Jejunal Feeding Guideline - The Royal Children's Hospital

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 ... 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IntroductionAimDefinitionoftermsStaffRolesAssessment Management SpecialconsiderationsCompaniondocumentsEvidencetableReferences IntroductionJejunalfeedingisthemethodoffeedingdirectlyintothesmallbowel.Thefeedingtubeispassedintothestomach,throughthepylorusandintothejejunum.Thistypeoffeedingisalsoknownaspost-pyloricortrans-pyloricfeeding.AimToprovideaframeworkforclinicalconsistencyinthemanagementofjejunalfeedingattheRoyalChildren’sHospital.DefinitionofTerms ClosedFeedingSystem–afeedingsystemwherebyasterilefeedingcontainerisspikedwithafeedingset,topreventcontaminationofthefeedduringadministration. DumpingSyndrome–rapidgastricemptyingwherefoodmovesthroughthesmallboweltooquickly,resultinginanumberofsymptomssuchasnausea,diarrhoeaandabdominalcramps.GastrojejunalTube(G-J)-alowprofileballoondeviceinsertedthroughanexistinggastrostomybyinterventionalradiologywhichextendstothejejunum.Itcontainstwoentrypoints(ports)-agastricportwhichopensintothestomach,andjejunalportwhichopensintothejejunumHomeEnteralNutrition(HEN)–enteraltubefeedingthatoccursoutsideofthehospital,administeredbyparents/carersorpatientsthemselves.NasojejunalTube(NJT)-Thinsofttubepassedthroughapatient’snose,downthebackofthethroat,throughtheoesophagus,stomachandpyloricsphincterintothejejunum.PercutaneousEndoscopicGastrostomy(PEG)-afeedingtubethatisplacedthroughtheabdominalwallandintothestomachPercutaneousEndoscopicGastrostomy-JejunostomyFreka(PEG-JFreka)–PEGdeviceinsertedasaprimarydevicewhennopreviousgastrostomyexists.TheJejunalextensionistheninsertedthroughthemiddleofthePEG.PercutaneousEndoscopicJejunostomy(PEJ)-afeedingtubewhichisinsertedthroughtheabdominalwalldirectlyintothesmallintestine(jejunum) StaffRolesRoleofNursingStaffSafeadministrationofjejunalfeedsandmedicationsduringinpatientstayToprovideeducationondeliveryoffeeds,flushes,medicationadministrationandensureparents/carersarecompetentinflushing,deliveringfeedsandcaringforjejunaltubeForpatientspostPEG-JFrekainsertion,educationshouldalsobecompletedonstomacare/deliveryoffeeds RoleoftheDietitianPatientspostinsertionofjejunalfeedingtubeshouldbemanagedbytheirmainunitdietitian.Adietitianreferralshouldbeinitiatedonadmissionorwhenjejunaltubeisplaced.Toensuregradeupfeedplanandtargetregimeisclearlydocumented FornewinsertionofPEJorG-Jtube,dietitiansshouldrefertoJejunaltubegradeuplocalguidelineEnsurejejunalspecificHomeEnteralNutrition(HEN)educationhasbeencompleted,includingpumptraining(forRCHpatientsnotpreviouslyknowntoRCHnutritiondepartment)RoleofthemanagingmedicalteamReferraltodietitianforrecommendedfeedingplanpostjejunaltubeinsertionReferraltodietitianforRCHHENprogram(asrequired).Pleaseensuredietitianisreferredatleast48hourspriortodischarge. Adviserouteandpreparationadviceformedicationadministration,inconjunctionwithpharmacyEnsureadequatepainmanagementplanisinplace(ifpostPEG-JFreka)AssessmentPatientgroupJejunalfeedingmaybeinitiatedforapatientofanyage.Jejunalfeedingisindicatedinpatientswithgastricoutletobstruction,gastroparesis,pancreatitis,severerefluxwithfalteringgrowth,andknownrefluxwithaspirationofgastriccontents,wherecontinuousgastricfeedinghasbeentrialedandunsuccessful.(1-4)Whileonerous,jejunalfeedingissaferandlessexpensivethanparenteralnutrition(PN).(5,6)Jejunalfeeding canbechallengingduetothefollowingfactors: Thereisanincreased riskofgastro-intestinalinfectionasthetubebypassesthenatural microbiologicaldefensesofthestomach,thereforesterileorpasteurized feedsmustbeusedandanasepticnon-touchtechniqueadheredtowhen manipulatingthefeedingsetThetubecaneasily becomeblockedrequiringfrequentflushingLongerperiodsof feedingresultinreducedmobilityofthepatientThetubesare difficulttoplaceInsertionunderdirectvisionviaradiologicalexposure ispreferred. NJTinsertionwithoutdirectvisionwillrequire confirmation4hourspostprocedurevia abdominalxray.Management Placingthetube Nasojejunal tubesmaybeplacedwiththeassistanceofendoscopyorfluoroscopy.Confirmation ofcorrectpositionofanewlyinsertedtubeismandatorybeforefeedingsor medicationsareadministered.(8-9)AtRCH,therecommendedtubetobeinserted forjejunalfeedingistheyellowCORFLO*silasticenteralfeedingtubewithENfit®connector.SixFrench(6FR) enteraltubesarenotrecommendedastheyblockeasily.  ForNJTplacementforpatientsinPICUand patientsrequiringoutofhoursNJTinsertionthefollowingguidelinewillbe utilisedbynursingstaffcompetentintheprocedure. PICUnutritionguideline(RCHonly):Insertion ofNaso-JejunalTube(NJT) Forlongertermjejunalfeeding,asurgicaljejunostomy(PEJ)tube oragastrostomy-jejunostomy(G-J)tubeisrecommended(2)AtRCH,thisis placedbythesurgicalorgastroenterologyteamandusuallyoccursvia placementofaPEGwithNJTforinitialjejunalfeeding,followedbyconversion toPEG-J.AlternativelyaPEG-JFreka(initialPEG-J)maybeinserted.Patients thatrequirejejunalfeedingcanutilizeajejunaltubeplacedthrougha previousgastrostomy.Thisrequiresalongertubeandhasthepotentialfor displacementcomparedtoatubewithdirectaccesstothejejunum. Confirming thepositionofNJT ThepHleveloftheNJTshouldnotbetested.  Thetipofthejejunaltubehaspotentialtomigratebackintothe stomach.Thetubemarkingatthenostrilshouldberecordedafterinsertion.This shouldbecheckedpriortoadministratinganyliquid,feedormedicationvia thetubetohelpconfirmcorrectposition.(3) Ifapatientisexperiencingclinicalsymptomssuchasretching, vomiting,excessivecoughing-thismayindicatethetubemayhavemigratedto thestomach.Anychangeinthechild’sabilitytotoleratethejejunalfeed shouldbeinvestigated,andthepositionofthejejunaltubecheckedviaX-ray. Tube management DonotaspiratetheNJTasthiscancausecollapseandrecoilof thetube.  ThePEJorG-Jtubemustnotberotatedasthereisariskof displacingthejejunaltubebycoilingitupinthestomach.(3)Asan alternative,thetubeshouldbemovedverygentlyinandoutofthetract approximatelyonecentimetre.(8) Water flushes Jejunalfeedingtubesneedregularflushingtomaintainpatency anditisrecommendedthatsterilewaterisalwaysused.(7,8)Blockingcan occurmorefrequentlyduetonarrowerlumens,thereforewaterflushesare recommendedfourtosixhourly.Thejejunalfeedingtubeshouldbeflushed: Beforeandafter administrationofenteralnutritionBeforeandafter administrationofmedication4hourlywhenon continuousfeeds(ateachbottlechange)4hourlywhenthe tubeisnotinuse Flushingwillbemoreeffectivewithapush-pausetechnique.The lowestvolumenecessarytoclearthetubeisrecommendedforneonatalandpaediatric patients.Suggestedvolumesare: Neonatalpatients: 1-3mLPaediatric patients:3-5mLNote: recommendationscanbe5-10mldependingonthechild’sfluidbalanceand size(8) FeedRegimen Withoutthestomachactingasareservoir,feedgivenasabolus directlyintothejejunumcancauseabdominalpain,diarrhoeaanddumping syndrome.Thisresultsfromrapiddeliveryofhyperosmolarfeedintothe jejunum.Therefore,feedsdeliveredintothejejunumshouldalwaysbegiven slowlybycontinuousinfusion.(2)Anenteralfeedingpumpisthedelivery methodofchoice,asthefeedingratecanbeaccuratelycontrolledintothe jejunum.(7,8) Withinthepaediatricpopulation,thereislittledatatosuggest whatratescanbesafelytolerated.Individualtoleranceneedstobedetermined byclinicalconditionandgradualincreasesinvolumedelivery.  Tomeetthechild’snutritionalrequirements,thefeedwillneed tobeadministeredoveralongperiodoftime,mostlikely16-24hourseach day.(8)Thedietitianshouldproviderecommendationsregardinganappropriate feedingregimenandtoorganisepumptraining. Commencement offeedspostinitialPEJ/G-Jinsertion DietitiantoprovidegradeupfeedplanasguidedbyJejunalfeedingtube gradeuplocalguideline. FeedType Whenfeedingdirectlyintothejejunum,feedenterstheintestine distaltothesiteofreleaseofpancreaticenzymesandbile.(2)Standardpolymeric formulamaybewelltoleratedandshouldbestandardpractice.Ifmalabsorption occurs,atrialperiodofhydrolysedformulaisrecommended.(2,7)Symptomsof malabsorptionincludeabdominalpainanddiarrhoea.Elementalformulaand otherhyperosmolarfeedsshouldbeusedwithcaution.Thickened andfibrecontainingfeedsshouldbeusedwithcautionduetoriskoftube blockage.(7,8)Whereappropriate,closedsystemfeedsshouldbeusedathome. (7) Pureedfoodshouldnotbeputdownthetubeforanyreason. Medications Medications causeocclusioninapproximately15%ofpatientswithenteralfeedingtubes.(10) Complicationsbeyondtubeobstructionthatcanbeattributedtomedicationmay includelackoftherapeuticbenefitanddiarrhoeaanditisrecommendednottousethejejunal feedingtubefortheadministrationofmedicationunlessabsolutelyessential and/ordeliveryintothestomachisnotpossible.(7) Oraldrugadministrationviaajejunaltubeshouldbediscussed withthepharmacyandchild’sdoctorassomemedicationmaybeincompatible withthesmallintestine.Cliniciansshouldevaluate: TubetypeanddiameterLocationofthe distalendofthefeedingtuberelativetothesiteofdrugabsorptionEffectsoffoodon drugabsorption(10) Forexample,antacidsactlocallyinthestomachandarenot suitableforpost-pyloricadministration.Bioavailabilitymayincreasewith intra-jejunaldeliveryofsomedrugs,namelyopioids,tricyclics,betablockers ornitrates.(10)Thismayresultinamorerapidonsetofactionorgreater effectofthemedication. Medicationinliquidformisstronglyencouragedwhereavailable. Ingeneral,medicationshouldnotbeaddedtotheenteralformula,bothto reducetheriskofcontamination(forclosedsystems)andtoavoiddrug-nutrient incompatibilities.(10)Iftheonlywaytogivethedrugsisviathejejunal route,thenthepatientmayneedclosermonitoringforsignsofadverseeffects ofslowortoorapidabsorption.  Toavoidcompromisingnutritionalstatus,itisidealtominimize theamountoftimethatfeedingisinterruptedbyusingoncedailyortwice dailydosageregimens.(10)Ifyouhaveconcernsorquestionsregarding administrationofmedications,pleasespeakwithpharmacy. Frequency ofChange Thereis littleevidencetosupporthowfrequentlyjejunalfeedingtubesshouldbe changed.(11)Commonly,tubesarechangedwhentheybecomeblockedor dislodged.Consensus,withthankstoRCHGastroenterology,ClinicalNutrition andMedicalImagingStaffasshownbelow: Naso-jejunal tubes:upto3-6months(ensurenotexceedingmanufacturerguidelines)G-J/PEJ:6-12 months(12monthswhenanaesthesiarequiredforchangeover) Naso-jejunalfeedsareashort-termapproachtonutritionsupport andadefinitivedecisionforeitherPEG+FundoplicationorPEG-J/PEJfeeding shouldbemadewithin3monthsofcommencingonnaso-jejunalfeeds.Itisthe responsibilityofthemanagingmedicalteamtoarrangetubechangeswithinthe appropriatetimeframes.  HENDischarge Planning Ifthechildiscommencedonenteralfeeding whilsthe/sheisaninpatientatRCHanditisenvisagedthatthismethodof feedingwillcontinuefollowingdischarge,dischargeplanningandHEN preparationshouldcommenceattheearliestopportunity.Pleaseensurethe dietitianisreferredatleast48hourspriortodischarge.  Feedingpump:apumpisrequiredforjejunalfeeding,andispreferredfor gastricfeedingincriticallyillpatients.(8)Feedingshouldbecontinuous over16-24hours. SpecialConsiderationsFastingforprocedures Forpatients fedviaajejunaltube,requiredfastingtimesshouldbediscussedwiththeir anesthetistandmaybeadjustedatthediscretionoftheiranesthetist.  JejunalTube Blockages Tubeblockageisacommonissuewithpatientsreceivingjejunal feeding.(10)Onceblocked,jejunaltubesaredifficulttoclearandthe solutionmaybetoremovetheintestinaltubeandhaveanewtubeinserted.(8) Beforeremovingthetube,attempttocleartheobstructionwith additionalwaterflushes.Thereisnodatatosupporttheuseofcolaor cranberryjuicetounblockfeedingtubes-bothareacidicandmay accidentallycontributetotubeocclusionbydenaturingproteinintheenteral formula.(10,12)  Unblockingmustnotbeperformedusingpressureasthiscanresult insplittingofthetube;accidentalintubation;oesophagealtrauma,gut perforation.(8)CompanionDocumentsPICUnutritionguideline(RCHonly):Insertion ofNaso-JejunalTube(NJT) ClinicalGuideline(nursing):Enteralfeeding andmedicationadministration ConsensusguidelineforfeedingpostJejunal tubeinsertionsincludinginitialPEG-JFrekaandJejunalextensions(nutrition departmentlocalguideline)EvidenceTableThecompleteevidencetablecanbeviewedhere. ReferencesFerrie S.,etal(2018).NutritionSupport Interestgroup.Enteralnutritionmanualforadultsinhealthcare facilities.DietitiansAssociationofAustraliaShawV(2015) ClinicalPaediatric Dietetics,4thEdition. Oxford,WileyBlackwellASPENSafePracticesforEnteralNutritionTherapy.BoullataJI.et al.JournalofParenteraland EnteralNutrition.Volume41Number1.January201715–103Jabbar,A&McClave,SA.Pre-Pyloricversuspost-pyloric feeding.ClinicalNutrition(2005)24,719-726EnteralFeedinginpatientswithmajorburninjury:theuseof nasojejunalfeedingafterthefailureofnasogastricfeeding.Seftonet al,2002,Burns,28:386-390PostPyloricFeeding,NivE,FiremanZandViasmanN,WorldJournal ofGastroenterology,2009,March21,15(11):1281-1288The UseofJejunalTubeFeedinginChildren:APositionPaperbythe GastroenterologyandNutritionCommitteesoftheEuropeanSocietyfor PaediatricGastroenterology,Hepatology,andNutrition2019.BroekaertI. etal.JournalofPaediatricGastroenterologyandNutrition.2019,69(2): 239-258Scott,R.andElwood,T.GOSHguideline:Nasojejunal(NJ)andorojejunal(OJ)management.2015.GastricvsPost-pyloricfeeding:RelationshiptoTolerance, pneumoniarisk,andSuccessfulDeliveryofEnteralNutrition.UklejaAand Sanchez-FerminP,CurrentGastroenterologyReports,2007,9:309-316Beckwithetal.AGuidetoDrugTherapyinPatientswithEnteral FeedingTubes:DosageFormSelectionandAdministrationMethods.Hospital Pharmacy,2004,39(3):225-237Wilson RE.etal.ANaturalHistoryofGastrojejunostomyTubesinChildren.Journal ofSurgicalResearch.2020,245:461-466DandelesLMandLodolceAE.EfficacyofAgentstoPreventandTreatEnteral FeedingTubeClogs.TheAnnalsofPharmacotherapy,2011;45:676-80.Pleaserememberto readthedisclaimerThedevelopmentofthisnursingguidelinewascoordinatedbyEliseMcJannet,PaediatricDietitianandapprovedbytheNursingClinicalEffectivenessCommittee.LastupdateMay2021.  Tweet