Clinical Guidelines (Nursing)

Jejunal Feeding Guideline

  • Introduction

    Aim

    Definition of terms

    Assessment 

    Management 

    Special considerations

    Companion documents

    Evidence table

    References 

    Introduction

    Jejunal feeding is the method of feeding directly into the small bowel. The feeding tube is passed into the stomach, through the pylorus and into the jejunum. This type of feeding is also known as post-pyloric or trans-pyloric feeding.
    Jejunal feeding is indicated in patients who have a functioning gastro-intestinal tract, but who have an absent gag reflex, gastric dysmotility or persistent vomiting resulting in faltering growth. (1, 2)

    Aim

    To provide a framework for clinical consistency in the management of jejunal feeding at the Royal Children’s Hospital

    Definition of Terms 

    • Closed Feeding System – a feeding system whereby a sterile feeding container is spiked with a feeding set, to prevent contamination of the feed during administration. 
    • Dumping Syndrome – rapid gastric emptying where food moves through the small bowel too quickly, resulting in a number of symptoms such as nausea, diarrhoea and abdominal cramps.
    • Home Enteral Nutrition (HEN) – enteral tube feeding that occurs outside of the hospital, administered by parents/carers or patients themselves.
    • Nasojejunal Tube (NJT) - Thin soft tube passed through a patient’s nose, down the back of the throat, through the oesophagus, stomach and pyloric sphincter into the jejunum.
    • Percutaneous Endoscopic Jejunostomy (PEJ) - a feeding tube which is inserted through the abdominal wall into the stomach and then extends into the jejunum. 
    • Gastrostomy-Jejunostomy (G-J) – a feeding tube which is inserted through the abdominal wall, containing two entry points (ports) - a gastric port which opens into the stomach, and jejunal port which opens into the jejunum.

    Assessment

    Patient group

    Jejunal feeding may be initiated in any age group of patient, although the duration of feeding can be limited or difficult due to the following factors:

    • The tubes are difficult to place 
    • There is an increased risk of gastro-intestinal infection as the tube bypasses the natural microbiological defenses of the stomach, therefore sterile or pasteurized feeds must be used and an aseptic non-touch technique adhered to when manipulating the feeding set 
    • The tube can easily become blocked so requires frequent flushing 
    • Longer periods of feeding result in reduced mobility of the patient 
    • The type of feed given may require review 
    • Radiological exposure and expertise is often required


    Jejunal feeds are most appropriate for patients with gastric outlet obstruction, gastroparesis, pancreatitis and in those with known reflux and aspiration of gastric contents where gastric feeding has failed. (1-4) While onerous, it is safer and less expensive than parenteral nutrition (PN). (5, 6)

    Placing the tube

    Ensure referral to a dietitian is made prior to placement of jejunal tube.

    Nasojejunal tubes may be placed with the assistance of endoscopy or fluoroscopy. Confirmation of correct position of a newly inserted tube is mandatory before feedings or medications are administered. (7-9) 
    At RCH, the recommended tube to be inserted for jejunal feeding is the yellow Corflo silastic enteral tube. Six French (6FR) enteral tubes are not recommended as they block easily.

    For longer term feeding a surgical jejunostomy (PEJ) tube or a gastrostomy-jejunostomy (G-J) tube is usually a more successful route for delivering nutrition support. (2) Patients that require jejunal feeding can utilize a jejunal tube placed through a previous gastrostomy. This requires a longer tube and has the potential for displacement compared to a tube with direct access to the jejunum. Studies in children and adults have shown that feeding via a jejunostomy (vs gastrojejunostomy) require less manipulations and hospital admissions each year. (10)

    For NJT placement for patients in PICU, please refer to PICU nutrition guideline (RCH only): Insertion of Naso-Jejunal Tube (NJT) 

    Management 

    Confirming the position of NJT

    The pH level of the NJT should not be tested. 

    The tip of the jejunal tube has potential to migrate back into the stomach. The tube marking at the nostril should be recorded after insertion. This should be checked prior to administrating any liquid, feed or medication via the tube to confirm correct position.

    If a patient is experiencing clinical symptoms such as retching, vomiting, excessive coughing- this may indicate the tube may have migrated to the stomach. Any change in the child’s ability to tolerate the jejunal feed should be investigated, and the position of the jejunal tube checked via X-ray.

    Tube management

    Do not aspirate the NJT as this can cause collapse and recoil of the tube. 

    The PEJ or G-J tube must not be rotated as there is a risk of displacing the jejunal tube by coiling it up in the stomach. As an alternative, the tube should be moved very gently in and out of the tract approximately one centimetre. (7)

    Water flushes

    Jejunal feeding tubes need regular flushing to maintain patency and it is recommended that sterile water is always used. (2, 7) Blocking can occur more frequently due to narrower lumens, therefore sterile water flushes are recommended four to six hourly. The jejunal feeding tube should be flushed: 

    • Prior to each feeding session
    • After each feeding session
    • Prior to administration of medicines
    • After administration of medicines
    • 4 hourly if the tube is not in use
    • 4 hourly when on continuous feeds (at each bottle change)

    Flushing will be more effective with a push-pause technique. The lowest volume necessary to clear the tube is recommended for neonatal and paediatric patients. Suggested volumes are:

    • Neonatal patients: 1-3mL
    • Paediatric patients: 3-5mL (8)
    • Note: recommendations can be 5-10ml depending on the child’s fluid balance and size (7)

    Feed Regimen

    Without the stomach acting as a reservoir, feed given as a bolus directly into the jejunum can cause abdominal pain, diarrhoea and dumping syndrome. This results from rapid delivery of hyperosmolar feed into the jejunum. Therefore, feeds delivered into the jejunum should always be given slowly by continuous infusion. (2) An enteral feeding pump is the delivery method of choice, (7) as the feeding rate can be accurately controlled into the jejunum.

    Within the paediatric population, there is little data to suggest what rates can be safely tolerated. The Dietitians Association of Australia Enteral Feeding Guideline (1) suggests adults may tolerate jejunal feeds of up to 120ml/hr, however this is unknown for the paediatric population and individual tolerance needs to be determined by clinical condition and gradual increases in volume delivery. 

    To meet the child’s nutritional requirements, the feed will need to be administered over a long period of time, (7) most likely 18-24 hours each day. The dietitian should be referred to provide recommendations regarding an appropriate feeding regimen.

    Feed Type

    Through feeding directly into the jejunum, feed enters the intestine distal to the site of release of pancreatic enzymes and bile. (2) Whole protein feeds may be well tolerated and should be standard practice. If malabsorption occurs, a trial period of hydrolysed protein feed is recommended. (2) Symptoms of malabsorption include abdominal pain and diarrhoea. Thickened feeds are not recommended and can contribute to tube blockage. (7) Where appropriate, closed system feeds should be used at home.

    Pureed food should not be put down the tube for any reason.

    Medications

    Medications cause occlusion in approximately 15% of patients with enteral feeding tubes. (11) Complications beyond tube obstruction that can be attributed to medication may include lack of therapeutic benefit and diarrhoea. (1)

    Oral drug administration via a jejunal tube should be discussed with the pharmacy and child’s doctor as some medication may be incompatible with the small intestine. Clinicians should evaluate:

    • Tube type and diameter
    • Location of the distal end of the feeding tube relative to the site of drug absorption
    • Effects of food on drug absorption (11)

    For example, antacids act locally in the stomach and are not suitable for post-pyloric administration. Bioavailability may increase with intra-jejunal delivery of some drugs, namely opioids, tricyclics, beta blockers or nitrates. (11) This may result in a more rapid onset of action or greater effect of the medication.

    Medication in liquid form is strongly encouraged where available. In general, medication should not be added to the enteral formula, both to reduce the risk of contamination (for closed systems) and to avoid drug-nutrient incompatibilities. (11) If the only way to give the drugs is via the jejunal route, then the patient may need closer monitoring for signs of adverse effects of slow or too rapid absorption. 

    Diarrhoea, cramping and abdominal distension may occur after administration of hyperosmolar products through the feeding tube. These effects may be reduced by diluting medications with sterile water given that many commercial liquids have osmolality in excess of 1000mOsm/kg. (11)

    To avoid compromising nutritional status, it is ideal to minimize the amount of time that feeding is interrupted by using once daily or twice daily dosage regimens. Nutrient intake is reduced 12.5% to 17% with once daily dosing, and 25% to 33% with twice daily dosing, unless the feeding rate is increased to compensate. (11) If you have concerns or questions regarding administration of medications, please speak with pharmacy.

    Frequency of Change

    There is little evidence to support how frequently jejunal feeding tubes should be changed. Commonly, tubes are changed when they become blocked or dislodged. Consensus, with thanks to RCH Gastroenterology, Clinical Nutrition and Medical Imaging Staff as shown below: 

    • Naso-jejunal tubes: 3-6 months (or follow tube manufacturer guidelines)
    • G-J / PEJ: 6-12 months (12 months when anaesthesia required for changeover)

    Naso-jejunal feeds are a short-term approach to nutrition support and a definitive decision for either PEG + Fundoplication or PEG-J/PEJ feeding should be made within 3 months of commencing on naso-jejunal feeds. It is the responsibility of the managing medical team to arrange tube changes within the appropriate time frames. 

    HEN Allowances

    If the child is commenced on enteral feeding whilst he/she is an inpatient at RCH and it is envisaged that this method of feeding will continue following discharge, discharge planning and HEN preparation should commence at the earliest opportunity. Please ensure the dietitian is referred at least 48 hours prior to discharge. 

    Feeding pump: a pump is required for jejunal feeding, and is preferred for gastric feeding in critically ill patients. (8) Feeding should be continuous over 16-24 hours. 

    Equipment provision:

    • Giving set: 1 set per day (inpatient)
    • Extension Set (for PEG-J/PEJ): every 2 months
    • Hang time of feeds: 4 hourly as inpatient, as per HEN protocol for home

    Special Considerations

    Fasting for procedures

    For patients fed via a jejunal tube, required fasting times should be discussed with their anesthetist and may be adjusted at the discretion of their anesthetist. 

    Jejunal Tube Blockages

    Tube blockage is a common issue with patients receiving jejunal feeding that is both time and resource intensive to address. (11) Once blocked, jejunal tubes are difficult to clear and the solution may be to remove the intestinal tube and have a new tube inserted under imaging. (7)

    Before removing the tube, attempt to clear the obstruction with additional water flushes. There is no data to show that carbonated cola beverages are more effective than water as a flush solution, and research has proven the superiority of water over cranberry juice to maintain tube patency. (11) Therefore, cola and cranberry juice should be avoided when unblocking blockages – both are acidic and may accidentally contribute to tube occlusion by denaturing protein in the enteral formula. (11, 12) 

    Unblocking must not be performed using pressure as this can result in splitting of the tube; accidental intubation; oesophageal trauma, gut perforation. (7)

    Companion Documents

    PICU nutrition guideline (RCH only): Insertion of Naso-Jejunal Tube (NJT) 
    Clinical Guideline (nursing): Enteral feeding and medication administration

    Evidence Table

    The complete evidence table can be viewed here

    References

    1. Ferrie S., et al (2015). Nutrition Support Interest group. Enteral nutrition manual for adults in health care facilities. Dietitians Association of Australia
    2. Shaw V (2015) Clinical Paediatric Dietetics, 4th Edition. Oxford, Wiley Blackwell
    3. ASPEN Safe Practices for Enteral Nutrition Therapy. Boullata J I. et al. Journal of Parenteral and Enteral Nutrition. Volume 41 Number 1. January 2017 15–103
    4. Jabbar, A & McClave, S A. Pre-Pyloric versus post-pyloric feeding. Clinical Nutrition (2005) 24, 719-726
    5. Enteral Feeding in patients with major burn injury: the use of nasojejunal feeding after the failure of nasogastric feeding. Sefton et al, 2002, Burns, 28:386-390
    6. Post Pyloric Feeding, Niv E, Fireman Z and Viasman N, World Journal of Gastroenterology, 2009, March 21, 15(11): 1281-1288
    7. Scott, R. and Elwood, T. GOSH guideline: Nasojejunal (NJ) and orojejunal (OJ) management. 2015.
    8. ASPEN Clinical guidelines: Enteral Nutrition Practice Recommendations. Bankhead R. et al. Journal of Parenteral and Enteral Nutrition. 2009, 33(2): 143-146
    9. Gastric vs Post-pyloric feeding: Relationship to Tolerance, pneumonia risk, and Successful Delivery of Enteral Nutrition. Ukleja A and Sanchez-Fermin P, Current Gastroenterology Reports, 2007, 9:309-316
    10. ASPEN Clinical guidelines: Nutrition Support of the Critically Ill child. Mehta N. et al. Journal of Parenteral and Enteral Nutrition. Volume 33: 260. 2009
    11. Beckwith et al. A Guide to Drug Therapy in Patients with Enteral Feeding Tubes: Dosage Form Selection and Administration Methods. Hospital Pharmacy, 2004, 39 (3): 225-237
    12. Dandeles LM and Lodolce AE. Efficacy of Agents to Prevent and Treat Enteral Feeding Tube Clogs. The Annals of Pharmacotherapy, 2011 ;45:676-80.