Jejunal Feeding Guideline

  • 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.


    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)


    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.


    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 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


    1. Ferrie S., et al (2018). 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. 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
    8. Scott, R. and Elwood, T. GOSH guideline: Nasojejunal (NJ) and orojejunal (OJ) management. 2015.
    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. 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
    11. Wilson RE. et al. A Natural History of Gastrojejunostomy Tubes in Children. Journal of Surgical Research. 2020, 245:461-466
    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.

    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.