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Guideline Summary
Guideline Title
Enteral nutrition administration. In: A.S.P.E.N. enteral nutrition practice recommendations.
Bibliographic Source(s)
Bankhead R, Boullata J, Brantley S, Corkins M, Guenter P, Krenitsky J, Lyman B, Metheny NA, Mueller C, Robbins S, Wessel J. Enteral nutrition administration. In: A.S.P.E.N. enteral nutrition practice recommendations. JPEN J Parenter Enteral Nutr. 2009 Mar-Apr;33(2):149-58. [88 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Conditions or disease states requiring enteral nutrition

Guideline Category
Management
Clinical Specialty
Family Practice
Gastroenterology
Geriatrics
Infectious Diseases
Internal Medicine
Nephrology
Nursing
Nutrition
Pediatrics
Pharmacology
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Health Plans
Hospitals
Managed Care Organizations
Nurses
Pharmacists
Physician Assistants
Physicians
Utilization Management
Guideline Objective(s)
  • To examine the available literature related to the ordering, preparation, delivery, and monitoring of enteral nutrition
  • To establish evidence-based practice guidelines for the safe and effective use of enteral nutrition
Target Population

Patients in need of enteral nutrition throughout the lifecycle and throughout all practice settings

Interventions and Practices Considered
  1. Initiation and advancement of enteral nutrition regimens
    • Bolus feedings and gravity-controlled feedings in adults and children
    • Pump-assisted feedings in adults and children
  2. Special considerations for the preterm infant
  3. Enteral feeding pumps
  4. Patient positioning: head of bed positioning
  5. Flushes
    • Special considerations for pediatrics
    • Flush solutions to prevent tube clogging
  6. Enteral misconnections
Major Outcomes Considered
  • Duration of feeding
  • Time to reaching nutrition goals
  • Changes in body weight
  • Change in relative risk of morbidity and mortality in preterm infants
  • Frequency of enteral feeding pump calibration
  • Accuracy of feeding pump delivery volume
  • Incidence of clogged tubes and enteral misconnections
  • Incidence of gastroesophageal reflux or formula aspiration
  • Incidence of infection
  • Mortality

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

PubMed was used to search and collect the literature. Search was limited to English language journals and abstracts were excluded. All types of literature including research, case reports, and review articles. Government, regulatory, and standard setting websites such as the United States (US) Food and Drug Administration (FDA), US Pharmacopeia, and The Joint Commission on Accreditation of Healthcare Organizations were also utilized. Search terms included enteral nutrition, tube feeding, enteral complications, enteral safety, water safety, medication administration, enteral access device, aspiration, misconnections, enteral microbial growth, infant formulas, medical foods, and enteral formulary.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Not Given)
Rating Scheme for the Strength of the Evidence

Not stated

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

The literature and evidence were classified based on the Agency for Healthcare Research and Quality (AHRQ) method.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) established the Enteral Nutrition Practice Recommendations Task Force to examine the available literature related to the ordering, preparation, delivery, and monitoring of enteral nutrition and to establish evidence- based practice guidelines. It was recognized from the onset that there was either an absence of research or the research was of limited strength to support many aspects surrounding the practice of administering enteral nutrition. Therefore, in addition to the existing literature, a consensus of expert opinion based on current knowledge and best practices was used to formulate these practice recommendations.

The strength of each practice recommendation was graded using a method consistent with the 2002 A.S.P.E.N. Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients. The grading system was based on a modified version of the method used by the Agency for Healthcare Research and Quality (AHRQ), United States (US) Department of Health and Human Services. After review of the literature cited, the authors used the AHRQ criteria to classify the strength of the evidence supporting each recommendation statement.

Rating Scheme for the Strength of the Recommendations

Grade of Recommendation

  1. There is good research-based evidence to support the guideline (prospective, randomized trials).
  2. There is fair research-based evidence to support the guideline (well-designed studies without randomization).
  3. The guideline is based on expert opinion and editorial consensus.
Cost Analysis

Published cost analyses were reviewed.

Method of Guideline Validation
Comparison with Guidelines from Other Groups
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The draft document was sent to leaders of American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Clinical Practice Sections, Clinical Practice Committee, and Board of Directors for review and comment process.

The draft document was also sent to leaders of related medical organizations. Reviews were received back from the following groups: American Society of Health-System Pharmacists (ASHP), Institute of Safe Medication Practices (ISMP), North American Society for Pediatric Hepatology, Gastroenterology, and Nutrition (NASPHGAN), American Academy of Pediatrics (AAP), Dietitians in Nutrition Support, a dietetic practice group of the American Dietetics Association, and U.S. Pharmacopeia (USP).

The document was approved by the A.S.P.E.N. Board of Directors following review by internal and external content experts and the A.S.P.E.N. Clinical Practice Committee.

Recommendations

Major Recommendations

Definitions of the grades of recommendations (A-C) are provided at the end of the "Major Recommendations" field.

Practice Recommendations

Initiation and Advancement of Enteral Feedings

  1. Base enteral delivery method and initiation and advancement of enteral nutrition (EN) regimens on patient condition, age, enteral route (gastric vs. small bowel), nutrition requirements, and gastrointestinal (GI) status. (C)
  2. Choose full strength, isotonic formulas for initial feeding regimen. (C)
  3. Initiation and advancement of enteral formula in pediatric patients is best done over several days in a hospital setting using a flexible nutrition plan. (C)

Special Considerations for the Preterm Infant

  1. For premature infants weighing < 1500 g and at risk for necrotizing enterocolitis (NEC), it is recommended that mothers be encouraged to supply breast milk for their infants. (A)
  2. Extremely low-birth weight (ELBW) and very low-birth weight (VLBW) infants may benefit from minimal enteral feeding starting very slowly at 0.5-1 mL/kg/day and advancing to 20 mL/kg/day. (B)
  3. Advance nutritive feedings for VLBW and ELBW infants by a rate of 10-20 mL/kg/day. (C)

Enteral Feeding Pumps

  1. Enteral feeding pumps should deliver the prescribed volume within 10% accuracy for adults. (B)
  2. Enteral feeding pumps should deliver the prescribed volume within 5% accuracy for neonatal and pediatric patients. (C)
  3. Feeding pumps should be calibrated periodically to assure accuracy. (B)
  4. Human breast milk (HBM) infused at low rates should be administered via syringe pump with the syringe tip elevated. (C)
  5. Feeding pumps used for patients requiring EN at home should have features that promote safety and minimize sleep disturbances. (B)

Patient Positioning

  1. Elevate the backrest to a minimum of 30°, and preferably to 45°, for all patients receiving EN unless a medical contraindication exists. (A)
  2. Use the reverse Trendelenburg position to elevate the head-of-bed (HOB), unless contraindicated, when the patient cannot tolerate a backrest elevated position. (C)
  3. If necessary to lower the HOB for a procedure or a medical contraindication, return the patient to an HOB elevated position as soon as feasible. (C)

Flushes

  1. Flush feeding tubes with 30 mL of water every 4 hours during continuous feeding or before and after intermittent feedings in an adult patient. (Kohn-Keeth, 2000) (A)
  2. Flush the feeding tube with 30 mL of water after residual volume measurements in an adult patient. (Schallom et al., 2004; Kohn-Keeth, 2000) (B)
  3. Flushing of feeding tubes in neonatal and pediatric patients should be accomplished with the lowest volume necessary to clear the tube. (C)
  4. Sterile water is recommended for use in adult and neonatal/pediatric patients before and after medication administration. (C)
  5. Adhere to protocols that call for proper flushing of tubes before and after medication administration. (Kohn-Keeth, 2000; van den Bemt et al., 2006) (B)
  6. Use an administration pump when slow rates of enteral formula are required, such as in the neonatal population, and respond promptly to pump alarms. (Lord, 2003) (C)
  7. Use sterile water for tube flushes in immunocompromised or critically ill patients especially when the safety of tap water cannot be reasonably assumed. (Padula et al., 2004) (C)

Enteral Misconnections

  1. Review currently used systems to assess practices that include the potential for misconnection, including nonstandard, rigged work-arounds (luer adapters, etc.). (Pratt, 2006) (C)
  2. Train nonclinical staff and visitors not to reconnect lines but to seek clinical assistance instead. Only clinicians or users knowledgeable about the use of the device should make a reconnection, and should do so under proper lighting. ("Preventing misconnections," 2006) (C)
  3. Do not modify or adapt intravenous (IV) or feeding devices because doing so may compromise the safety features incorporated into their design. ("Preventing misconnections," 2006) (C)
  4. When making a reconnection, practitioners should routinely trace lines back to their origins and then ensure that they are secure. ("Preventing misconnections," 2006) Route tubes and catheters that have different purposes in unique and standardized directions (e.g., IV lines should be routed toward the patient's head, and enteric lines should be routed toward the feet). (Joint Commission on Accreditation of Healthcare Organizations, 2006) (C)
  5. When arriving at a new setting or as part of a hand-off process, staff should recheck connections and trace all tubes. (Joint Commission on Accreditation of Healthcare Organizations, 2006) (C)
  6. Label or color-code feeding tubes and connectors, and educate staff about the labeling or color-coding process in the institution's enteral feeding system. (Joint Commission on Accreditation of Healthcare Organizations, 2006) (C)
  7. Identify and confirm the EN label, because a 3-in-1 PN admixture can appear similar to an EN formulation bag. Label the bags with large, bold statements such as "WARNING! For Enteral Use Only—NOT for IV Use." (Institute for Safe Medication Practices [ISMP], 2003) (C)
  8. Avoid buying enteral equipment that can mate with female luer connectors. (Joint Commission on Accreditation of Healthcare Organizations, 2006) Evaluate the need for and reduce the purchases of adapters and connectors that can be modified to make enteral feeding sets compatible with female luer connectors. (C)
  9. Purchase an adequate number of enteral pumps so that IV pumps are not used for enteral delivery for adult patients. When syringe pumps are used in neonatal intensive care units (ICUs) for human milk or other feedings, they should be clearly distinct from syringe pumps used for IV or other medical purposes. Ideally, they should be a different model, color, or as different in appearance from IV pumps as possible. The enteral feeding pumps should be clearly labeled as enteral feeding pumps. (C)
  10. Ensure that hospital purchasing policies mandate buying only enteral feeding sets that are compliant with American National Standards Institute/Association for the Advancement of Medical Instrumentation (ANSI/AAMI) standard ID54, which effectively excludes any that are compatible with female luer connectors. These devices must also be clearly labeled (e.g., "Not for IV Use"). (ANSI/AAMI ID54, 1996) (C)
  11. Avoid buying pre-filled enteral feeding containers, except for those with design technology labeled non-IV compatible. In all cases, ensure that the enteral administration set is packaged with the enteral feeding bag or container before it is sent to the patient care unit. (The set should be secured to the bag, perhaps with a rubber band, or preattached sets should be requested from the manufacturer). In either case, the objective is to prevent bags or containers from being spiked with IV administration sets. (ISMP, 2001) (C)
  12. Purchase and use oral syringes instead of luer lock syringes to draw up and deliver medications into the enteral feeding system. Include pharmacy department recommendations to ensure the correct syringe type, along with dispensing and proper labeling protocols. Other syringes that may be used include large catheter tip syringes that cannot fit into IV systems. (C)

Summary

The complexity of EN feedings cannot be underestimated. All healthcare professionals should be vigilant in continuous surveillance of high risk practices, products and systems as they relate to the enterally fed patient. Recognition of ordering, administration, and monitoring steps of EN delivery which may increase risk of complications to the enterally fed patient is essential.

Definitions:

Grade of Recommendation

  1. There is good research-based evidence to support the guideline (prospective, randomized trials).
  2. There is fair research-based evidence to support the guideline (well-designed studies without randomization).
  3. The guideline is based on expert opinion and editorial consensus.
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence ranges from prospective randomized trials to expert opinion/consensus.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Standardized processes for enteral nutrition care including ordering, preparation, administration, and monitoring
  • Optimal care and minimal risk of error
Potential Harms
  • Gastroesophageal reflux and aspiration can occur.
  • Feeding tubes are prone to clogging for a variety of reasons.
  • It has been suggested that the direct administration of distilled or tap water into the intestine may injure the intestinal epithelium.
  • Cases of infections resulting from the use of contaminated water in tube-fed patients have been reported.
  • An enteral misconnection is an inadvertent connection between an enteral feeding system and a non-enteral system such as an intravascular catheter, peritoneal dialysis catheter, tracheostomy, medical gas tubing, etc. In each case, serious patient harm—including death—can occur if fluid, medication, or nutritional formula intended for administration into the gastrointestinal tract, are administered via the wrong route.

Contraindications

Contraindications
  • Enteral nutrition is contraindicated in a patient with significant hemodynamic compromise.
  • Among the recognized contraindications to a semirecumbent position for enteral feeding are an unstable spine, hemodynamic instability, prone positioning, and certain medical procedures (such as a central venous catheter insertion).

Qualifying Statements

Qualifying Statements

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Enteral Nutrition Practice Recommendations are based upon general conclusions of health professionals who, in developing such recommendations, have balanced potential benefits to be derived from a particular mode of providing enteral nutrition with known associated risks of this therapy. The underlying judgment regarding the propriety of any specific practice recommendation or procedure shall be made by the attending health professional in light of all the circumstances presented by the individual patient and the needs and resources particular to the locality. These recommendations are not a substitute for the exercise of such judgment by the health professional, but rather are a tool to be used by the health professional in the exercise of such judgment. Use of this document is voluntary and should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed toward obtaining the same result.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
Slide Presentation
Staff Training/Competency Material
Wall Poster
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
End of Life Care
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Bankhead R, Boullata J, Brantley S, Corkins M, Guenter P, Krenitsky J, Lyman B, Metheny NA, Mueller C, Robbins S, Wessel J. Enteral nutrition administration. In: A.S.P.E.N. enteral nutrition practice recommendations. JPEN J Parenter Enteral Nutr. 2009 Mar-Apr;33(2):149-58. [88 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Jan
Guideline Developer(s)
American Society for Parenteral and Enteral Nutrition - Professional Association
Source(s) of Funding

American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)

Guideline Committee

The Enteral Nutrition Practice Recommendations Task Force

Composition of Group That Authored the Guideline

Task Force Members: Robin Bankhead, CRNP, MS, CNSN, Chair; Joseph Boullata, PharmD, BCNSP; Susan Brantley, MS, RD, LDN, CNSD; Mark Corkins, MD, CNSP; Peggi Guenter, PhD, RN, CNSN; Joseph Krenitsky, MS, RD; Beth Lyman, RN, MSN; Norma A. Metheny, PhD, RN, FAAN; Charles Mueller, PhD, RD, CNSD; Sandra Robbins, RD, CSP, LD; Jacqueline Wessel, MEd, RD, CSP, CNSD, CLE

Financial Disclosures/Conflicts of Interest

Jacqueline Wessell is on the Abbot Nutrition Speakers Bureau. No other potential conflicts were reported.

Guideline Endorser(s)
Academy of Nutrition and Dietetics - Professional Association
American Society of Health-System Pharmacists - Professional Association
Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the American Society for Parenteral & Enteral Nutrition (A.S.P.E.N.) Web site External Web Site Policy.

Print copies: Available in hardcopy from A.S.P.E.N. Telephone: 1-800-727-4567.

Availability of Companion Documents

The following are available:

In addition, the following forms are available in the original guideline document External Web Site Policy:

  • Adult Enteral Nutrition Order Form
  • Pediatric Enteral Nutrition Order Form
  • Standard Enteral Nutrition Label Template (Adult Patient)
  • Standard Human Breast Milk Label Template (Infant Patient)
  • Human Breast Milk Storage Label
Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on February 5, 2010. The information was verified by the guideline developer on March 15, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Reprint request/permissions should be sent to: Permissions Department, ASPEN; 8630 Fenton St. #412; Silver Spring, MD 20910; Fax: 301-587-2365.

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