Clinical Guidelines (Nursing)

Enteral feeding and medication administration

  • Introduction

    Enteral feeding is a method of supplying nutrients directly into the gastrointestinal tract. This guideline will use this term describe Orogastric, Nasogastric and Gastrostomy tube feeding. A wide range of children may require enteral feeding either for a short or long period of time for a variety of reasons including:

    • Unable to consume adequate nutrients
    • Impaired swallowing/sucking
    • Facial or oesophageal structural abnormalities
    • Anorexia related to a chronic illness
    • Eating disorders
    • Increased nutritional requirements,
    • Congenital anomalies
    • Primary disease management.

    Enteral feeding tubes can be used to:

    • Administer bolus, intermittent feeds and continuous feeds
    • Medication administration
    • Facilitate free drainage and aspiration of the stomach contents
    • Facilitate venting/decompression of the stomach
    • Stent the oesophagus 

    It is imperative that nursing staff caring for children who have enteral tubes in understand why it is in-situ.
    For information regarding the Jejunal feeding and medication administration please see the Jejunal Feeding Guideline.

    Aim

    This guideline aims to support nurses in administering feeds and medications via a nasogastric, orogastric or gastrostomy tube in a safe and appropriate manner.
    Please note this guideline does not refer to the management of Jejunal tubes, for information regarding care of these please see the Jejunal Feeding Guideline.
    Please note this guideline does not refer to the care of trans-anastomotic tube (TAT), these remain in-situ post-operatively and should not be removed or replaced. If the TAT is dislodged inadvertently, immediately notify the neonatal and surgical teams. Feeds and medications should only be administered via a TAT tube at the direction of the treating medical team. 

    Definition of terms

    • Orogastric Tube (OGT) - Thin soft tube passed through a child’s mouth, through the oropharynx, through the oesophagus and into the stomach
    • Nasogastric Tube (NGT) – Thin soft tube passed through a child’s nose, down the back of the throat, through the oesophagus and into the stomach.
    • Gastrostomy tube - a feeding tube which is inserted endoscopically or surgically through the abdominal wall and directly into the stomach.
    • Temporary balloon device (G-Tube) – a gastrostomy tube 
    • Percutaneous endoscopic gastrostomy tube (PEG) – a gastrostomy tube which is held in place with an internal fixator
    • Gastrostomy-Button (Mickey-Button™) - skin level button gastrostomy tube inserted into a pre-formed stoma.
    • Gastric Residual Volume (GRV’s) – the amount of fluid aspirated from the stomach via an enteral tube to monitor gastric emptying, tolerance to enteral feeding and abdominal decompression. Once removed it may be returned to the patient or discarded. 
    • Trans-Anastomotic Tube (TAT tube) - Utilised after surgery to repair oesophageal atresia inserted by surgeons in the Neonatal patient population.

    Link for insertion of Nasogastric and Orogastric Tube Insertion policy, Nutrition on PICU Guidelines and Jejunal Feeding Guideline.

    Assessment

    Nasogastric Tube/Orogastric Tube- Checking the Position 

    Prior to accessing a NGT/OGT for any reason nursing staff members must ensure that the tube is located in the stomach. Coughing, vomiting and movement can move the tube out of the correct position.The position of the tube must be checked:

    • Prior to each feed
    • Before each medication
    • Before putting anything down the tube
    • If the child has vomited
    • 4 hourly if receiving continuous feeds 

    Nursing staff should perform the following observations and obtain a gastric aspirate to establish tube position.

    • Ensure taping is secure
    • Observe and document the position marker on NGT/OGT – compare to initial measurements.
    • Observe child for any signs of respiratory distress

    Please note: patients who have a history of Liver Failure and known/or suspected oesophageal varices should not have a gastric aspirate removed from the NGT. Instead tube position should be initially confirmed via x-ray with clear documentation of NGT position marker. The medical team should document rationale for not obtaining gastric aspirate in the patient’s progress note as well as an alternative plan to confirm NGT placement.

    Obtain gastric aspirate

    To check the position of the tube nursing staff members need to have prepared the following equipment:

    Procedure:

    1. Attach a 10-20ml oral/enteral syringe to the enteral tube in the infant/child
    2. Attach a 5-10ml oral/enteral syringe to the enteral tube in a neonate
    3. Aspirate minimum 0.5 - 1ml of gastric content (or sufficient amount to enable pH testing). Consider the “dead space” in the tubing.
    4. Utilising pH indicator strips a reading of between 0-5 should be obtained and documented. 


    Some medications and formulas may affect the pH reading. Refer to Nasogastric and Orogastric Tube Insertion procedure (RCH only.) If the patient is receiving a medication which is known to alter pH readings notify medical team, pharmacy and senior nursing staff, a clear plan for confirming the tubes position should be documented in the progress notes.
    If a reading greater than 5 is obtained, placement of the tube is questionable and it should not be used until the position of the tube is confirmed.
    If a reading greater than 5 is obtained leave for up to 1 hour and try aspirating again.
    Small-bore tubes can be difficult to aspirate therefore the following are suggested techniques to try enhance the ability to obtain aspirate:

    1. Turn the patient onto their side. This will allow the tip of the tube to move to a position where fluid has accumulate
    2. Using a 10-20ml oral/enteral syringe (5-10 ml in neonates) insufflate 1-5ml of air (1-2 ml in neonates) into the tube. This may move the tube away from the wall of the stomach. It will also clear the tube of any residual fluid. If a child belches immediately following air insufflation, the tip of the tube may be in the oesophagus
    3. Wait for 15-30 minutes. This will allow fluid to accumulate in the stomach and try aspirating again.
    4. If it is safe to do so and the child is able to tolerate oral intake consider providing them with a drink and attempt aspirate in 15-30minutes
    5. If no aspirate obtained, advance the tube by 1-2 cm and try aspirating again
    6. If aspirate not obtained discuss with senior nursing staff or medical staff and consider removing the tube or checking position by x-ray.

    Gastrostomy tube

    Correct placement of the tube should be confirmed prior to administration of an enteral feed by checking insertion site at the abdominal wall and observing the child for abdominal pain or discomfort. If the nurse is unsure regarding the position of the gastrostomy or jejunostomy tube contact the medical team immediately. 

    Ongoing Assessment 

    During Continuous feeds – Nasogastric/Orogastric Tube:

    1.     The position of the tube needs to be checked 4 hourly with change of feeds

    • It is recommended that the feed be ceased, withdraw aspirate and test pH.
    • If reading greater than 5, cease the feed for 30 minutes, aspirate and test pH
    • Should there be any dispute as to the position of the tube, do not recommence feeds. Discuss with senior nursing staff or medical staff.

    2.     The following needs to be checked 2 hourly during the feed:

    • Taping
    • Marker on NGT
    • Observe child for signs of respiratory distress. 
    • Check infusion hourly and document intake.
    • Feeds should hang for no longer than 4 hours to reduce the risk of bacterial growth. 

    Other assessment considerations for the child receiving enteral feeds

    • Regular Weights (at least twice weekly or as clinically indicated)
    • Blood tests
    • Referral to dietitian to review feeding plan
    • Referrals to speech therapy and/or occupational therapy.

    Management 

    Flushing enteral tubes

    The purpose of flushing is to check for tube patency and prevent clogging of enteral tubes.

    Flushing is not routine on the Neonatal unit and flushing with air is the preferred method.

    Enteral feeding tubes should be flushed regularly with water (or sterile water if appropriate):

    • Prior to and after feeding
    • Prior to, in-between and after medications
    • Regularly in between tube use
    • Modify flush volumes throughout as needed for infants and children with fluid restrictions – these patients may require minimal volume (0.5mL) flushing and/or flushing with air to push feed or medication to the end of the tube

    Nurses should prepare an enteral/oral syringe, enteral tube connector and water for a flush.

    • Tap water is suitable for most children with OGT or NGT
    • Boiled/sterile water may be necessary for children under 6 months of age or as clinically indicated e.g. immunocompromised patients

    Flushing

    • Enteral tubes should be flushed with between 5 – 20mls of water depending on the viscosity of the feed/medication, the child’s fluid status balance and the child’s size (The minimum volume required to clear the tube is 2mls. However in shorter tubes 1.5mls would be sufficient).  

    Venting

    • Feeding tubes may be used to facilitate venting or decompression of the stomach from the accumulation of air during such interventions as High Flow Nasal Prongs, Non-Invasive or Invasive Ventilation.
    • Enteral feeding or administration of medication may proceed in this case dependent on the individual child’s condition
    • The tube may be clamped for 30 minutes to an hour post administration to prevent loss of feed or medication
    • Continuous venting may be facilitated following administration by securing the distal end of the tube above the head of the child. This may be attached to the end of a 5 or 10mL enteral/oral syringe with the plunger removed to create a reservoir should gastric contents reflux

    Link to High Flow Nasal Prong (HFNP) therapy clinical guideline.

    Feeds

    Feeds can be administered via syringe, gravity feeding set or feeding pump. The method selected is dependent of the nature of the feed and clinical status of the child. There is limited evidence available to support one method of feeding over the other.


    For children who have a newly established enteral tube feeding regime:

    • Feeds should be recommended and ordered by the medical team and/or dietitian, taking in to account the nutritional needs and clinical condition of the child.
    • For further information regarding nutrition in PICU please see the PICU nutrition guideline (RCH only).
    • For further information regarding Preterm Infants please see the Enteral Nutrition for Preterm Infants guideline
    • For children who have enteral feeding regimes at home:
    • Speak with the family and child to establish normal feeding regimes and where possible, considering the reason for admission and clinical condition of the child, continue this regime in hospital
    • Ensure the medical team/dietitian have ordered the child’s home feeding regime
    • Formula can be ordered from the Formula Room
    • Discuss feeding options with the family if the infant is usually breast fed, but cannot continue whilst hospitalised. Consider providing education regarding expressed breast milk (Breastfeeding support and promotion clinical guideline.)


    Do not administer feeds through enteral tubes that are being used for aspiration or are on free drainage. 

    Administration of Feeds

    When preparing to administer feeds nursing staff must confirm the position of the enteral tube.

    Prior to and after feeds nurses should adequately flush the enteral tube.

    Position:

    • Lying prone/supine during feeding increases the risk of aspiration and therefore where clinically possible the child should be placed in an upright position.
    • If unable to sit up for a bolus feed or if receiving continuous feeding, the head of the bed should be elevated 30-45 degrees during feeding and for at least 30 minutes after the feed to reduce the risk of aspiration.

    Using a syringe for a bolus feed

    • Remove the plunger from the syringe and place the tip of the syringe into the enteral tube connector at end of the enteral tube.
    • Holding the syringe and enteral tube straight, pour the prescribed amount of feed into the syringe. Let it flow slowly through the tube e.g. 250ml over 20 minutes.
    • Pour the prescribed amount of water into the syringe and allow to flow through to flush the feeding tube appropriately.

    Using gravity feeding for bolus, intermittent feeds and continuous feeds.

    • Using a gravity feeding set with the roller clamp closed, attach the set to the feeding container with the correct prescribed amount of feed and hang the container on the pole.
    • Squeeze the drip chamber until it is one third full of the feeding solution.
    • Remove the protective cap from the end of the giving set and open the roller clamp, allowing the feed to run down to the end of the giving set (to prime the line), then close the roller clamp.
    • Connect the giving set to the enteral tube connector at the end of the enteral tube.
    • Open the roller clamp and set the flow rate by counting the drops per minute. As a guide, 20 drops of standard feed is approximately 1ml. Use the following equation or the table below to calculate the drip rate: (ml/hour) /3 = drops/minute
    • Open and close the roller clamp until the desired drip rate is set correctly. Check the drip rate regularly to ensure the feed is still running at the required rate.

    Using an enteral feeding pump for bolus or intermittent enteral feeding

    An enteral feeding pump can be used intermittent, bolus or continuous administration of feeds, but is best suited for continuous feeding when tolerance to rate of feeding is an issue.

    Enteral feeding pumps can be obtained via CARPS if the ward area does not have its own supply. Infinity pumps are now in use throughout RCH and the giving set can be primed by pushing the fill set button. For further information regarding the use of the infinity pump please see the manufactures instructions.

    Please note: in most situations an IV syringe pump is not recommended for administration of enteral feeds and should not be used on the ward. If very small rates are required, consider using frequent syringe bolus feeding techniques as an alternative.  

    Temperature of the feed

    Bolus feeds 

    For older children feeds given as a bolus should be removed from the fridge 15-20 minutes before administration to bring them to room temperature. Feeds given as a bolus may be warmed in an approved bottle warmer. This would be appropriate for all infants and older children who experience discomfort with cooler feeds.

    Continuous feeds 

    Continuous feeds should NOT be warmed. They may be removed from the fridge 15-20 minutes prior to administration to bring it to room temperature and should not hung for longer than 4 hours – use the dose limit function on the feed pump to ensure this occurs. 

    Please Note: Feeds should NOT be warmed in a microwave or in jugs of boiling water.

    Completion of feed

    The tube must be flushed with water (air in neonates) to prevent tube from blocking (see above).

    Giving sets:

    • Rinsed out with warm water (tap or sterile).
    • Ensure tip of giving set is covered between uses.
    • Only prime the giving set with formula immediately prior to feeding time.
    • The set should be changed every 24 hours or as per manufactures instructions.

    Titrating feeds 

    Nursing staff may need to titrate the rate/volume of an enteral feed up or down depending on the clinical status, nutritional needs, size and ability to tolerate feeds of the child. 
    When titrating feeds up nurses should have a goal rate/volume of feed ordered by dietician or the medical team. Feeds should be titrated up in a slow but steady manner, which may need to be adjusted if the child is not able to tolerate the rate/volume of feed. Caution should be taken if titrating feeds up and down in patients with a metabolic condition. 
    When titrating a feed down nursing staff should document why the feed was titrated down, notify dietician and/or medical team to inform them that the child is not tolerating feeds and make a plan to ensure the child is still receiving adequate nutrition and hydration.

    Types of feeds

    The decision for which type of enteral feed a child should receive should be made in consultation with the dietician, medical team, nursing staff and family, taking into account the nutritional needs, clinical status and tolerance of feeds of the child. 


    If a child who receives regular enteral feeds at home is admitted to RCH, nursing staff can order and commence their regular feeding regime as the child’s clinical status allows. Enteral feeds can be ordered from the RCH formula room. The family should be offered a dietician review while they are an inpatient to ensure the current feeding regime meets the ongoing nutritional needs of the child.

    Medication administration

    Nurses who are preparing and administrating medication via an enteral tube must adhere to the Medication Management Procedure

      • Do not administer drugs through tubes used for aspiration or on free drainage unless specifically directed by medical staff.
      • Confirm that the enteral feeding tube is the intended route for a medication before administration.
      • Confirm the position of the enteral tube prior to medication administration (see above).
      • Adequately flush the enteral tube before, in-between and after medication administration (see above).

      Choice of drug preparation

      Consult your ward pharmacist or call Medicines Information (ext: 55208) for advice on how to prepare a drug for enteral administration.

      • Liquid formulations are usually preferred for enteral tube administration, unless the formulation contains other ingredients that could cause unwanted side-effects (e.g. sorbitol can cause diarrhoea). Liquid formulations may inappropriate in some patients (e.g. the carbohydrate content may be too high for patients on a ketogenic diet).
      • Viscous liquid medications may require dilution to prevent clogging of the enteral tube. 
      • If a liquid formulation is not available consult a pharmacist to confirm if the tablet form can be crushed to a fine powder and then dispersed in water, or whether a capsules can be opened to disperse the contents in water. 
      • Do not mix medications with feeds. 
      • Do not crush enteric coated or sustained/controlled release medications. 
      • See Appendix 1 for examples of medications not recommended for enteral administration and/or may cause interactions. 

      Adverse effects

      Unblocking tubes

      Blocking of tubes can occur due to:

      • Interaction between gastric acid, formula and medications
      • Interactions between medications if tube is not flushed between medications
      • Inappropriately prepared medications e.g. inadequately crushed tablets
      • Small internal diameter of the tubes and longer tubes
      • Binding of medication to the tube
      • Viscosity of some liquid preparation
      • Poor flushing technique
      • Bacterial colonization of the nasogastric tube

      Flushing is the single most effective action that prolongs the life of nasogastric tubes. It is recommended that flushing occur BEFORE, DURING and AFTER administration of enteral medications and feeds.

      To unblock enteral tubes, flush the tube in a pulsating manner (push/pull) with 10-20ml with warm water, if it is safe to do so taking into account the child’s age, size and clinical status. It may be appropriate to allow the warm water to soak, by clamping/capping the tube, in the tube to assist with unblocking.

      Please note there is no evidence to support the practice of using carbonated drinks such as Coca Cola™ to unblock enteral tubes.

      Feed Intolerance

      • Nurses should monitor and observe the patient to assess if the patient is tolerating enteral feeds.
      • Signs the child is not tolerating feeds include:

      Nurses should consider titrating feeds down or ceasing feeds for a short period of time depending on the clinical status and nutritional needs of the child.
      When titrating a feed down nursing staff should document why the feed was titrated down, notify dietician and/or medical team to inform them that the child is not tolerating feeds and make a plan to ensure the child is still receiving adequate nutrition and hydration.
      High acuity and intensive care patients may require management of Gastric Residual Volumes (GRV) to assist in management of gastric emptying delays, feeding intolerance, electrolyte balance and patient comfort. Further guidance regarding the management and return of GRV’s can be located under Nutrition in PICU (RCH only).
      Patients who have a non-functioning GIT (i.e. Ileus post abdominal surgery) may require GRV’s to be discarded post measurement as per the surgical/medical team orders.

      Tubes falling out

      • Nasogastric tube dislodgment or accidental removal consider ongoing nutritional needs and clinical status of the child and in consultation with senior nursing staff, medical team and/or dietician decide if tube should be replaced. If re-inserting tube please refer to Nasogastric and Orogastric Tube Insertion Procedure.
      • Dislodgement of a Gastrostomy tube - Stop the feed/medication administration immediately. Contact the medical team and/or Gastroenterology Clinical Nurse Consultant to review. Keep the tube in place by taping it to the skin until a plan for re-insertion can be made.
      • Accidental removal of a Gastrostomy tube – tube needs to be reinserted as soon as possible to prevent stoma closure. Gastrostomy tubes should be reinserted and taped into position if the balloon has burst. If the tube cannot be reinserted consider using a foley catheter to keep stoma patent until an appropriate tube can be found. Contact the medical team and/or Gastroenterology Clinical Nurse Consultant to review. 

      Companion documents 

      References

      • Clinical Nutrition Manual, Enteral Nutrition Administration tube feeds, Nutricia Advanced Medical Nutrition, June 2008
      • Datford and Gravesham, ' Paediatric enteral feeding guidelines & operational policy (infants & children)', Jan 2007, NHS Trust.
      • Durai, R et al 2009,' Naogastric tubes 1: insertion technique and confirming position', Nursing Times, vol. 105 issue16, pp.12-13
      • Gilbertson, H., Rogers, E., & Ukoumunne, O., 2011. Determination of a practical pH cutoff level for reliable confirmation of nasogastric tube placement, 35(4), pg 540-544.
      • Gilbertson, H.R et al 2007,' To determine a practical pH cutoff level for safer confirmation of nasogastic tube placement', Unpublished study, Royal Children's Hospital, Melbourne
      • Horn, D., Chaboyer W., & Schluter, P., 2004. Gastric residual volumes in critically ill paediatric patients: A comparison of feeding regimens, Australian Critical Care, 17(3),pg  98-103.
      • Juve-Udina, M. Valls-Miro, C., Carreno-Granero, A., Martinez-Estralella, G., Monterde-Prat, D., Domingo-Felici, C., & Llusa-Finestres, G., 2009. To return or to discard? Randomised trial on gastric residual volume management. Intensive and Critical Care Nursing, 25, pg 258-267
      • Macqueen. E., Bruce. E., & Gibson. F. (2012). The Great Ormond Street Hospital, Manual of Children’s Nursing Practices. Wiley-Blackwell : West Sussex, United Kingdom.
      • Metropolitan working party: 2007,' Enteral tubes: Enteral feeding management best practice'. Department of health, Western Australia
      • Nijs, E., & Cahill, A., 2010. Pediatric enteric feeding techniques: insertion, maintenance, and management of problems, Cardiovascular Intervention Radiology, 33, pg 1101-1110.
      • Peter, S Gill, F 2009,' Development of a clinical practice guideline for testing nasogastric tube placement'. Paediatric Nursing,vol.14 issue 1, pp. 3 – 11
      • Phillips, N M., & Endacott, R., 2011. Medication administration via enteral tubes: a survey of nurses’ practices, Journal of Advanced Nursing, 67(12), 2586-2592.
      • Sutherland, A 2009, 'Guidelines on administration of medication via enteral feeding tubes', NHS
      • Taylor, S., 2013, Confirming nasogastric feeding tube position versus the need to feed, Intensive and Critical Care Nursing, 29, pg 59-69.
      • Turgay, A S., & Khorshid, L. 2010. Effectiveness of the auscultatory and pH methods in predicting feeding tube placement, Journal of Clinical Nursing, 19, pg 1553-1559.
      • White R., Bradnam V., Handbook of Drug Administration via Enteral Feeding Tubes, Pharmaceutical Press 2007
      • Wilkes-Holmes, C 2006,' Safe placement of nasogastric tubes in children',  Paediatric Nursing , vol.18 issue 9, pp. 14-17
      • Williams, T., & Leslie, G., 2010. Should gastric aspirate be discarded or retained when gastric residual volume is removed from gastric tubes? Australian College of Critical Care Nurses, 23, pg 215-217. 

      Evidence table 

      Evidence Table - Enteral Feeding and Medication Administration


      Please remember to read the  disclaimer.

       

      The development of this nursing guideline was coordinated by Stacey Richards, Nurse Consultant, Nursing Research, and approved by the Nursing Clinical Effectiveness Committee. Published December 2017.