Clinical Guidelines (Nursing) : Jejunal Feeding Guideline (2023)

• Introduction
• Aim
• Definition of terms
• Staff Roles
• Assessment
• Management
• Special considerations
• Companion documents
• Evidence table
• References

Introduction

Jejunal feeding is the method of feeding directly into the small bowel. The feeding tube is passed into the stomach, through the pylorus and into the jejunum. This type of feeding is also known as post-pyloric or trans-pyloric feeding.

Aim

To provide a framework for clinical consistency in the management of jejunal feeding at the Royal Children’s Hospital.

Definition of Terms

• Closed Feeding System – a feeding system whereby a sterile feeding container is spiked with a feeding set, to prevent contamination of the feed during administration.
  
• Dumping Syndrome – rapid gastric emptying where food moves through the small bowel too quickly, resulting in a number of symptoms such as nausea, diarrhoea and abdominal cramps.
  
• Gastrojejunal Tube (G-J) - a low profile balloon device inserted through an existing gastrostomy by interventional radiology which extends to the jejunum. It contains two entry points (ports) - a gastric port which opens into the stomach, and jejunal port which opens into the jejunum
  
• Home Enteral Nutrition (HEN) – enteral tube feeding that occurs outside of the hospital, administered by parents/carers or patients themselves.
  
• Nasojejunal Tube (NJT) - Thin soft tube passed through a patient’s nose, down the back of the throat, through the oesophagus, stomach and pyloric sphincter into the jejunum.
  
• Percutaneous Endoscopic Gastrostomy (PEG) - a feeding tube that is placed through the abdominal wall and into the stomach
  
• Percutaneous Endoscopic Gastrostomy-Jejunostomy Freka (PEG-J Freka) – PEG device inserted as a primary device when no previous gastrostomy exists. The Jejunal extension is then inserted through the middle of the PEG.
  
• Percutaneous Endoscopic Jejunostomy (PEJ) - a feeding tube which is inserted through the abdominal wall directly into the small intestine (jejunum)
  

Staff Roles

Role of Nursing Staff

• Safe administration of jejunal feeds and medications during inpatient stay
• To provide education on delivery of feeds, flushes, medication administration and ensure parents/carers are competent in flushing, delivering feeds and caring for jejunal tube
  
• For patients post PEG-J Freka insertion, education should also be completed on stoma care/delivery of feeds
  

Role of the Dietitian

• Patients post insertion of jejunal feeding tube should be managed by their main unit dietitian. A dietitian referral should be initiated on admission or when jejunal tube is placed.
  
• To ensure grade up feed plan and target regime is clearly documented
  
• For new insertion of PEJ or G-J tube, dietitians should refer to Jejunal tube grade up local guideline
  
• Ensure jejunal specific Home Enteral Nutrition (HEN) education has been completed, including pump training (for RCH patients not previously known to RCH nutrition department)
  

Role of the managing medical team

• Referral to dietitian for recommended feeding plan post jejunal tube insertion
  
• Referral to dietitian for RCH HEN program (as required). Please ensure dietitian is referred at least 48 hours prior to discharge.
  
• Advise route and preparation advice for medication administration, in conjunction with pharmacy
  
• Ensure adequate pain management plan is in place (if post PEG-J Freka)
  

Assessment

Patient group

Jejunal feeding may be initiated for a patient of any age. Jejunal feeding is indicated in patients with gastric outlet obstruction, gastroparesis, pancreatitis, severe reflux with faltering growth, and known reflux with aspiration of gastric contents, where continuous gastric feeding has been trialed and unsuccessful. (1-4) While onerous, jejunal feeding is safer and less expensive than parenteral nutrition (PN). (5, 6)

Jejunal feedingcan be challenging due to the following factors:

• There is an increased risk of gastro-intestinal infection as the tube bypasses the natural microbiological defenses of the stomach, therefore sterile or pasteurized feeds must be used and an aseptic non-touch technique adhered to when manipulating the feeding set
• The tube can easily become blocked requiring frequent flushing
• Longer periods of feeding result in reduced mobility of the patient
• The tubes are difficult to place
• Insertion under direct vision via radiological exposure is preferred.NJT insertion without direct vision will require confirmation 4 hours post procedure viaabdominal xray.

Management

Placing the tube

Nasojejunaltubes may be placed with the assistance of endoscopy or fluoroscopy. Confirmationof correct position of a newly inserted tube is mandatory before feedings ormedications are administered. (8-9) At RCH, the recommended tube to be insertedfor jejunal feeding is the yellow CORFLO* silastic enteral feeding tube with ENfit® connector. Six French (6FR)enteral tubes are not recommended as they block easily.

For NJT placement for patients in PICU andpatients requiring out of hours NJT insertion the following guideline will beutilised by nursing staff competent in the procedure.PICU nutrition guideline (RCH only): Insertionof Naso-Jejunal Tube (NJT)

For longer term jejunal feeding, a surgical jejunostomy (PEJ) tubeor a gastrostomy-jejunostomy (G-J) tube is recommended (2) At RCH, this isplaced by the surgical or gastroenterology team and usually occurs viaplacement of a PEG with NJT for initial jejunal feeding, followed by conversionto PEG-J. Alternatively a PEG-J Freka (initial PEG-J) may be inserted. Patientsthat require jejunal feeding can utilize a jejunal tube placed through aprevious gastrostomy. This requires a longer tube and has the potential fordisplacement compared to a tube with direct access to the jejunum.

Confirmingthe position of NJT

The pH level of the NJT should not be tested.

The tip of the jejunal tube has potential to migrate back into thestomach. The tube marking at the nostril should be recorded after insertion. Thisshould be checked prior to administrating any liquid, feed or medication viathe tube to help confirm correct position. (3)

If a patient is experiencing clinical symptoms such as retching,vomiting, excessive coughing- this may indicate the tube may have migrated tothe stomach. Any change in the child’s ability to tolerate the jejunal feedshould be investigated, and the position of the jejunal tube checked via X-ray.

Tubemanagement

Do not aspirate the NJT as this can cause collapse and recoil ofthe tube.

The PEJ or G-J tube must not be rotated as there is a risk ofdisplacing the jejunal tube by coiling it up in the stomach. (3) As analternative, the tube should be moved very gently in and out of the tractapproximately one centimetre. (8)

Waterflushes

Jejunal feeding tubes need regular flushing to maintain patencyand it is recommended that sterile water is always used. (7, 8) Blocking canoccur more frequently due to narrower lumens, therefore water flushes arerecommended four to six hourly. The jejunal feeding tube should be flushed:

• Before and after administration of enteral nutrition
• Before and after administration of medication
• 4 hourly when on continuous feeds (at each bottle change)
• 4 hourly when the tube is not in use

Flushing will be more effective with a push-pause technique. Thelowest volume necessary to clear the tube is recommended for neonatal and paediatricpatients. Suggested volumes are:

• Neonatal patients: 1-3mL
• Paediatric patients: 3-5mL
• Note: recommendations can be 5-10ml depending on the child’s fluid balance and size (8)

Feed Regimen

Without the stomach acting as a reservoir, feed given as a bolusdirectly into the jejunum can cause abdominal pain, diarrhoea and dumpingsyndrome. This results from rapid delivery of hyperosmolar feed into thejejunum. Therefore, feeds delivered into the jejunum should always be givenslowly by continuous infusion. (2) An enteral feeding pump is the deliverymethod of choice, as the feeding rate can be accurately controlled into thejejunum.(7,8)

Within the paediatric population, there is little data to suggestwhat rates can be safely tolerated. Individual tolerance needs to be determinedby clinical condition and gradual increases in volume delivery.

To meet the child’s nutritional requirements, the feed will needto be administered over a long period of time, most likely 16-24 hours eachday. (8) The dietitian should provide recommendations regarding an appropriatefeeding regimen and to organise pump training.

Commencementof feeds post initial PEJ/G-J insertion

Dietitian to provide grade up feed plan as guided by Jejunal feeding tubegrade up local guideline.

Feed Type

When feeding directly into the jejunum, feed enters the intestinedistal to the site of release of pancreatic enzymes and bile. (2) Standard polymericformula may be well tolerated and should be standard practice. If malabsorptionoccurs, a trial period of hydrolysed formula is recommended. (2, 7) Symptoms ofmalabsorption include abdominal pain and diarrhoea. Elemental formula andother hyperosmolar feeds should be used with caution. Thickenedand fibre containing feeds should be used with caution due to risk of tubeblockage. (7,8) Where appropriate, closed system feeds should be used at home.(7)

Pureed food should not be put down the tube for any reason.

Medications

Medicationscause occlusion in approximately 15% of patients with enteral feeding tubes. (10)Complications beyond tube obstruction that can be attributed to medication mayinclude lack of therapeutic benefit and diarrhoea and it is recommended not to use the jejunalfeeding tube for the administration of medication unless absolutely essentialand/or delivery into the stomach is not possible. (7)

Oral drug administration via a jejunal tube should be discussedwith the pharmacy and child’s doctor as some medication may be incompatiblewith the small intestine. Clinicians should evaluate:

• Tube type and diameter
• Location of the distal end of the feeding tube relative to the site of drug absorption
• Effects of food on drug absorption (10)

For example, antacids act locally in the stomach and are notsuitable for post-pyloric administration. Bioavailability may increase withintra-jejunal delivery of some drugs, namely opioids, tricyclics, beta blockersor nitrates. (10) This may result in a more rapid onset of action or greatereffect of the medication.

Medication in liquid form is strongly encouraged where available.In general, medication should not be added to the enteral formula, both toreduce the risk of contamination (for closed systems) and to avoid drug-nutrientincompatibilities. (10) If the only way to give the drugs is via the jejunalroute, then the patient may need closer monitoring for signs of adverse effectsof slow or too rapid absorption.

To avoid compromising nutritional status, it is ideal to minimizethe amount of time that feeding is interrupted by using once daily or twicedaily dosage regimens. (10) If you have concerns or questions regardingadministration of medications, please speak with pharmacy.

Frequencyof Change

There islittle evidence to support how frequently jejunal feeding tubes should bechanged. (11) Commonly, tubes are changed when they become blocked ordislodged. Consensus, with thanks to RCH Gastroenterology, Clinical Nutritionand Medical Imaging Staff as shown below:

• Naso-jejunal tubes: up to 3-6 months (ensure not exceeding manufacturer guidelines)
• G-J / PEJ: 6-12 months (12 months when anaesthesia required for changeover)

Naso-jejunal feeds are a short-term approach to nutrition supportand a definitive decision for either PEG + Fundoplication or PEG-J/PEJ feedingshould be made within 3 months of commencing on naso-jejunal feeds. It is theresponsibility of the managing medical team to arrange tube changes within theappropriate time frames.

HEN DischargePlanning

Special Considerations

Fasting for procedures

For patientsfed via a jejunal tube, required fasting times should be discussed with theiranesthetist and may be adjusted at the discretion of their anesthetist.

Jejunal TubeBlockages

Tube blockage is a common issue with patients receiving jejunalfeeding. (10) Once blocked, jejunal tubes are difficult to clear and thesolution may be to remove the intestinal tube and have a new tube inserted. (8)

Before removing the tube, attempt to clear the obstruction withadditional water flushes. There is no data to support the use of cola orcranberry juice to unblock feeding tubes - both are acidic and mayaccidentally contribute to tube occlusion by denaturing protein in the enteralformula. (10,12)

Unblocking must not be performed using pressure as this can resultin splitting of the tube; accidental intubation; oesophageal trauma, gutperforation. (8)

Companion Documents

PICU nutrition guideline (RCH only): Insertionof Naso-Jejunal Tube (NJT)

Clinical Guideline (nursing): Enteral feedingand medication administration

Consensus guideline for feeding post Jejunaltube insertions including initial PEG-J Freka and Jejunal extensions (nutritiondepartment local guideline)

Evidence Table

The complete evidence table can be viewed here.

References

1. FerrieS., et al (2018). Nutrition SupportInterest group. Enteral nutrition manual for adults in health carefacilities. Dietitians Association of Australia
2. Shaw V (2015)Clinical Paediatric Dietetics, 4th Edition.Oxford, Wiley Blackwell
3. ASPEN Safe Practices for Enteral Nutrition Therapy. Boullata J I. et al. Journal of Parenteral and Enteral Nutrition. Volume 41 Number 1. January 2017 15–103
4. Jabbar, A & McClave, S A. Pre-Pyloric versus post-pyloric feeding. Clinical Nutrition (2005) 24, 719-726
5. Enteral Feeding in patients with major burn injury: the use of nasojejunal feeding after the failure of nasogastric feeding. Sefton et al, 2002, Burns, 28:386-390
6. Post Pyloric Feeding, Niv E, Fireman Z and Viasman N, World Journal of Gastroenterology, 2009, March 21, 15(11): 1281-1288
7. The Use of Jejunal Tube Feeding in Children: A Position Paper by the Gastroenterology and Nutrition Committees of the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition 2019. Broekaert I. et al. Journal of Paediatric Gastroenterology and Nutrition. 2019, 69(2): 239-258
8. Scott, R. and Elwood, T. GOSH guideline: Nasojejunal (NJ) and orojejunal (OJ) management. 2015.
9. Gastric vs Post-pyloric feeding: Relationship to Tolerance, pneumonia risk, and Successful Delivery of Enteral Nutrition. Ukleja A and Sanchez-Fermin P, Current Gastroenterology Reports, 2007, 9:309-316
10. Beckwith et al. A Guide to Drug Therapy in Patients with Enteral Feeding Tubes: Dosage Form Selection and Administration Methods. Hospital Pharmacy, 2004, 39 (3): 225-237
11. Wilson RE. et al. A Natural History of Gastrojejunostomy Tubes in Children. Journal of Surgical Research. 2020, 245:461-466
12. Dandeles LM and Lodolce AE. Efficacy of Agents to Prevent and Treat Enteral Feeding Tube Clogs. The Annals of Pharmacotherapy, 2011 ;45:676-80.

Please remember toread the disclaimer

The development of this nursing guideline was coordinated by Elise McJannet, Paediatric Dietitian and approved by the Nursing Clinical Effectiveness Committee. Last update May 2021.