Introduction

Enteral feeding is a method of supplying nutrition directly into the gastrointestinal tract. This guideline refers to enteral feeding and medication administration methods via orogastric, nasogastric tubes and gastrostomy tubes. 

This guideline does not include enteral feeding and medication administration using Jejunal tubes. 

This guideline also does not refer to the care of trans-anastomotic tube (TAT); Feeds and medications should only be administered via a TAT tube at the discretion of the treating medical team.

Children may require enteral feeding or medication administration via an enteral tube, either for a short or long period of time for a variety of reasons including:  

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

Aim 

This guideline aims to support clinicians in administering feeds and medications via an enteral feeding tube including nasogastric, orogastric and gastrostomy tubes in a safe and appropriate manner.

Definition of terms  

• Gastrostomy tube - a feeding tube which is insered  directly into stomach either endoscopically or surgically through the abdominal wall
• Low profile Gastrostomy Tube (MIC-Key ®,  The MiniONE®) - skin level gastrostomy tube, commonly known as a ‘button’ tube .  
• Gastric Residual Volume (GRV) – 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.  
• Jejunal tube- is a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine.
• 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.  
• Orogastric Tube (OGT) - Thin soft tube passed through a child’s mouth, through the oropharynx, through the oesophagus and into the stomach. 
• Percutaneous Endoscopic Gastrostomy tube (PEG) – a gastrostomy tube which is inserted through the skin and under endoscopic guidance. It can be held in place with an internal fixator or balloon.   
• pH – quantitative measure of the acidity or basicity of liquid
  

Checking the position 

NGT/OGT  

Before administering enteral feeds, water flush or medications, the NGT/OGT position must be checked, confirmed and documented in the flowsheet to ensure their safe use. 

For information regarding how to obtain a gastric pH to check the position of an NGT/OGT please see the RCH Nursing guideline: Nasogastric and orogastric tube insertion and management.

Gastrostomy tube

The position of the gastrostomy tube must be confirmed before using the tube. Check the insertion site at the abdominal wall and observe the child for pain or discomfort. If the nurse is unsure regarding the position of the tube, contact the medical team immediately.

For further information regarding gastrostomy tube please refer to the RCH Nursing Guideline: Gastrostomy.

Administration of Feeds

Enteral feeds can be administered via syringe, gravity feeding set or feeding pump. The method of administration will be dependent on the nature of the feed and the clinical status of the child.

Starting an enteral tube feeding regime and the type of feed the infant/child receives should be based on the recommendation of the medical team and dietitian, considering the nutritional needs and clinical condition of the child.

Enteral feeds can be administered intermittently or continuously, depending on the child’s nutritional needs and tolerance of feeding.

Prior to starting the feed, review the prescribed feeding regimen documented in the EMR. Ensure the prescribed feed is the correct feed ordered by the dietitian and supplied by the formula room.   

Equipment for feeding  

• Enteral syringes to aspirate gastric contents (for OGT/NGT) or deliver bolus feed
• pH strip to check for tube placement (for OGT/NGT)  
• extension set for the infant/child’s PEG tube (may be provided by infant/child’s parent/carer)
• feed pump (if applicable)
• feed set (if applicable)
• prescribed formula for the infant/child  
• water to flush after an intermittent feed  
• Documented feeding regimen
  

Preparing the feed

• Feeds should not be prepared on the ward. Obtain pre-prepared feeds from the formula room, or EBM.
• Check the expiry date and time of feed. Gently shake the feed before use.  
• Feeds DO NOT need to be brought to room temperature.
• When administering bolus feeds for infants who are uncomfortable with cooler feeds, EBM and infant formula can be warmed in an approved bottle warmer. Feeds should NOT be warmed in a microwave or in jugs of boiling water. 
• For continuous feeding, DO NOT warm the feeds.  Feeds can be administered for 4 hours.
• Discard any feeds left at room temperature after 4 hours. For continuous feeds, change the feed every 4 hours. Feeds left or hung for long periods of time in a warm environment are at risk of becoming contaminated with bacteria.

Positioning the patient for the feed

• Where clinically appropriate position the child in an upright position to minimise the risk of aspiration. Lying prone/supine during feeding increases the risk of aspiration.
• If the child is unable to sit upright, elevate the head of the bed to 30-45 degrees during feed administration and for at least 30 minutes after the feed to reduce the risk of aspiration.  
• Nursing staff should be aware of the risk of aspiration when administering continuous overnight feeds; where possible, other feed regime options should be considered, considering patient and family preferences.

Procedure  

1. The 5 moments of hand hygiene must be practiced before, during, and after this procedure.
2. Confirm the infant/child identification and obtain the correct prescribed feed. Scan the EMR barcode. Ensure EBM administration is in line with Expressed Breast Milk Management.
3. Confirm the tube position before commencing the enteral feed.  
4. For PEG feed, attach the PEG tube extension set to the infant/child’s feed port. 
5.  If using a syringe to administer gravity feed:  
   - Remove the plunger from the syringe and place the tip of the syringe into the enteral tube connector.
   - Hold the syringe straight and slightly lift the tube and pour the prescribed amount of feed into the syringe. Let the feed flow slowly through the enteral tube via gravity.
6. If using a feed set to administer the feed:  
   - Prime the feeding set with the prescribed formula/EBM or feed
   - If using the gravity feeding set, fill in the set chamber and open the roller clamp. Let the feed flow through until there is no more air in the feed set. 
   - If using the feed pump, attach the feed set to the feed bottle and, fill the feed set chamber with the feed by squeezing it. Open the feed pump and attach the feed set. Press the prime button on the feed pump and stop when there is no more air in the feed set.  
   - Attach the end of the feeding set to the end of the enteral tube.
   - If using a gravity feed set, open the roller clamp and let the feed flow through. Adjust the flow according to the prescribed amount (mL/hr) for the infant/child. The equation for calculation is (mL/hr)/ 3= drops/minute. Check the drip rate regularly to ensure the feed is still running at the prescribed flow.  
   - If using a feed pump, program the feed set according to the prescribed rate for the infant/child.  
7. After the completion of the feed, the enteral tube should be flushed with water. Flush the enteral tube with prescribed water flush or 5-20mL of water depending on the viscosity of the feed and the age of the infant/child.  Note neonates with frequent feeds, or those with fluid restrictions may not requiring flushing. Refer to prescribed feeding regimen and treating team orders. 
8. For intermittent use of feed sets, rinse out the set with warm water and cover the tip of the giving set in between use. 
9. For continuous feeds, change the feed set every 24 hours or as per the manufacturer’s instruction.

Ongoing assessment during enteral feed administration

Enteral feeding may cause unintended respiratory aspiration and may lead to life-threatening aspiration pneumonia.

To minimise the risk of aspiration  

• Position the infant/child appropriately  
• Avoid the use of medications that cause sedation if possible
• Check the tube placement at least every 4 hours  
• Check for feeding intolerance at least every 4 hours  
• Check the taping and OGT/NGT marker at least every 4 hours
•  Check the infant/child for any acute signs of respiratory distress.   

Other assessment 

• Check and document volume infused every hour for continuous feed  
• For continuous feeds, change the feeding bottle at least every 4 hours to reduce the risk of bacterial growth.
• Referral to usual dietitian if not currently involved
• Referral to speech therapy and/or occupational therapy if appropriate
  

Titrating feeds

Feeds may need to be titrated up and down depending on the clinical status, nutritional needs, and the ability of the child/infant to tolerate the feeds.

When titrating feeds, nursing staff should check that the prescribed goal rate/volume is ordered by dietitian or the medical team. Feeds should be titrated in a slow but steady manner depending on the infant/child’s tolerance. Nursing staff should be mindful of titrating feeds if the infant/child has a metabolic condition.

Nursing staff should document when the feed was titrated and notify the dietitian and/or medical team about the infant’s/child’s nutritional status to ensure that the infant/child has adequate hydration and nutrition.

Feed Intolerance  

• Monitor and observe the patient to assess if tolerating enteral feeds.  
• Signs the child is not tolerating feeds include abdominal discomfort, bloating, vomiting or diarrhoea.  
• Consider titrating feeds down or ceasing feeds for a short period depending on the clinical status and nutritional needs of the child.

Please note that 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 GRVs can be located under Nutrition in PICU (RCH only).  
Patients who have a non-functioning GIT (i.e. Ileus post abdominal surgery) may require GRVs to be discarded post measurement as per the surgical/medical team orders.

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 confirmed, documented and ordered the child’s home feeding regime. 
  
• Formula can be ordered from the central Formula Room
  (RCH only) 
• 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.)

Medication administration via enteral tube 

Nursing staff who are preparing and administering medication via an enteral tube must adhere to the Medication Management Procedure .

Equipment  

• Enteral syringe to aspirate gastric content (for OGT/NGT)
• pH strip to confirm tube placement (for OGT/NGT)  
• Extension set for PEG tube 
• The right medication prepared as per pharmacist’s recommendation
• Water for flushing the tube after medication administration.

Procedure  

1. The 5 moments of hand hygiene must be practiced before, during, and after medication administration via enteral tube.  
   
2. Confirm the right medication and right route for the infant/child medication  
   
3. Position the infant/child  
4. Confirm the enteral tube position before medication administration  
5. Flush the enteral tube with water before, in between and after medication administration.  
6. Using the syringe with the prepared medication, attach the tip syringe to the enteral tube.  
7. Administer the medication in a slow and steady manner.  
8. After the completion of medication administration, flush the enteral tube with water.

If nursing staff are unsure of the flush volume please check with senior nursing staff, treating team or the ward pharmacist.

Special considerations 

• DO NOT administer medications through enteral tubes used for aspiration or on free drainage unless specifically directed by medical staff.  
• For gastrostomy tubes, DO NOT use the balloon inflation valve for medication administration. 
• Liquid formulations are usually preferred for enteral tube medication administration; however, some formulation may contain other ingredients that can cause unwanted side-effects (e.g. sorbitol can cause diarrhoea).
• Liquid formulations may also be inappropriate for some patients (e.g. the carbohydrate content may be too high for patients on a ketogenic diet).
• DO NOT mix medications with feeds.  
• DO NOT crush enteric coated or sustained/controlled release medications.  
• If there is no liquid formulation of the medicine, discuss with pharmacist if tablets can be crushed or capsules can be opened.   
• If administering crushed tablets, ensure the tablets are crushed and dissolved well to prevent blockage of the enteral tube.  
• DO NOT use boiling water to flush enteral tube after medication administration.  
• Nursing staff should discuss with pharmacist if there are any drug interaction concerns.  
• Nursing staff should liaise with dietitian and pharmacist if there are certain medications that need to be administered on empty stomach.
  

Companion documents 

• RCH Nursing Guidelines
  • Jejunal feeding and medication administration
  • Nasogastric/orogastric insertion and management 
    
  • Gastrostomy
  • Breastfeeding support and promotion
• RCH Policy and Procedures
  • Expressed breast milk management
  • Medication Management
  • Hand Hygiene
• RCH Departmental Guidelines
  • Nutrition in PICU
• Kids health info
  • Nasogastric tubes
  • Gastrostomy tube
• RCH Formula Room