, BARD® button), jejunal tube, or transpyloric tubes (G-J tube, skin-level G-J tube).
Enteral feedings are indicated for children who are unable to ingest an adequate amount of nutrition orally. This may include children who are unconscious, ventilated, transitioning from parenteral nutrition, are unable to swallow, or have primary aspiration.
Children who are comatose, are neurologically delayed, or otherwise have a decreased cough and gag reflex are at increased risk for aspiration with tube feedings and should therefore receive feedings that are transpyloric.
The child receiving enteral nutrition must have a functioning gastrointestinal tract (e.g., audible bowel sounds and occurring peristalsis) for nutrition to be digested and absorbed.
Feedings provided by way of the gastrointestinal tract promote gut barrier structure and function, are more cost effective than parenteral nutrition, provide the child with a much lower risk for complications (e.g., catheter sepsis, thrombophlebitis), and prevent the development or worsening of malnutrition.
The most common method of enteral feeding delivery for children is an enteral feeding pump, which controls delivery. Feedings may be intermittent, also called a bolus, or by continuous drip or a combination of delivery methods that best meet the needs of the infant or child.
Because jejunostomy tube placement is in the small intestine, high-osmolality formulas may not be tolerated well if they are given in bolus form; therefore, jejunostomy tube feedings should be administered through a continuous feeding via an enteral pump.
Numerous commercially made formulas are available and are prepared to meet a variety of the child’s needs, including nutritional and calorie requirements in relation to disease states.
Children may require additional free water to be delivered through the feeding tube to prevent dehydration and a hyperosmolar state. However, some conditions place children at risk for fluid overload due to their underlying diagnosis and age.
Placement of the enteral tube must be confirmed before administration of tube feedings or with each syringe change with continuous feeding. Most institutions require that tube placement be confirmed by X-ray to prevent aspiration. Verify tube placement when a change in clinical status suggests tube migration.

EQUIPMENT

For intermittent or bolus feeds:

Enteral tube (see Chapters 38 and 39)
Towel or washcloth
Nonsterile gloves
60-mL catheter-tip syringe
Prescribed enteral formula
Clean graduated measuring cup
Stethoscope
Pacifier (optional)

For continuous drip feeds:

Enteral tube (see Chapters 38 and 39)
Towel or washcloth
Nonsterile gloves
Towel or washcloth
5-mL catheter-tip syringe
Prescribed enteral formula
Stethoscope
Enteral feeding bag and administration set
Enteral feeding administration pump
Intravenous (IV) pole
Pacifier (optional)

CHILD AND FAMILY ASSESSMENT AND PREPARATION

Refer to Chapters 38 and 39 for preliminary questions regarding child and family assessment and preparation.
Assess the child for symptoms of malnutrition, including weight loss, muscle atrophy, edema, weakness, lethargy, failure to wean from ventilatory support, or poor wound healing, which may indicate the severity of malnutrition.
Assess the child’s gastrointestinal tract, auscultate for the presence of bowel sounds, and palpate the abdomen to ensure that it is soft, nondistended, and nontender.
Obtain the child’s baseline weight; note the presence or absence of edema. Note the child’s weight from admission and track weight trends; this provides evidence of the effectiveness of nutritional support and the patient’s response to the nutritional interventions.
Assess the child for a history of cardiac, renal, hepatic, or pulmonary disease because these may limit the fluid volume or the type of formula the child can receive and the volume of flushes administered.
Assess the child for conditions that increase metabolic demand and therefore increase caloric requirements.
Assess the cognitive level, readiness, and ability to process information of the child and family. The readiness to learn and process information may be impaired as a result of age, stress, or anxiety.
Reinforce the need and identify and discuss the risks and benefits of enteral tube feedings, as appropriate, to both the child and family.
Explain the procedure, as appropriate, to both the child and family.

PROCEDURE
Intermittent or Bolus Enteral Feeds

Steps	Rationale/Points of Emphasis
1 Perform hand hygiene.	Reduces transmission of microorganisms.
2 Gather the necessary supplies.	Promotes efficient time management and provides an organized approach to the procedure.
3 Don gloves.	Standard precaution to reduce transmission of microorganisms.
4 Place child in a supine position, before the procedure begins, with the head of bed up 30 degrees (if not otherwise contraindicated). Older children may be placed in a sitting position or a position of comfort.	Discourages aspiration of gastric contents by using positioning and gravity to keep formula down when feeding. caREminder
	A semi-Fowler, head-of-bed up, right side-lying position is best for promoting gastric emptying and peristalsis.
5 Measure prescribed amount of enteral formula to be infused into clean graduated measuring cup or catheter-tip syringe.	Prepares formula for administration. Promotes safety for the delivery of the ordered volume of feeding.
6 Place a towel or washcloth under child’s indwelling enteral tube or below chin and chest.	Protects clothing and linens from emesis or secretions.
7 To verify proper tube placement of nasogastric, orogastric, and nasojejunal tubes, refer to Chapter 39 . With gastrostomy, jejunal, or PEG tubes, malposition may be evidenced by the external tube length being shorter than baseline measurement, distended abdomen, high-pitched bowel sounds indicating obstruction, or blocked lumen of the bowel by the tube balloon from tube migration. Semicomatose and comatose (vs. alert) children and those with either swallowing problems or vomiting are more likely to experience tube insertion and tube positioning errors.	Avoids complications associated with inappropriate administration of feeding.
8 For skin-level devices, attach feeding tube extension to enteral device (as needed depending on type of enteral device) (Figure 41-1).	Skin-level devices require that a feeding tube be connected to the device to administer the feedings or medications.
Figure 41-1 Enteral devices, such as the button, require that a feeding tube be connected to the device to instill any medications or fluids.
9 Attach 60-mL catheter-tip syringe with plunger removed to the end of the enteral tube or the end of the feeding tube.	Syringe is used to administer bolus feeding.
10 Assess for residual fluid in gastrointestinal tract for gastrostomy tubes (this is not indicated for jejunal or transpyloric tubes) (Figure 41-2): Nasogastric or orogastric tubes—use syringe to aspirate for residual fluid. Gastrostomy tubes—use passive flow by positioning the tube with an open syringe attached (without the plunger) below the stomach level. Low-profile gastrostomy tubes—use the manufacturerrecommended decompression/vent tube attached to an open syringe. Attach decompression/vent tube to lowprofile gastrostomy tube and position the open syringe to assess residual. It may be necessary to gently aspirate the stomach contents by using the syringe plunger to determine entire residual.	Monitoring residuals aids in prevention of overfeeding and detecting early signs of feeding intolerance. Gastric residuals may be elevated because of formula intolerance, delayed gastric emptying, sepsis, or underlying gastrointestinal disease process. Figure 41-2 Before beginning the feeding, gently aspirate a gastrostomy tube for gastric contents or attach the barrel of a syringe to the tubing and gently palpate the child’s abdomen. Note presence of gastric contents in syringe. Avoid vigorous aspiration because it may pull gastric mucosa against the tube.
caREminder
The MIC-KEY® skin-level device has a one-way valve positioned at the top of the device that allows for aspiration of stomach contents and for venting of the stomach when feeding extension is connected. The Bard button has the one-way valve at the base of the device, requiring separate decompression/venting tubing.
• Manufacturer’s recommendation is to not check residuals with jejunal or transpyloric tubes.
11 If residual feeding is obtained and is greater than one half of the previous feeding volume, return the aspirate but hold the present feeding, noting color and consistency, and notify the healthcare prescriber. If there is a small amount of residual, return the aspirate and continue with the enteral feeding procedure.	Continued feeding may cause negative vital sign changes, vomiting, and potential aspiration. Gastric aspirates contain enzymes, electrolytes, and secretions essential for digestion, so discarding aspirates repeatedly could lead to electrolyte imbalances.
12 Elevate catheter-tip syringe to a level to deliver the feeding over about 15 minutes, gradually adding the total feeding volume to the syringe. Allow feeding to flow slowly by gravity; raising or lowering syringe can adjust the rate of flow (Figure 41-3). The flow of feeding may need to be initiated by placing plunger into barrel of syringe and depressing slightly.	Gravity allows any back pressure to be released and avoids direct forceful pressure on gastric mucosa. Figure 41-3 The enteral feeding should flow freely by gravity to administer the feeding over about 15 minutes, which is a typical time frame for a feeding.
Enteral feedings delivered too rapidly may interfere with peristalsis, causing abdominal distention, possible cramping, regurgitation, and/or diarrhea.
13 Observe child during the feeding for intolerance and complications: elevated gastric residuals, emesis, abdominal distention, bradycardia, or apnea. In the sedated or comatose child, retching may not be observed.	Stimulation of the vagal nerve by the enteral tube can cause bradycardia or apnea. Feeding intolerance can occur with decreased gastric peristalsis secondary to underlying disease process, leading to inability to digest formula. KidKare Offer a pacifier to an infant during enteral feedings to promote secretion of digestive aids and stimulate oral motor muscles.
14 After feeding is complete, gently clear tubing and catheter-tip syringe with warm-water flush.	Warm water helps prevent the tube from clogging. Depending on child’s age and diagnosis, added free water may be needed to avoid potential dehydration that can result from high-osmolality formulas. Free water may also place some children at risk for fluid overload. KidKare Infants and children may be fluid sensitive secondary to age, specific diagnoses (e.g., pulmonary, renal, and/or cardiac conditions), and acute illness. Free water may not be indicated for many of these children. Assess and monitor total volume of free water, including flush volumes.
15 If feeding tube is discontinued after each feeding, pinch or clamp the enteral tubing and withdraw the tubing with a slow, smooth, steady movement.	Avoids leakage of contents from tubing, preventing possible aspiration of contents during removal. Minimizes risk for vomiting.
16 Used supplies, such as catheter-tip syringe and feeding extension tubing, can have repeated use for up to 24 hours. Label administration set with date and time when first used; cleanse thoroughly with warm, soapy water and rinse well. Place clean supplies in safe area away from child’s reach.	Changing enteral feeding set/disposable supplies every 24 hours prevents bacterial overgrowth in set. Date and time labeling indicates to family and nursing staff when supplies should be changed.
17 Dispose of equipment and waste in appropriate receptacle.	Standard precautions.
18 Remove gloves and perform hand hygiene.	Reduces transmission of microorganisms.