Enteral Tube Policy (3)

NICU—Enteral Tubes for Feeding or Drainage Care Guidelines Manual: Clinical Manual

Document No.:

Section: Maternal Child Program

Original Date: Oct 2009

Developed by: Maternal Child Program

Revision Date(s):

Approved by:

Review Date:

Cross Reference to:

NICU—Enteral Feeding Guidelines, Vital Sign Monitoring Guidelines, Skin Care Guidelines, Oral Feeding Guidelines Document Applies to: NICU and Paediatric’s A printed copy of this document may not reflect the current, electronic version on Lakeridge Health’s Intranet, ‘The Wave.’ Any copies of this document appearing in paper form should ALWAYS be checked against the electronic version prior to use.

Preamble: Critically ill or premature infants require a coordinated suck/swallow/breath mechanism, sustain alert/awake behaviours, and maintain cardio respiratory stability in order to achieve successful oral feeding. These mechanisms and behaviours develop through a gradual maturation process. A critically ill or premature infant may require gavage feeding until they reach readiness and maturational levels required to successfully oral feed.

Definitions: Orgogastric Tube or (OGT): a polyethylene or silasticweighted enteral f feeding tube that is inserted into the oral cavity and passed through to the stomach for the purpose of stomach decompression, feeding, or medication administration. Nasogastric Tube or (NGT): a polyethylene or weighted enteral silastic feeding tube that is inserted into the nares and passed through to the stomach for the purpose of stomach decompression, feeding, or medication administration.

______________________________________________________________________________________________ This material has been prepared solely for the use at Lakeridge Health Corporation (Lakeridge Health). Lakeridge Health accepts no responsibility for use of this material by any person or organization not associated with Lakeridge Health. No part of this document may be reproduced in any form for publication without the permission of Lakeridge Health.

NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

Guidelines: a) Initiation and Maintenance Guidelines: 

Insertion, position verification, tube utilization, and removal of a Nasogastric Tube (NGT) or Orogastric Tube (OGT) will be performed by a Registered Nurse.



Insertion of enteral tube and/or initiation of gavage feeding will be completed by physician order OR based on a nursing assessment meeting the following qualifications(AWHONN, 2006; PPPESO, 2008; PPPESO, 2008b):

o Gestational age greater than 34 weeks AND o Free of signs and symptoms suggestive of respiratory distress (i.e. respiratory rate greater than 60 breaths per minute) AND

o Hypoglycemic and unable to orally feed AND o Inability to breast feed or bottle feed due to physiologic status AND o Absence of oral feeding readiness cues (i.e. feeding behavioural cues, infant sucking behaviours, absent or weak gag reflex, and disorganized suck/swallow/breathing coordination) 

Continuous enteral feedings will be initiated as per physician order (AWHONN, 2006).



Oral and nasal assessment and hygiene will be performed at least once a shift, ideally every 3 to 4 hours or PRN (AWHONN, 2006; AWHONN, 2006b). Regular assessment and care of skin around tube entry site and securing devices facilitates early recognition of skin break down and supports implementation of skin care practices (AWOHNN, 2006b).



OGT insertion is required for all infants who are receiving bag/mask ventilation or are receiving CPAP ventilation support (AHA/CPS/AAP, 2006). The OGT will remain open to straight drainage unless otherwise ordered (AHA/CPS/AAP, 2006).



The smallest size enteral feeding tube (i.e. 5 or 6 Fr) will be utilized to reduce incidence of swallowing difficulties, blockage of nares, and gastroesophageal reflux (AWHONN, 2006; Cloherty & Stark, 1991; Merentstein & Gardner, 1993; PPPESO, 2008; PPPESO, 2008b).

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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines



Larger size enteral feeding tubes will be utilized for gastric drainage or decompression (i.e. 8Fr) (AHA/CPS/AAP, 2006; PPPESO, 2008).



Utilization of enteral tubes for infants with certain conditions (i.e. facial or tracheoesophageal congenital anomalies) will be done cautiously and in consultation with a physician (AWHONN, 2006).



Polyvinyl Chloride (PVC) tubes will be routinely changed every 72 hours— alternating nares as possible (PPPESO, 2008).



Weighted enteral feeding tubes will be changed every 4 to 6 weeks or by order of the physician (PPPESO, 2008).



Tube placement verification frequency recommendations (PPPESO, 2008; PPPESO, 2008b): o

Intermittent feeds: after tube insertion and prior to beginning each feed

o

Continuous feeds: after tube insertion and every four hours

o

Medication administration: after tube insertions, prior to medication administration, prior to tube irrigation, or prior to any fluid instillation



Tube placement will completed by(PPPESO, 2008; PPPESO, 2008b):

o Measurement of enteral tube via centimeter marking are nares OR measurement of tube from nares to end of tube (if no centimeter marking available)

o Auscultation of gastric ‘pop’ prior to EACH feeding o Gastric pH testing and assessment of gastric aspirate after insertion, prior to the first feeding session of a shift, and as needed for the duration of the shift based on nursing assessment o

Weighted enteral feeding tube placement will be verified via x-ray confirmation



A registered nurse will remain present throughout the enteral feeding session (Merenstein & Gardner, 1993; PPPESO, 2008b).



An infant receiving enteral feedings will have a functional suctioning system and emergency oxygen with a bag-mask set up at their bedside.



Infants being continuously monitored will have monitors ON with audible alarms set for duration of feeding to support assessment of tolerance and potential signs

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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

of feeding intolerance (i.e. change in oxygen requirement evidenced by decreases in oxygen saturation, colour changes, and changes in heart and respiratory rates (AWHONN, 2006; Cloherty & Stark, 1991; Merenstein & Gardner, 1993).



Infants will be offered a pacifier during gavage feedings after informed consent from parents is obtained. Non-nutritive sucking has been shown to accelerate maturation of sucking reflex, lead to earlier initiation of oral feedings, and increase daily weight gain (AWHONN, 2006; Boiron, Da Nobrega, Roux, Henrot, & Saliba, 2007; Cloherty & Stark, 1991).



Bottle feeding or breast feeding attempts will last a total of 20-30 minutes with the balance of the feeding administered via enteral tube (Kirk, Alder, & King, 2007; Merenstein & Gardiner, 1993; PPPESO, 2008b).



During insertion and removal procedures infant’s eyes will be protected to reduce risk for conjunctivitis (PPPESO, 2008).

b) Equipment:

1. Sterile feeding tube of appropriate size (Merenstein & Gardner, 1993; PPPESO, 2008) 

5 Fr tube utilized for infants less than 1500 kgs



6 Fr tube utilized for infants greater than 1501 kgs



8 Fr tube utilized for gastric drainage or decompression

2. Clear, non-allergenic tape, transparent semi-permeable membrane dressing, or other (i.e. Hypafix or Mepore) 3. 10 mL syringe 4. Non-sterile procedure gloves 5. Stethoscope 6. Measuring Tape 7. pH testing stripes 8. Water based lubricant or sterile water 9. Feeding system set-up (syringe, feeding bag, extension tubing, and/or syringe/feeding pump) c) Insertion Procedure: Lakeridge Health Corporation

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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

1. Prepare equipment, see section (b). 2. Complete abdominal assessment. 3. Position infant supine with head slightly extended and head of bed elevated. 4. Measure tube to determine distance. •

With the tube, measure from bridge of nose to the earlobe, then down to the mid-point between the xyphoid process and the umbilicus. Mark the tube at that point with a piece of tape.

5. Bundle infant leaving chest exposed. 6. Lubricate tip of the tube with sterile water just before insertion. 7. Immobilize infant’s head with one hand. 8. Gently insert tube via mouth or nose towards the pharynx and advance it down until the tape marker is reached. 9. Remove tube if infant begins coughing, fighting, or becomes cyanotic. Reinsert tube when infant is stable. 10.

Check for correct placement, see section (d).

11.

Anchor tube in place with a semi-permeable dressing.

12.

Label tube with date and time of insertion.

13.

For enteral tubes with NO cm markings—Measure length of tube from nose to distal end and note measurement on patient chart.

Respources:



Refer to Wong’s Nursing Care of Infants and Children, page 1133-1134 for detailed procedure: Hockenberry, M. J., & Wilson, D., (2007). Wong’s Nursing Care of Infants and Children. Mosby Elsevier: St. Louis, Missouri.



Refer to Neonatal Resuscitation Textbook, pages 3-26 to 3-28 for detailed procedure: American Heart Association (AHA), Canadian Paediatric Society (CPS), & American Academy of Pediatrics (AAP). (2006). Neonatal Resuscitation Textbook. 5th Edition. Canadian Paediatric Society: Ottawa, ON.

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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

d) Tube Position Verification:

1. Verification of placement utilizing measurement of an indwelling enteral tube (PPPESO, 2008)

i. Feeding tubes with centimeter marking present 

Verify centimeter marking located at the nares and confirm

with prior data

ii. Feeding tube without centimeter marking present 

Verify position by measuring the length of enteral tube

remaining ‘outside’ (i.e. measure from nares to end of enteral tube connecting port)

2. Auscultation of Gastric ‘pop’ (PPPESO, 2008; PPPESO, 2008b). 1. Position stethoscope over epigastric region (i.e. upper left quadrant) of stomach

2. Using a 10 mL syringe, rapidly inject 1-2 mL (full-term) or 0.5-1 mL (premature) of air into tube while auscultating for resultant ‘pop’ in the stomach 3. If gastric ‘pop’ is not auscultated, repeat procedure with a slightly larger volume of air 4. Always withdraw the same amount of air that was injected 5. Discard syringe

6. A gastric ‘pop’ by itself is not a reliable measure for confirmation of proper enteral tube placement. Referred sounds can still be heard in the stomach if the tube end is placed in the respiratory, intestinal, or esophageal systems. This method of placement verification must be used in conjunction with other verification methods, such as the assessment of gastric pH.

3. Assessment of gastric pH procedure guideline (PPPESO, 2008; PPPESO, 2008b): i.

Obtain gastric aspirate:

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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

a. Intermittent Feeds or Medication Administration: 

Attach syringe to feeding tube and inject 1-3 mL of air to clear tube



Apply gentle suction and withdraw approximately 1 mL of gastric contents



Apply gastric contents on pH testing strip—ensure saturation of testing square—remove excess fluid by placing strip on its side —test pad may take up to 10 minutes for complete colour change

b. Continuous Feeds: 

Turn feeding pump off and detach feeding tube



Attach syringe to feeding tube and inject 1-3 mL of air to clear tube



Apply gentle suction and withdraw approximately 1 mL of gastric contents



Apply gastric contents on pH testing strip—ensure saturation of testing square—remove excess fluid by placing strip on its side —test pad may take up to 10 minutes for complete colour change

ii. Gastric pH testing (May, 2007; PPPESO, 2008; PPPESO, 2008b): c. Assess and document gastric contents: 

Gastric aspirates range in colour from clear/white/tan to green/blood-tinged/brown. Consistency may be clear, cloudy, or curdled looking



Duodenal secretions tend to be yellow and clear



Pleural aspirates are usually clear to yellow serous type fluid and may be blood tinged from trauma



Tracheobronchial secretions are usually mucousy/white to yellow in colour

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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

d. Assessment of pH strip (May, 2007; PPPESO, 2008; PPPESO, 2008b): 

Compare test strip to chart included with test strip pack



Match the colours of the test pad to the reference chart and document resulting pH level

•

The pH of gastric contents are less than or equal to 5

•

Infants who have been feed recently, continuously, or are receiving acid-suppressing medications may have a gastric pH level equal to or less than 6

•

Gastric pH levels of greater than 6 are more likely to occur if the enteral tube is positioned in the duodenum or respiratory system and should have the enteral tube removed and re-inserted



Discard the syringe used for gastric testing immediately after use to reduce risk of colonization of gastrointestinal bacteria

e) Feeding: 1. Assemble equipment 

Sterile syringe of appropriate size for feed



Expressed breast milk or formula



Sterile water



Feeding or syringe pump and extension tubing as required

2. Verify correct enteral tube placement 

Complete position verification procedures—see section (d)



In addition to this, aspirate stomach for gastric residual from

previous feeding (PPPESO, 2008, PPPESO, 2008b) o

Assess colour, consistency, and amount of residual

o

Re-feed residual unless otherwise ordered

o

Gastric contents contain vital enzymes and nutrients.

Unless otherwise ordered or aspirate is bloody, green, bright Lakeridge Health Corporation

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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

yellow, or otherwise unusual in appearance—return the contents to the stomach (PPPESO, 2008; PPPESO, 2008b). Incompletely digested aspirates of 2ml/kg, or a 1 hour

o

volume, 1 hour volume if on continuous feeding is considered normal and should be returned to the infant (Merenstein & Gardner, 1993) Feedings should be held and a physician notified if:

o •

Abnormal abdominal exam;

•

Presence of bile, blood or coffee grounds in residuals;

•

Abdominal girth has increased by 1 cm in infant less than 28 weeks corrected age;

•

Abdominal girth has increased by 2 cm in infant 28 weeks or greater corrected age;

•

25% residual of previous feed for a second consecutive time OR residual is greater than 25% of previous feed plus other abnormal signs

3. Complete gastrointestinal assessment (Cloherty & Stark, 1991; Merenstein & Gardner, 1993; PPPESO, 2008; PPPESO, 2008b) 

Abdominal girth



Appearance of abdomen (i.e. size, shape, an softness)



Auscultation of all quadrants for bowel sounds



Observe for: bowel loops, abdominal discoloration, abdominal

distention, emesis or increased gastric residuals, blood in stools, or regurgitation (i.e. frequent swallowing, coughing, or arching) 

Weight gain/loss patterns

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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

4. Feeding Administration



Intermittent Feedings (Cloherty & Stark, 1991; Merenstein & Gardner,

1993; PPPESO, 2008; PPPESO, 2008b): 1.

Position infant prone, side-lying, or semi-upright (30 degree

angle) during and after feed 2.

Measure feeding amount in graduated bottled

3.

Attach syringe barrel to feeding tube

4.

Fill syringe to desired amount of feed

5.

Holde syringe barrel 6 to 8 inches above infants head

6.

Allow feed to flow into stomach via gravity, enteral feedings

must never be administered under pressure 7.

Administer feeding at a rate of 1-2 mL/kg/min or

approximately over 15-30 minutes 8.

After completion, instill 1 to 2 mL of sterile water or air to clear

tubing and re-cap



Continuous or Timed Feedings (Cloherty & Stark, 1991; Merenstein &

Gardner, 1993; PPPESO, 2008; PPPESO, 2008b): 1.

Position infant prone, side-lying, or semi-upright (30 degree

angle) during and after feed 2.

Measure feeding amount in syringe

3.

Attach syringe to extension tubing and prime

4.

Load syringe or tubing into feeding/syringe pump

5.

Connect to enteral tube

6.

Program pump to administer feeding volume at prescribed rate

7.

Administer feeding

8.

After completion, instill 1 to 2 mL of sterile water or air to clear

tubing and re-cap 9.

Flush extension tubing

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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines



Extension tubing or feeding systems will be changed every 12

hours—if feeding amounts are small systems will be changed every 8 hours 

All tubing will labeled for change requirements (i.e. date

opened) 

For continuous feedings—a maximum of 4 hours of feeding

volume will be hung for infusion

f) Drainage (AHA/CPS/AAP, 2006; PPPESO, 2008): 1. Assemble equipment (refer to previous section) 2. Verify placement (refer to previous section) 3. Leave tube open to drainage—a collection container may need to be applied to the end of tube if there are copious secretions draining 4. Document drainage amounts on patient chart—consult with physician if drainage amounts are profuse or increase incrementally over a shift —replacement fluids may need to be given

g) Tube Removal (Cloherty & Stark, 1991; Merenstein & Gardner, 1993; PPPESO, 2008): 1. Obtain equipment as necessary 2. Explain procedure to parents if present 3. Position infant prone or lateral 4. Loosen tapes 5. Pinch tubing while withdrawing tube in a steady motion 6. Complete nasal and/or mouth care as required h) Documentation: •

As per Lakeridge Health Corporation Documentation Standards.

References: American Heart Association (AHA), Canadian Paediatric Society (CPS), & American Academy of Pediatrics (AAP). (2006). Neonatal Resuscitation Textbook. 5th Edition. Canadian Paediatric Society: Ottawa, ON. Lakeridge Health Corporation

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American Academy of Pediatrics (AAP) & American Heart Association (AHA). (2005). Pediatric Advanced Life Support Professional Provider Manual. 5th Edition. American Heart Association: Dallas, Texas. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), (2006). Neonatal Orientation and Education Program—Module 4 Metabolic and Nutritional Support. Association of Women’s Health, Obstetric and Neonatal Nurses: Washington, DC. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), (2006b). Neonatal Orientation and Education Program—Module 5 Skin and Skin Care. Association of Women’s Health, Obstetric and Neonatal Nurses: Washington, DC. Boiron, M, Da Nobrega, L., Roux, S., Henrot, A., & Saliba, E., (2007). Effects of oral stimulation and oral support on non-nutritive sucking and feeding performance in preterm infants. Developmental Medicine & Child Neurology. 49(6), 439-444. Cloherty, J. P. & Stark, A. R. (eds.), (1991). Manual of Neonatal Care—Joint Program in Neonatology, Harvard Medical School, Beth Israel Hospital, Brigham and Women’s Hospital, and The Children’s Hospital of Boston. 3rd Edition. Little, Brown and Company: Boston, USA. Hockenberry, M. J., & Wilson, D., (2007). Wong’s Nursing Care of Infants and Children. Mosby Elsevier: St. Louis, Missouri. Karlsen, K. (2006). The S.T.A.B.L.E. Program. Post-resuscitation/Pre-transport Stabilization Care of Sick Infants. Guidelines for Neonatal Healthcare Providers. 5th Edition. S.T.A.B.L.E. Inc.: Park City, Utah. Kirk, A. T., Alder, S. C., & King, J. D., (2007). Cue-based oral feeding clinical pathway results in earlier attainment of full oral feeding in premature infants. Journal of Perinatology. 2007(27), 572-578. May, S., (2007). Testing nasogastric tube positioning in critically ill: exploring the evidence. British Journal of Nursing. 16(7), 414-418. Merenstein, G. B. & Gardner, S. L., (1993). Handbook of Neonatal Intensive Care. 3rd Edition. Mosby Year Book: St. Louis, USA. PPPESO, (2008). Gastric Tube Insertion. Perinatal Nursing Procedure by Perinatal Partnership Program of Eastern & Southeastern Ontario. Accessed at: http://www.pppeso.on.ca PPPESO, (2008b). Gavage Feeding. Perinatal Nursing Procedure by Perinatal Partnership Program of Eastern & Southeastern Ontario. Accessed at: http://www.pppeso.on.ca

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