Jejunostomy feeding is an aseptic non-touch technique (ANTT) procedure as opposed to the ‘clean’ procedure of gastric feeding (Rationale 1
All jejunal tubes need to be flushed four- to six-hourly (Rationale 2
Do not rotate gastro-jejunostomy (GJ) tubes (Rationale 3
On testing the tube prior to use, a pH reading of 6–8 indicates a correct position.
Enteral feeding is a very useful method of ensuring adequate intake of nutrients in patients who, for a variety of reasons are unable to use the oral route, or are unable to take sufficient nutrients to maintain growth and development. Successful use of the enteral route to supply nutrients is dependent on the child having a functioning gastrointestinal tract.
Enteral feeding is governed by the requirements of the Food Safety Act (1990)
This guideline includes naso-jejunal (NJ) and jejunostomy tubes.
Note: This forms part of a series of guidelines regarding the management of enteral tubes, including placement, access and management. Please also see guidelines for:
If the child is commenced on enteral feeding whilst he/she is an inpatient at Great Ormond Street Hospital (GOSH) and it is envisaged that this method of feeding will continue following discharge, discharge planning should commence at the earliest opportunity (Rationale 4
Please refer to the enteral feeding guideline for further information about discharge planning (Rationale 5
Inform the child and family
Ensure that the child and family are informed of the following (Rationales 6 and 7
- the reason for the naso-duodenal (ND) or NJ tube
- what it will involve
- the likely duration of the tubes placement
- the potential difficulties of this feeding route and system
- the likely impact on the child and family
If required, involve a play specialist, psychologist or nurse to work with and the child (Rationale 8
Naso-jejunal/transgastric tubes - introduction
Duodenal or jejunal tube 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 duodenum or jejunum. This type of feeding is also known as post-pyloric or trans-pyloric feeding (Rationale 9
This type of feeding is indicated in patients who have a functioning gastro-intestinal tract, but who have an absent gag reflex, delayed stomach emptying or persistent vomiting (Monturo 1990
The decision to place the tube in the duodenum (the first section of the small bowel) or the jejunum (the second section of the small bowel) depends on the clinical condition of the child (Rationale 10
All tubes can remain in situ for six weeks (Rationale 11
NJ or ND feeding may be initiated in any age group of patient, although the duration of feeding can be limited or difficult due to the following factors:
- The tubes are difficult to place (Rationale 12).
- The tube requires testing before every use using Universal Indicator Paper (Rationale 13).
- There is an increased risk of gastro-intestinal infection, therefore sterile or pasteurised feeds must be used and an aseptic technique adhered to when manipulating the feeding set (Rationale 14).
- The tube can easily become blocked so requires frequent flushing (Rationale 15).
- Longer periods of feeding result in reduced mobility of the patient (Rationale 16).
- The type of feed given may require review (Rationale 17 and 18).
- Radiological exposure and expertise is often required.
However it is safer and less expensive than parenteral nutrition (PN) (Muscari-Lin 1991
Prepare the child
The child should be measured and weighed before feeding commences (Rationale 19
The tube can be passed at any time of the day but it is advisable to ensure that an X-ray post insertion will be available, to ensure correct placement.
The child does not have to be nil orally, however each patient should be individually assessed (Rationale 20
). NB: check with policy of insertion area.
It is important to be aware of any medication that the child may be taking which could affect the pH of the gastric aspirate. Radiological examination will be indicated if there is a discrepancy caused by medication (Metheny 1989
) (Rationale 21
The following equipment should be gathered:
- the tube to be used
- foil bowl (Rationale 22)
- universal indicator paper (reading pH from 1 to 11) with colour chart (Rationale 23)
- 50ml syringe to aspirate stomach contents (Rationale 24)
- tape suitable for the condition of the child's skin (Rationale 25)
An 8Fr naso-duodenal tube with a guidewire is the preferred feeding tube (Rationale 26
A 6Fr jejunal tube is available for very small infants (Rationale 27
This tube is not supplied with a guidewire.
Tubes do not require lubrication (Rationale 28
All tubes can remain in situ for six weeks (Rationale 11
Placing the tube
Tube placement may be difficult and placement in GOSH is carried out by the Interventional Radiology team (Rationale 29
This procedure is performed using ANTT (Rationale 30
The naso-duodenal tube should be measured to determine the length that should be passed (Rationale 31
This is done by (Rationale 32
- Placing the tip of the tube against the ear lobe.
- Running the tube along the face to the nostril.
- Running the tube from the nostril down to the sternal notch.
This length of tube should then be passed.
To pass the tube:
Prepare yourself and the working environment (Rationale 33
- prepare a clean surface
- gather equipment
- perform a surgical hand wash
- wear non-sterile gloves and an apron
Prepare the child:
- Ensure the nose is clean and if appropriate ask the child to clear his/her nose (Rationale 34).
- The child's arms may need to be securely held by a colleague or parent/carer. Wrapping the child in a blanket can assist this (Rationale 35).
- Open required equipment using an aseptic technique (Rationale 33).
- Gently insert the tip of the tube into the clean nostril.
- Whilst encouraging the child to swallow continue to gently insert the required length of tube into the stomach (Rationale 36).
- If the child starts to choke or becomes cyanosed the tube must be immediately removed (Rationale 37).
- Recommence passing of the tube once the child has recovered (Rationale 38).
- If the child is very upset by the procedure the nurse should determine appropriate resting time.
- Secure the tube to the child's face using an appropriate tape (Rationale 39).
- Clear away equipment according to the Waste Policy (Rationale 40).
- Wash hands.
- Using a 50ml syringe aspirate enough stomach content to obtain a reaction on the universal indicator paper (Rationale 41).
- Apply aspirate to the universal indicator paper and observe for a colour change (Rationale 42).
- The colour change should be read according to the manufacturer’s instructions on the pH paper container (Rationale 43).
- gastric position pH ≤5.5
- bronchial position pH 6-8
- small bowel position pH 6-8
- It is important to be aware that some medications, such as proton pump inhibitors and H2 receptor blocking agents can elevate gastric pH readings.
- If the aspirate records a pH <5.0 the tube is still in the stomach.
- Whilst the tube is in the stomach it must not be used (Rationale 44).
- The procedure may take some time. It is up to the clinician to decide how long to wait, taking into consideration the nutritional condition of the child (Rationales 45 and 46). Whilst waiting for the tube to pass the child should continue with their normal activities.
- Sometimes prokinetic agents eg metoclopramide or erythromycin may be administered (Courtney-Moore 1985) (Rationale 47).
- The use of prokinectic agents should be discussed with the ward pharmacist (Rationales 48 and 49).
- The size of tube and the date of passing should be recorded in the child's health care records (Rationale 49).
- Any problems encountered should also be documented.
- The child's doctor may decide radiological placement is appropriate if the tube cannot be placed on the ward.
- If this is the case the child should be sent to the radiology department with a tube and the correct tape for securing it.
- The radiology department and the doctor will decide if the child needs to be fasted for the procedure.
The nasal passages should be checked at least twice a day to ensure they are clean and cleaned with warm soapy water and thoroughly dried (Rationale 50
Whilst doing this the nurse should check that the nasal passages are not (Rationale 51
If any of the above is present, an experienced nurse or doctor should be consulted regarding management of the problem (Rationale 52
The tube must always be tested with universal indicator paper prior to feeding or administration of medicines (Rationale 53
The tube should be flushed with 5 to 10ml of sterile water for irrigation depending on the child's fluid balance and size (Rationales 54, 55 and 56
- prior to each feeding session
- after each feeding session
- prior to administration of medicines
- after administration of medicines
- four-hourly if the tube is not in use
- when on continuous feed
It should be flushed using an ANTT and universal precautions (Rationale 33
The flushing should be recorded on the child's fluid balance chart (Rationale 49
Contact an experienced nurse or doctor if the tube cannot be flushed (Rationale 57
Unblocking must not be performed using pressure (Rationale 58
Unblocking may be achieved by the use of enzyme agents and carbonated water.
When not in use the tube should be closed using the integral stopper (Rationale 59
Administration of feed
When feeding directly into the small bowel, feeds must be delivered continuously via a feeding pump (Rationale 60
To provide a total daily intake the feed will need to be administered over a long period of time (Rationale 61
Feeds are ordered through a referral to the dietitian (Rationale 62
Administer only the prescribed feed.
Avoid thickened feeds (Rationale 63
Feed bottles should be changed every six hours and the feeding set every 24 hours (Rationale 33
If the child is going to be mobile during the day a portable pump may be indicated in which case the following should be initiated:
- Contact biomedical engineering for the loan of a portable pump and backpack system.
- Contact one of the nutrition nurses during office hours if you are unsure how the pump is used in its portable capacity.
Under no circumstances should the feed be decanted from the bottle containers into the bag sets on the ward
- Contact the ward dietitian if feeds need to be dispensed from the milk room in bag sets.
The bag feeding set should be changed every six hours.
The purple funnel shaped adapter on the administration set will fit into the integral end of the feeding tube but a luer-locking connection is preferable (Rationales 64 and 65
Non-specified adapters must not
be used (Rationales 33, 66, 67 and 68
Contact the nutrition nurses if any problems are experienced.
All feeds should be monitored and recorded hourly using a fluid balance chart (Rationale 69
If oral feeding is appropriate, this must also be recorded.
Mouth care will be required if the child is having no oral intake (Rationale 70
If no oral intake is permitted oral stimulation will be required (Rationale 71
Advice can be sought from the relevant clinical nurse specialist.
The child's output should be measured and recorded (Rationales 72, 73 and 74
The child's fluid balance must be totalled every hour (Rationales 75, 76 and 77
The child's doctor and dietitian should be notified if the child's fluid balance is negative or excessively
positive (Rationales 78 and 79
The child should be measured and weighed before feeding commences (Rationale 80
They should then be weighed twice weekly.
Their length should then be measured monthly.
The use of this feeding method should be re-assessed and evaluated daily (Rationale 81
This assessment should be recorded.
NB All three-year course pre-registration student nurses must have all feeds double checked by a qualified member of the nursing staff prior to administration.
Administration of medicines
Oral drug administration via a naso-duodenal tube should be discussed with the pharmacy and child's doctor (Rationale 82
If possible the tube should not be used for the administration of medicines and if necessary syrups and suspensions should be avoided (Rationales 83, 84, 85
The naso-duodenal tube should be flushed before and after drug administration using 5-10ml of sterile water for irrigation or according to the child's overall fluid balance (Rationales 86 and 87
For neonates a smaller volume of flush may be indicated (Rationale 88
An ANTT must be used (Rationale 33
When feeding using this method is no longer required, ie if it has been unsatisfactory or normal nutritional intake can be commenced, the tube can be removed by gently withdrawing the tube from the nostril using universal precautions.
The tube must not be removed without prior discussion with the child's doctor and the nutrition support team (Rationale 89
The child's weight and height must be recorded at the end of treatment (Rationale 90
The child's weight, height and enteral intake must continue to be monitored (Rationale 91
The removal of the tube must be recorded in the child's health care records (Rationale 49
Percutaneous endoscopic gastrostomy with jejunal tube (PEG-J)
For information on pre- and postoperative care, daily stoma care and tube maintenance, please refer to the gastrostomy management clinical procedure guideline
Strict adherence to aseptic non-touch technique is essential when caring for a child with a PEG-J tube (Rationale 92
Jejunal tubes must be flushed with sterile water four- to six-hourly, especially during feeds, and also when not in use (Rationale 93
The jejunal tube should not be used for administration of medications without prior discussion with the pharmacist (Rationale 94
If the only way to give the drugs is via the jejunal route, then the patient may need closer monitoring for signs of adverse effects of too rapid or too slow absorption (Rationales 95 and 96
Once blocked, jejunal tubes are difficult to clear of the blockage, and the solution may be to remove the intestinal tube and have a new tube inserted under imaging.
The PEG-J tube must not be rotated (Rationale 97
As an alternative, the tube should be moved very gently in and out of the tract approximately 1 centimetre, and secured firmly.
The tip of the jejunal tube can also migrate back into the stomach. Any change in the child’s ability to tolerate the jejunal feed should be investigated, and the position of the jejunal tube checked, usually by X-ray.
The hospital now also uses Button jejunal tubes. See gastrostomy management guidelines
for insertion information and general principles of caring for a button device.
NB If the button jejunal balloon bursts, the tube can become dislodged and medical help should be sought so it can be replaced under radiological guidance (Rationale 98
Rationale 1: Feeding bypasses the stomach acid and therefore also the natural bacterial protection.
Rationale 2: Blocking occurs more easily due to narrower lumens.
Rationale 3: This may dislodge them and require re-passing.
Rationale 4: To facilitate smooth and effective discharge planning.
Rationale 5: To prevent a delay in the child’s discharge.
Rationale 6: To obtain ‘informed consent’.
Rationale 7: To maximise the effectiveness of the procedure (Holden 1997
Rationale 8: To help to psychologically prepare the child.
Rationale 9: Suitable for patients who cannot absorb sufficient gastric feeds.
Rationale 10: Patients with a high aspiration risk may need the tube placed further down into the small bowel to limit the risk of reflux back into the stomach (Courtney-Moore 1985
Rationale 11: The condition of the nasal passages is affected by prolonged use.
Rationale 12: Passage of the tube through the pylorus and into the small intestine relies on normal gut motility. This can take a number of days without the aid of fluoroscopy and can result in periods of poor nutrition.
Rationale 13: There is a risk that movement of the tube can occur proximal to the pylorus.
Rationale 14: The tube bypasses the natural microbiological defences of the stomach (Courtney-Moore 1985
Rationale 15: The tubes often have a narrow bore.
Rationale 16: The natural reservoir of the stomach is by-passed and therefore feeds are best tolerated as frequent boluses or continuously (Courtney-Moore 1985
Rationale 17: There is a reduction in the mixing of pancreatic enzymes, which delay fat absorption (Courtney-Moore 1985
Rationale 18: There is a loss of stomach enzymes, which begin the digestive process.
Rationale 19: To provide a benchmark for monitoring the effectiveness of the feeding regime.
Rationale 20: Some children may vomit as the tube is passed.
Rationale 21: Confirmation of correct placement relies on a clear pH reading of acid and then alkaline.
Rationale 22: In case of vomiting.
Rationale 23: To read the changes in pH aspirate as the tube passes through the gut.
Rationale 24: Larger syringes exert a lower pressure.
Rationale 25: To secure the tube.
Rationale 26: The guidewire assists in the passage of the tube through the pylorus.
Rationale 27: If the 8Fr tube is unsuitable.
Rationale 28: Nasal secretions are adequate.
Rationale 29: To facilitate verification of placement.
Rationale 30: Bacterial contamination is possible because the gastric juices are being by-passed.
Rationale 31: To help determine correct placement.
Rationale 32: Measuring the tube in this way ensures that the tube is in the stomach from where it will advance slowly into the small intestine.
Rationale 33: To minimise the risk of infection.
Rationale 34: To prepare for the procedure.
Rationale 35: To prevent accidental removal by the child.
Rationale 36: To aid passage of the tube.
Rationale 37: Airway intubation may have occurred.
Rationale 38: To allow composure to be regained.
Rationale 39: To prevent accidental removal.
Rationale 40: To meet hospital policy.
Rationale 41: To facilitate testing.
Rationale 42: To determine pH.
Rationale 43: To meet manufacturer’s recommendations.
Rationale 44: Due to the associated aspiration risks.
Rationale 45: The tube may not immediately pass into the small bowel.
Rationale 46: To assist in the passage of the tube through the pylorus in patients with delayed stomach emptying.
Rationale 47: Potentially hazardous drug interactions may occur with these drugs.
Rationale 48: They may not be suitable for use in neonates.
Rationale 49: To provide an accurate record of care.
Rationale 50: To prevent the build up of mucus.
Rationale 51: To determine condition of the nasal passages while the tube is in situ.
Rationale 52: To determine future management of feeding method.
Rationale 53: To verify position.
Rationale 54: To prevent blockage of the fine bore.
Rationale 55: Medicines are thought to stick to the inner surface of the tube and encourage infection.
Rationale 56: Flushing the tube allows the carer to check that it is clear for delivery.
Rationale 57: To initiate unblocking measures.
Rationale 58: To prevent: splitting of the tube; accidental intubation; oesophageal trauma, gut perforation.
Rationale 59: To prevent leakage of gastric contents, infection
Rationale 60: The small bowel cannot hold large volumes of feed. Bolus feeds can result in: diarrhoea; vomiting; abdominal discomfort (Muscari-Lin 1991
Rationale 61: To meet the child's nutritional requirements and to prevent the complications of bolus feeding cited above occurring.
Rationale 62: A hydrolysed feed may be better absorbed (Johnson 2001
Rationale 63: Thickened feeds have the potential to block the tube.
Rationale 64: To reduce the chance of disconnection with subsequent hypoglycaemia, decompensation, and other associated complications.
Rationale 65: Adaptors can also present a choking hazard to the child if it becomes disconnected.
Rationale 66: They may not have been approved for safety reasons in the hospital.
Rationale 67: It makes the ordering of supplies difficult for the community.
Rationale 68: It complicates issues for the carer.
Rationale 69: To ensure accurate and adequate nutritional intake.
Rationale 70: To maintain oral hygiene.
Rationale 71: To aid normal development.
Rationale 72: To monitor fluid loss.
Rationale 73: To monitor the effectiveness of the feeding regime.
Rationale 74: To assess the general condition of the child.
Rationale 75: To monitor the effectiveness of the feed.
Rationale 76: To ensure the feed is being tolerated.
Rationale 77: To facilitate reassessment of the child.
Rationale 78: To reassess the feeding regime.
Rationale 79: To determine the appropriateness of the feeding method.
Rationale 80: Medication may not be suitable for intestinal administration and could cause harm.
Rationale 81: Medication may not be properly absorbed.
Rationale 82: Medication may be incompatible with the small intestine.
Rationale 83: Medication may be incompatible with the feed.
Rationale 84: Medication can block the tube (Adams 1994
Rationale 85: To minimise the risk of infection and tube related problems.
Rationale 86: To maintain patency of tube.
Rationale 87: To ensure medication reaches the small intestine.
Rationale 88: Fluid balances are carefully controlled in neonates.
Rationale 89: To ensure the tube is not removed unnecessarily.
Rationale 90: To audit the effectiveness of treatment.
Rationale 91: To monitor progress.
Rationale 92: There is an increased risk of introducing infection due to bypassing the stomach’s acid defences.
Rationale 93: Jejunal tubes are particularly prone to blocking.
Rationale 94: This is due to the different absorption rate of the drugs between the stomach and jejunum.
Rationale 95: Some drugs need to be broken down by the stomach to be effective.
Rationale 96: There is an added risk of blocking the tube when administering medicines.
Rationale 97: There is a risk of displacing the jejunal tube by coiling it up in the stomach.
Rationale 98: To ensure correct placement.
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Document control information
Maggie Stewart, formerly Clinical Nurse Specialist, Nutrition, Gastroenterology
Crispin Walkling-lea (editor), Clinical Guidelines and Care Pathway Co-ordinator, Strategic Development
Vanessa Shaw, Head of Department, Dietetics
Susan Macqueen, Clinical Nurse Specialist, Infection Control, Microbiology
Nettie Fabian, formerly Senior Staff Nurse, Transitional Care Unit
Anna Hughes and Joanne Brind, Clinical Nurse Specialists, Nutrition, Gastroenterology
Clinical Practice Committee
First introduced: 6 June 2005
Date approved: 8 November 2011
Review schedule: Two years
Next review: 8 November 2013
Document version: 2.0
Replaces version: 1.0