Enteral Tube feeding - Southern Health and Social Care Trust

SOUTHERN HEALTH & SOCIAL CARE TRUST
Children & Young People’s Directorate
Procedure/Guidelines/Protocol Checklist & Version Control Sheet
1 Name of Procedure/Guidelines/
Protocol:
Procedure for Enteral Tube feeding in the
Neonatal /SCBU environment
2 Purpose of Procedure/
Guidelines/ Protocol:
To provide guidance on Enteral tube
feeding the neonate
3 Replaces: New
4 Applicable to which staff: Neonatal and SCBU nursing staff
5 Name & title of author: Una Toland Lead Nurse Neonatal
Services and ANNP team SH&SCT
6 Equality Screened by:
N/A
Note any issues:
7 Proposals for dissemination: Una Toland via team managers to
nursing staff
8 Proposals for implementation: With immediate effect
9 Training Implications: To be included in induction training of all
new nursing staff
10 Date Procedure/Guideline/ 31:03:13
Protocol submitted to
Procedures Committee:
11 Outcome: Approved Comment:
Approved/Minor
amendments
Not approved
Deferred
12 Date of CYP SMT approval
Comments:
13 Date of approval by Trust SMT
(if required):
14 Date approved by HSCB (Social
Work only):
15 Date for further review (3 year
default):
16 Date added to repository:
17 Date added to Intranet:
State where to be placed on
Intranet:

SOUTHERN HEALTH & SOCIAL CARE TRUST
PROCEDURE FOR ENTERAL TUBE FEEDING IN THE
NEONATAL UNIT
STATEMENT
Within the neonatal environment naso/orogastric tubes are used primarily for the
initiation and progression of enteral feeding, administration of oral medications
and they can also be used for gastric decompression.
The rationale for choice of size of feeding tube and whether or not it is for
short term or long term use is determined by individualised infant care
plans
Gastric tubes are usually passed nasally for ease of insertion and fixation thus
minimising the risk of displacement, but as this occludes one nostril gastric tubes
may be passed orally when there is evidence of respiratory distress
Where thickened feeds are prescribed, larger diameter tubes may be required.
Free drainage of gastric tubes is used when gut decompression is required. To
carry out free drainage, the external end of the tube is inserted into a container
and the stopper opened.
Wide bore tubes (usually PVC) are for short term use only and generally
size 6fg and size 8fg are used.
Infants 1500g will usually have a size 8fg gastric tube passed
PVC tubes should be replaced every 7 days if indwelling or more often if
clinically indicated
If tube is not indwelling a new tube is inserted with every feed.
Fine bore tubes (polyurethane) are intended for long term use
The most common length used in the Neonatal unit is 56cms and size 6fg
and size 8fg. These tubes should be replaced as per manufacturer’s
instructions.
Equipment – non indwelling orogastric tube
Gastric feeding tube
Appropriate milk feed and/ or medication
Syringes – 1 for aspiration
- 1 for bolus feed
pH indicator strips

SOUTHERN HEALTH & SOCIAL CARE TRUST
Equipment – indwelling nasogastric tube
Gastric feeding tube size
Syringes – 1 for aspiration (5ml or 10ml)
- 1 for bolus feed (size depends on feed volume)
Appropriate milk feed
pH indicator strips
Hydrocolloid
Tegaderm
Sterile scissors
NB -if infant is distressed during insertion of feeding tube a soother may be
offered. Or alternatively if clinically indicated oral sucrose may be offered as per
Pain Management Guidelines.
ACTION
Explain procedure to parents/carers
Preparation
Decontaminate hands as per local
policy adhering to 7 step technique
and 5 moments.
Collect appropriate equipment, place
at cot side in preparation for
procedure.
Decontaminate hands again..
Wear appropriate PPE -disposable
apron and
Risk assess each situation. If there
is a risk of contamination with
bodily fluids, ie gastric aspirate or
breast milk then non sterile gloves
should be worn.
Orogastric Insertion using ANTT
approach
Hold the feeding tube approx.
5cms from the end
Use the natural bend of the
tube to follow the natural curves
of the mouth and throat
Insert the tube in the mouth and
towards the back of the throat,
gently pushing it down the
oesophagus until it reaches the
RATIONALE
To ensure parental/carers
understanding, and gain informed
consent.
To prevent cross contamination and
to have all requirements readily
available.
Ensures correct positioning of
feeding tube.
End of feeding tube should remain
inside pack until point of use. Do not
touch key part—tip of feeding tube
and syringe tips.

SOUTHERN HEALTH & SOCIAL CARE TRUST
pre-measured mark on the tube
Establishing correct placement of
the feeding tube
Gently aspirate tube using 5-10ml
syringe. Test reaction of aspirate using
pH indicator strips.
Securing the feeding tube in place
If there is a clinical decision made to
keep the feeding tube in place it
should be secured using a
hydrocolloid base dressing placed on
the infant’s skin onto which the feeding
tube is secured in place. Always check
the correct positioning of the feeding
tube before commencing each feed.
An external sticker should be attached
to the stopper end of the tube
indicating the date the tube was
inserted and the length of insertion.
Procedure for giving a tube feed
Always check the expiry date of
the feed and that the type and
amount of feed required is
correct.
Remove the plunger of a 10,20
or 50ml sterile syringe
Connect the barrel of the
syringe to the end of the gastric
tube
Pinch the feeding tube while
filling the syringe
Fill the barrel with the correct
volume of milk
Let milk flow under gravity
Hold the syringe 5-10cms
above the infant until the
syringe is empty.
It should take approx. 10
minutes for the milk to flow into
the infant’s stomach. Changing
the height of the syringe will
also affect the speed of milk
To check tube position following
insertion. 5-10ml syringe generates
lower pressure on stomach wall.
(Syringe size still under NPSA
review)
NB: if unable to obtain aspirate
consult NPSA Guidelines, 2005 for
checking position of feeding tubes in
babies.
Use of hydrocolloid tape limits
disruption of skin integrity.
Accidental dislodgement can occur
between feeds.
Gravity feeds prevent pressure rises
within the stomach thus decreasing
the risk of regurgitation.
Lowering the syringe slows the milk
flow raising the syringe makes the
milk flow faster.

SOUTHERN HEALTH & SOCIAL CARE TRUST
flow.
Observe the infant during the
entire gastric feed. Do not leave
the infant unattended. Stop the
tube feed if the infant shows
any sign of breathing difficulty,
colour change, looks blue,
becomes floppy, or vomits.
Pinch the feeding tube during
removal or cap the end of the
gastric tube between feeds.
Documentation
Document relevant information in care
pathway to include
Who inserted the feeding tube
Feeding tube size and position
at the lips/nares
Is tube secure
Route of administration of the
feed
pH and amount and colour of
aspirate
Time and volume of feed
administered.
Type of feed administered
To comply with NMC Standards for
record keeping and
recommendations from NPSA alert
―Reducing the harm caused by
misplaced gastric feeding tubes in
babies under the care of neonatal
units August 2005‖
Continuous feeding via a Syringe
pump connected to an indwelling
feeding tube
Only draw up and attach a
syringe containing the volume
of milk required for a 4 hour
period.
Use a new syringe to draw up
milk at every 4 hourly change.
Discard any unused milk and
the syringe at the end of the 4
hour period
The syringe should be labelled
with the date and time of
erection, the infant’s name,
DOB, the type of milk used and
the date and time of the expiry
of the milk.
To reduce risk of microbial growth in
milk or syringe containing milk over
period of time
To ensure the infant receives the
right milk and the milk is within date.

SOUTHERN HEALTH & SOCIAL CARE TRUST
The syringe pump should be
clearly labelled MILK using the
designated milk labels.
A MILK sticker alert should be
placed on the feeding tube
close to the syringe pump and a
further label placed close to the
infant’s nares.
To alert staff that this pump is for
administration of MILK only
To allow staff to track feeding tube
from source to pump as part of
safety checks
March 2013
REFERENCES
Bradford City Teaching Primary Care Trust (2006) Community Children’s
Team Nasogastric Feeding Policy and Procedure. Bradford City Teaching
Primary Care Trust.
Bradford Teaching Hospitals NHS Trust (2004) Children and Neonatal
Services Nasogastric tube policy. Bradford City NHS Trust.
S.H.S.C.T. (2009) Policy on Gaining Consent.
Knox, T and Davie J, (2009) Nasogastric tube feeding – which syringe size
produces lower pressure and is safest to use Nursing Times, 105:27
National Patient Safety Agency (2007) Patient Safety Alert 19. Promoting
safer measurement and administration of liquid medicines via oral and
other enteral routes. London: NPSA
National Patient Safety Agency (2005) Patient Safety Alert 05. How to
confirm the correct position of nasogastric feeding tubes in infants,
children and adults. London: NPSA
Great Ormond Street Hospital NHS Trust (2009). Clinical Guideline:
nasogastric and orogastric tube management
NMC (2008) Guidelines for Record Keeping.
National Patient Safety Agency (2005) Patient Safety Alert 09. Reducing
the harm caused by misplaced naso and orogastric feeding tubes in
babies under the care of neonatal units. London: NPSA.
Freer, Y. and Lyon, A. (2005) Nasogastric tube aspirate pH values
associated with typical enteral feeding patterns in infants admitted to an
NICU, Journal of Neonatal Nursing, 11, 106-109.
ReferenceNewborn Services Clinical Guideline
http://www.adhb.govt.nz/guidelines/nutrition/withholding feeds.htm

SOUTHERN HEALTH & SOCIAL CARE TRUST
FEED TOLERANCE GUIDE FOR NEONATES RECEIVING TUBE FEEDS
Frequency of tube feeds Frequency of aspiration of tube
to assess feed tolerance
hourly
6 hourly
2 hourly 4 hourly
3 hourly 3 hourly
4 hourly 4 hourly
When assessing aspirate volumes always consider
Colour of aspirate
Indicative Colour Chart for Assessing Aspirate Colour
Milk Lemon Mustard Wasabi Lime Avocado Spinach
1 2 3 4 5 6 7
Aspirate colour 4 - 7 Seek medical /ANNP advise before proceeding with feed
Consistency of aspirate -- altered milk appearance
Volume of aspirate
Frequency of feeds
Evidence of possits
Stool pattern, amount, consistency, evidence of blood and/or mucous in
stool. Consider need for glycerine suppository.
Evidence of abdominal distension, discoloration, abdominal tenderness.
Consider need for AXR.
General clinical condition, cardio respiratory instability, temperature
instability.
If aspirate
50% of 3 or
4 hourly total
feed volume
Return
aspirate if
altered milk
Aspirate
stomach
contents
Alert ANNP /Medical
staff, clinically assess
review feeding plan,
document changes..
Alert ANNP / Medical
staff clinically assess.
Review feeding plan
and document changes.
Do not increment
feed.