In this section
Enteral feeding is a method of supplying nutrients directly into the gastrointestinal tract. This guideline will use this term describe Orogastric, Nasogastric and Gastrostomy tube feeding. A wide range of children may require enteral feeding either for a short or long period of time for a variety of reasons including:
Enteral feeding tubes can be used to:
It is imperative that nursing staff caring for children who have enteral tubes in understand why it is in-situ.For information regarding the Jejunal feeding and medication administration please see the Jejunal Feeding Guideline.
This guideline aims to support nurses in administering feeds and medications via a nasogastric, orogastric or gastrostomy tube in a safe and appropriate manner.Please note this guideline does not refer to the management of Jejunal tubes, for information regarding care of these please see the Jejunal Feeding Guideline.Please note this guideline does not refer to the care of trans-anastomotic tube (TAT), these remain in-situ post-operatively and should not be removed or replaced. If the TAT is dislodged inadvertently, immediately notify the neonatal and surgical teams. Feeds and medications should only be administered via a TAT tube at the direction of the treating medical team.
Link for insertion of Nasogastric and Orogastric Tube Insertion policy, Nutrition on PICU Guidelines and Jejunal Feeding Guideline.
Prior to accessing a NGT/OGT for any reason nursing staff members must ensure that the tube is located in the stomach. Coughing, vomiting and movement can move the tube out of the correct position.The position of the tube must be checked:
Nursing staff should perform the following observations and obtain a gastric aspirate to establish tube position.
Please note: patients who have a history of Liver Failure and known/or suspected oesophageal varices should not have a gastric aspirate removed from the NGT. Instead tube position should be initially confirmed via x-ray with clear documentation of NGT position marker. The medical team should document rationale for not obtaining gastric aspirate in the patient’s progress note as well as an alternative plan to confirm NGT placement.
To check the position of the tube nursing staff members need to have prepared the following equipment:
Some medications and formulas may affect the pH reading. Refer to Nasogastric and Orogastric Tube Insertion procedure (RCH only.) If the patient is receiving a medication which is known to alter pH readings notify medical team, pharmacy and senior nursing staff, a clear plan for confirming the tubes position should be documented in the progress notes.If a reading greater than 5 is obtained, placement of the tube is questionable and it should not be used until the position of the tube is confirmed.If a reading greater than 5 is obtained leave for up to 1 hour and try aspirating again.Small-bore tubes can be difficult to aspirate therefore the following are suggested techniques to try enhance the ability to obtain aspirate:
Correct placement of the tube should be confirmed prior to administration of an enteral feed by checking insertion site at the abdominal wall and observing the child for abdominal pain or discomfort. If the nurse is unsure regarding the position of the gastrostomy
or jejunostomy tube contact the medical team immediately.
During Continuous feeds – Nasogastric/Orogastric Tube:
1. The position of the tube needs to be checked 4 hourly with change of feeds
2. The following needs to be checked 2 hourly during the feed:
Other assessment considerations for the child receiving enteral feeds
The purpose of flushing is to check for tube patency and prevent clogging of enteral tubes.
Flushing is not routine on the Neonatal unit and flushing with air is the preferred method.
Enteral feeding tubes should be flushed regularly with water (or sterile water if appropriate):
Nurses should prepare an enteral/oral syringe, enteral tube connector and water for a flush.
Link to High Flow Nasal Prong (HFNP) therapy clinical guideline.
Feeds can be administered via syringe, gravity feeding set or feeding pump. The method selected is dependent of the nature of the feed and clinical status of the child. There is limited evidence available to support one method of feeding over the other.
For children who have a newly established enteral tube feeding regime:
Do not administer feeds through enteral tubes that are being used for aspiration or are on free drainage.
When preparing to administer feeds nursing staff must confirm the position of the enteral tube.
Prior to and after feeds nurses should adequately flush the enteral tube.
syringe for a bolus feed
gravity feeding for bolus, intermittent feeds and continuous feeds.
An enteral feeding pump can be used intermittent, bolus or continuous administration of feeds, but is best suited for continuous feeding when tolerance to rate of feeding is an issue.
Enteral feeding pumps can be obtained via CARPS if the ward area does not have its own supply. Infinity pumps are now in use throughout RCH and the giving set can be primed by pushing the fill set button. For further information regarding the use of the infinity pump please see the
note: in most situations an IV syringe pump is not recommended for administration of enteral feeds and should not be used on the ward. If very small rates are required, consider using frequent syringe bolus feeding techniques as an alternative.
For older children feeds given as a bolus should be removed from the fridge 15-20 minutes before administration to bring them to room temperature. Feeds given as a bolus may be warmed in an approved bottle warmer. This would be appropriate for all infants and older children who experience discomfort with cooler feeds.
Continuous feeds should NOT be warmed. They may be removed from the fridge 15-20 minutes prior to administration to bring it to room temperature and should not hung for longer than 4 hours – use the dose limit function on the feed pump to ensure this occurs.
Feeds should NOT be warmed in a microwave or in jugs of boiling water.
The tube must be flushed with water (air in neonates) to prevent tube from blocking (see above).
Nursing staff may need to titrate the rate/volume of an enteral feed up or down depending on the clinical status, nutritional needs, size and ability to tolerate feeds of the child. When titrating feeds up nurses should have a goal rate/volume of feed ordered by dietician or the medical team. Feeds should be titrated up in a slow but steady manner, which may need to be adjusted if the child is not able to tolerate the rate/volume of feed. Caution should be taken if titrating feeds up and down in patients with a metabolic condition. When titrating a feed down nursing staff should document why the feed was titrated down, notify dietician and/or medical team to inform them that the child is not tolerating feeds and make a plan to ensure the child is still receiving adequate nutrition and hydration.
Types of feeds
The decision for which type of enteral feed a child should receive should be made in consultation with the dietician, medical team, nursing staff and family, taking into account the nutritional needs, clinical status and tolerance of feeds of the child.
If a child who receives regular enteral feeds at home is admitted to RCH, nursing staff can order and commence their regular feeding regime as the child’s clinical status allows. Enteral feeds can be ordered from the RCH formula room. The family should be offered a dietician review while they are an inpatient to ensure the current feeding regime meets the ongoing nutritional needs of the child.
Nurses who are preparing and administrating medication via an enteral tube must adhere to the Medication Management Procedure.
Consult your ward pharmacist or call Medicines Information (ext: 55208) for advice on how to prepare a drug for enteral administration.
Blocking of tubes can occur due to:
Flushing is the single most effective action that prolongs the life of nasogastric tubes. It is recommended that flushing occur BEFORE, DURING and AFTER administration of enteral medications and feeds.
To unblock enteral tubes, flush the tube in a pulsating manner (push/pull) with 10-20ml with warm water, if it is safe to do so taking into account the child’s age, size and clinical status. It may be appropriate to allow the warm water to soak, by clamping/capping the tube, in the tube to assist with unblocking.
Please note there is no evidence to support the practice of using carbonated drinks such as Coca Cola™ to unblock enteral tubes.
Nurses should consider titrating feeds down or ceasing feeds for a short period of time depending on the clinical status and nutritional needs of the child.When titrating a feed down nursing staff should document why the feed was titrated down, notify dietician and/or medical team to inform them that the child is not tolerating feeds and make a plan to ensure the child is still receiving adequate nutrition and hydration.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 GRV’s can be located under Nutrition in PICU (RCH only).Patients who have a non-functioning GIT (i.e. Ileus post abdominal surgery) may require GRV’s to be discarded post measurement as per the surgical/medical team orders.
Evidence Table - Enteral Feeding and Medication Administration
Please remember to read the
The development of this nursing guideline was coordinated by Stacey Richards, Nurse Consultant, Nursing Research, and approved by the Nursing Clinical Effectiveness Committee. Published December 2017.