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.
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.
- Gastrojejunal Tube (G-J) - a low profile balloon device inserted through an existing gastrostomy by interventional radiology which extends to the jejunum. It contains two entry points (ports) - a gastric port which opens into the stomach, and jejunal port which opens into the jejunum
- 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 Gastrostomy (PEG) - a feeding tube that is placed through the abdominal wall and into the stomach
- Percutaneous Endoscopic Gastrostomy-Jejunostomy Freka (PEG-J Freka) – PEG device inserted as a primary device when no previous gastrostomy exists. The Jejunal extension is then inserted through the middle of the PEG.
- Percutaneous Endoscopic Jejunostomy (PEJ) - a feeding tube which is inserted through the abdominal wall directly into the small intestine (jejunum)
Staff Roles
Role of Nursing Staff
- Safe administration of jejunal feeds and medications during inpatient stay
- To provide education on delivery of feeds, flushes, medication administration and ensure parents/carers are competent in flushing, delivering feeds and caring for jejunal tube
- For patients post PEG-J Freka insertion, education should also be completed on stoma care/delivery of feeds
Role of the Dietitian
- Patients post insertion of jejunal feeding tube should be managed by their main unit dietitian. A dietitian referral should be initiated on admission or when jejunal tube is placed.
- To ensure grade up feed plan and target regime is clearly documented
- For new insertion of PEJ or G-J tube, dietitians should refer to Jejunal tube grade up local guideline
- Ensure jejunal specific Home Enteral Nutrition (HEN) education has been completed, including pump training (for RCH patients not previously known to RCH nutrition department)
Role of the managing medical team
- Referral to dietitian for recommended feeding plan post jejunal tube insertion
- Referral to dietitian for RCH HEN program (as required). Please ensure dietitian is referred at least 48 hours prior to discharge.
- Advise route and preparation advice for medication administration, in conjunction with pharmacy
- Ensure adequate pain management plan is in place (if post PEG-J Freka)
Assessment
Patient group
Jejunal feeding may be initiated for a patient of any age. Jejunal feeding is indicated in patients with gastric outlet obstruction, gastroparesis, pancreatitis, severe reflux with faltering growth, and known reflux with aspiration of gastric contents, where continuous gastric feeding has been trialed and unsuccessful. (1-4) While onerous, jejunal feeding is safer and less expensive than parenteral nutrition (PN). (5, 6)
Jejunal feeding
can be challenging due to the following factors:
- 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 requiring frequent flushing
- Longer periods of
feeding result in reduced mobility of the patient
- The tubes are
difficult to place
- Insertion under direct vision via radiological exposure
is preferred. NJT insertion without direct vision will require
confirmation 4 hours post procedure via abdominal xray.
Management
Placing the 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. (8-9) At RCH, the recommended tube to be inserted
for jejunal feeding is the yellow CORFLO* silastic enteral feeding tube with ENfit® connector. Six French (6FR)
enteral tubes are not recommended as they block easily.
For NJT placement for patients in PICU and
patients requiring out of hours NJT insertion the following guideline will be
utilised by nursing staff competent in the procedure. PICU nutrition guideline (RCH only): Insertion
of Naso-Jejunal Tube (NJT)
For longer term jejunal feeding, a surgical jejunostomy (PEJ) tube
or a gastrostomy-jejunostomy (G-J) tube is recommended (2) At RCH, this is
placed by the surgical or gastroenterology team and usually occurs via
placement of a PEG with NJT for initial jejunal feeding, followed by conversion
to PEG-J. Alternatively a PEG-J Freka (initial PEG-J) may be inserted. 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.
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 help confirm correct position. (3)
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. (3) As an
alternative, the tube should be moved very gently in and out of the tract
approximately one centimetre. (8)
Water
flushes
Jejunal feeding tubes need regular flushing to maintain patency
and it is recommended that sterile water is always used. (7, 8) Blocking can
occur more frequently due to narrower lumens, therefore water flushes are
recommended four to six hourly. The jejunal feeding tube should be flushed:
- Before and after
administration of enteral nutrition
- Before and after
administration of medication
- 4 hourly when on
continuous feeds (at each bottle change)
- 4 hourly when the
tube is not in use
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
- Note:
recommendations can be 5-10ml depending on the child’s fluid balance and
size (8)
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, as the feeding rate can be accurately controlled into the
jejunum.(7,8)
Within the paediatric population, there is little data to suggest
what rates can be safely tolerated. 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, most likely 16-24 hours each
day. (8) The dietitian should provide recommendations regarding an appropriate
feeding regimen and to organise pump training.
Commencement
of feeds post initial PEJ/G-J insertion
Dietitian to provide grade up feed plan as guided by Jejunal feeding tube
grade up local guideline.
Feed Type
When feeding directly into the jejunum, feed enters the intestine
distal to the site of release of pancreatic enzymes and bile. (2) Standard polymeric
formula may be well tolerated and should be standard practice. If malabsorption
occurs, a trial period of hydrolysed formula is recommended. (2, 7) Symptoms of
malabsorption include abdominal pain and diarrhoea. Elemental formula and
other hyperosmolar feeds should be used with caution. Thickened
and fibre containing feeds should be used with caution due to risk of tube
blockage. (7,8) Where appropriate, closed system feeds should be used at home.
(7)
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. (10)
Complications beyond tube obstruction that can be attributed to medication may
include lack of therapeutic benefit and diarrhoea and it is recommended not to use the jejunal
feeding tube for the administration of medication unless absolutely essential
and/or delivery into the stomach is not possible. (7)
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 (10)
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. (10) 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. (10) 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.
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. (10) 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. (11) 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: up to 3-6 months (ensure not exceeding 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 Discharge
Planning
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.
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. (10) Once blocked, jejunal tubes are difficult to clear and the
solution may be to remove the intestinal tube and have a new tube inserted. (8)
Before removing the tube, attempt to clear the obstruction with
additional water flushes. There is no data to support the use of cola or
cranberry juice to unblock feeding tubes - both are acidic and may
accidentally contribute to tube occlusion by denaturing protein in the enteral
formula. (10,12)
Unblocking must not be performed using pressure as this can result
in splitting of the tube; accidental intubation; oesophageal trauma, gut
perforation. (8)
Companion Documents
PICU nutrition guideline (RCH only): Insertion
of Naso-Jejunal Tube (NJT)
Clinical Guideline (nursing): Enteral feeding
and medication administration
Consensus guideline for feeding post Jejunal
tube insertions including initial PEG-J Freka and Jejunal extensions (nutrition
department local guideline)
Evidence Table
The complete evidence table can be viewed here.
References
- Ferrie
S., et al (2018). Nutrition Support
Interest group. Enteral nutrition manual for adults in health care
facilities. Dietitians Association of Australia
- Shaw V (2015) Clinical Paediatric
Dietetics, 4th Edition. Oxford, Wiley Blackwell
- 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
- Jabbar, A & McClave, S A. Pre-Pyloric versus post-pyloric
feeding. Clinical Nutrition (2005) 24, 719-726
- 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
- Post Pyloric Feeding, Niv E, Fireman Z and Viasman N, World Journal
of Gastroenterology, 2009, March 21, 15(11): 1281-1288
- The
Use of Jejunal Tube Feeding in Children: A Position Paper by the
Gastroenterology and Nutrition Committees of the European Society for
Paediatric Gastroenterology, Hepatology, and Nutrition 2019. Broekaert I.
et al. Journal of Paediatric Gastroenterology and Nutrition. 2019, 69(2):
239-258
- Scott, R. and Elwood, T. GOSH guideline: Nasojejunal (NJ) and orojejunal (OJ) management. 2015.
- 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
- 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
- Wilson
RE. et al. A Natural History of Gastrojejunostomy Tubes in Children. Journal
of Surgical Research. 2020, 245:461-466
- Dandeles LM and Lodolce AE. Efficacy of Agents to Prevent and Treat Enteral
Feeding Tube Clogs. The Annals of Pharmacotherapy, 2011 ;45:676-80.
Please remember to read the disclaimer
The development of this nursing guideline was coordinated by Elise McJannet, Paediatric Dietitian and approved by the Nursing Clinical Effectiveness Committee. Last update May 2021.