Nasojejunal (NJ) and orojejunal (OJ) management

The purpose of this guideline is to provide guidance about nasojejunal and orojejunal tube management at Great Ormond Street Hospital (GOSH).

Introduction

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. This guideline outlines the care and management of NJ and OJ 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 GOSH, and it is envisaged that this method of feeding will continue following discharge, discharge planning should commence at the earliest opportunity (Rationale 1).

NJ/OJ tubes - introduction

Jejunal tube feeding is the method of feeding directly into the small bowel. The feeding tube is passed by the nose or mouth into the oesophagus, on into the stomach, through the pylorus and into the duodenum or jejunum. This type of feeding can also be known as duodenal, post-pyloric or trans-pyloric feeding.

Some indications for use:

  • absent gag reflex

  • severe gastro oesophageal reflux

  • delayed gastric emptying

  • persistent vomiting 

(Johnson, 2014)

Contraindications:

  • upper GI obstruction

  • oesophageal atresia/stenosis

  • significant upper GI bleeding

  • oesophageal varicies

  • recent fundoplication

  • extensive short gut

Consideration for orojejunal rather than nasojejunal tube:

  • basal skull fracture

  • maxillo facial abnormalities

  • nasopharyngeal abnormalities

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 2).

Jejunal 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 3).

  • There is an increased risk of gastro-intestinal infection, therefore sterile or pasteurised feeds must be used and a non touch aseptic technique (ANTT) adhered to when manipulating the feeding set (Rationale 4).

  • The tube can easily become blocked so requires frequent flushing (Rationale 5).

  • Longer periods of feeding result in reduced mobility of the patient (Rationale 6).

  • The type of feed given may require review (Rationale 7).

  • The tubes may need to be passed under radiological guidance and therefore the patient incur a radiation dose.

However it is safer and less expensive than parenteral nutrition (PN) (De lucas, 2000).

Inform the child and family

Ensure that the child and family are informed of the following:

  • the reason for the NJ/OJ tube

  • what it will involve

  • the likely duration of the tube's 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).

Prepare the child

The child should be measured and weighed before feeding commences (Rationale 9).

The tube can be passed at any time but it is advisable to pass during the day so that its position can be checked in fluoroscopy (in main X-ray)/Interventional Radiology (IR) (Rationale 10).

Out of hours, or if the patient is in NICU/PICU/ICU or too unstable to transfer, then an extended chest x-ray requesting an NJ tube position check must be done and position confirmed before use, preferably after around an hour after passing the tube.

The child does not have to be nil orally, however it is not advisable to pass the tube immediately following a big feed (Rationale 11). Each patient should be individually assessed, and if in doubt the decision should be clinician led.

Prepare equipment

The following equipment should be gathered: 

  • The appropriate size and type of tube.

  • Sterile water to lubricate the tube.

  • Foil bowl and tissues (Rationale 12).

  • Universal testing paper (Rationale 13).

  • 20ml syringe to withdraw aspirate from the stomach.

  • Sterile water to flush the tube clear of aspirate, once correct placement has been confirmed.

  • Non-sterile gloves.

  • Tape to secure the tube to the child’s skin.

  • A drink with a straw or a dummy for the child to suck on (Rationale 14).

Phone fluoroscopy (or main x-ray if out of hours, or child on NICU/PICU/CICU) to request a check of an NJ tube placement and arrange this for at least one hour post insertion.

Placement of the tube

Placement in GOSH is recommended as follows:

  • NJ/OJ tubes should be passed on the wards following the guidelines and then the position checked in fluoroscopy.

  • Out of hours the NJ/OJ tube should be passed on the ward and then the position checked with an extended chest x-ray requesting an NJ tube position check; this will then need to be reviewed by a clinician or a suitably trained nurse prior to use.

  • If the child is in NICU, PICU, CICU or too unstable to transfer to x-ray the NJ/OJ tube should be passed on the ward and then the position checked with an extended chest x-ray requesting an NJ tube position check, this will then need to be reviewed by a clinician or a suitably trained nurse prior to use.

In the following circumstances the tube may need to be passed in fluoroscopy/IR:

  • The child’s condition is unsuitable for the tube to be passed ‘blind’ eg they have an altered anatomy, eg craniofacial abnormalities.

  • If the patient has already had failed attempts.

Measuring for a nasojejunal tube 

The NJ tube should be measured to determine the length that it should be. This should be done in two measurements:

Distance A: the measurement from the outside to the level of stomach

Distance B: the measurement from the outside to the level of the jejunum (which will be the final position of the tube). Distance B should be clearly documented on the jejunal tube testing chart. Oral jejunal tubes should be measured from the mouth and not the nose for all age groups. The measurements are obtained as follows:

Distance A (for all ages):

  • Placing the tip of the tube against the bridge of the nose.

  • Run the tube along the face to the ear.

  • Run the tube from the Ear down to the xiphisternum.

Distance B (is measured according to age)

Distance B - for neonates
Distance B - for neonates

  • Place the tip at the bridge of the nose.
  • Run down to the ankle of a fully extended leg.

For infants <1 year

Distance B - for infants  under 1 year
Distance B - for infants under 1 year

  • Place the tip of the tube against the nose.

  • Run the tube along the face to the ear.

  • Run the tube down to the mid-point between xiphisternum and umbilicus.

  • Continue to right iliac crest.

For children >1 year

Distance B - for children over 1 year
Distance B - for children over 1 year

  • Place the tip of the tube against the bridge of the nose.

  • Run the tube along the face to the ear.

  • Run the tube down to the mid-xiphisternum.

  • Continue to right iliac crest.

Inserting the NJ tube

This procedure is performed using ANTT (Rationale 15).

Wash and dry hands thoroughly, gathering together all the equipment needed and place on a clean tray.

Position the child/infant lying on their right side with the head of the bed raised 15-30 degrees if possible (Rationale 14).

An infant may be wrapped in a sheet or blanket to help position them (Royal College of Nursing, 2010).

Ensure the chosen nostril is clear of debris. Ask the child, if age appropriate, which side they would prefer to have the tube positioned.

Wash and dry hands thoroughly, put on non-sterile gloves and apron.

Check that the tube is intact. The tube should be gently stretched to remove any shape retained from being packaged. 

Measure distance A and distance B as described above insuring these are both documented.

Lubricate the end of the tube in sterile water; do not use K-Y Jelly® as this may affect the pH reading.

Bend the child’s head slightly forward and gently pass the tube into the child’s nostril, advancing it along the floor of the nasopharynx to the oropharynx. At this point, ask the child to swallow a little water or offer a younger child their dummy, to assist passage of the tube down the oesophagus until the required length of tube to Distance A has been inserted.

Never advance the tube against resistance, to avoid the risk of perforation.

If the child shows signs of breathlessness or severe coughing, remove the tube immediately as the tube may have been passed into the trachea.

Lightly secure the tube with tape, or have an assistant hold the tube in place until the position has been checked.

Initial testing to ensure the NJ tube has reached the stomach

At this point the position must be checked using the NPSA decision tree for NGT placement checks (NPSA, 2011).

The feed may need to be stopped to allow time for the stomach to empty and the pH to become acidic. However, this may not be possible in some patients with metabolic/endocrine conditions who quickly become hypoglycaemic. If the feed needs to be stopped in these patients then this needs to be discussed with their medical team as to whether this is possible, an action plan decided and then documented in the patient's notes.

pH testing using universal indicator paper must be the first line method of checking the tube position for Distance A (to the stomach):

  • Aspirate a small amount of stomach contents using a 20ml or 50ml syringe in infants and children. For neonates use a 2-5 ml syringe (Auckland District Health Board, 2014; Knox and Davie, 2009). Test the aspirate on CE marked universal indicator paper intended by the manufacturer to test human gastric aspirates.

  • For the tube to be confirmed at Distance A (in the stomach) the safe pH range is between 1 and 5.5.

  • Each test and test results must be documented on the NJ testing chart as appropriate and must be kept at the child’s bedside.

If no aspirate can be obtained OR if the pH of the aspirate is NOT between 1-5.5 for gastric placement:

  • Change the child’s position and try to aspirate again.

  • Inject 1-5ml air into the tube to remove a blockage at the end of the line or move the end of the tube from the lining of the stomach.

  • Wait for 15-30 minutes and aspirate again.

  • Advance or withdraw the tube by 1-2cm.

  • Give mouth care to patients who are nil by mouth (this stimulates gastric secretions of acid).

  • NEVER use water to flush the tube before confirming the position (Rationale 16).

If no aspirate is then obtained or the aspirate is still outside of the safe range (gastric tubes 1-5.5), the tube should be removed and a second attempt made. When the second tube is passed repeat the testing as above. If it is still indeterminate then continue to pass the tube to distance B, leave for at least one hour, and then confirm position with an extended chest x-ray (with a request for ‘check of NJ tube position’.)

If the child shows signs of breathlessness or severe coughing during passing, remove the tube immediately (Rationale 19).

Feeding tube placement – techniques that must NEVER be used to confirm that the tube has reached as far as the stomach

  • The ‘whoosh test’ – injecting air into the tube and auscultating the stomach.

  • Acid/alkaline tests of gastric aspirates using litmus paper.

  • Interpretation based on the appearance of the aspirates alone.

  • Inject water into a feeding tube to confirm its position.

  • Confirmation of feeding tube position based on x-ray alone by staff that have not been deemed competent to perform this assessment by this trust (either by successful completion of the e-learning or are deemed as competent by a consultant radiologist).

Additional advice for neonates (NPSA 2005):

  • DO NOT interpret the absence of respiratory distress as an indicator of safe positioning.

  • DO NOT test for correct tube positioning by monitoring for bubbling at the end of the tube.

If no aspirate is obtained or the aspirate is still outside of the safe range (gastric tubes 1-5.5), the tube should be withdrawn and a second attempt made.

Once correct placement for NG has been confirmed

Flush the tube with 2mls of water (0.5mls for neonates) to encourage peristalsis and then slowly start to advance the tube 1cm every 15-30 minutes for neonates, 2-4cm every 5-10 minutes for infants and small children and 4-6 cm every 5-10 minutes for a bigger children, flushing with 2mls of water prior to advancing each time (For flush volume in neonates, please seek advice from local clinical team) until Distance B has been reached.

If any resistance is felt trying flushing with water to aid passage, if resistance is still felt pull back a small amount and try again.

NEVER push against resistance.

If possible keep the child positioned on their right side with the head of the bed raised 15-30 degrees.

After at LEAST one hour (to allow time for peristalsis to move tube through the pylorus) confirm tube position with fluoroscopy or out of hours an extended chest x-ray.

Confirming feeding tube position by x-ray

The x-ray request form must clearly request an extended chest x-ray and state that the purpose of the x-ray is to establish the position of a jejunal tube for the purposes of feeding or medication administration. The radiographer must take responsibility for ensuring that the feeding tube can be clearly seen on this x-ray.

The x-ray must be interpreted by clinicians who have been deemed competent in assessing the position of feeding tubes by x-ray. This includes:

  • All radiologists, as this is a core part of their training and role.

  • Medical staff who have been assessed as competent by completing the Trust e-learning module (available internally to GOSH staff via GOSH Gold) or, if this is not possible, by a consultant radiologist or radiology registrar.

  • Nurses and Allied Health Care Professionals who have undertaken an advanced practice programme at masters level AND have completed the Trust e-learning module (available internally to GOSH staff via GOSH Gold).

The assessment of feeding tube placement must be documented in the patients’ healthcare record. Documentation must include:

  • Confirmation that the x-ray viewed was the most recent for that patient.

  • How the placement was interpreted.

  • Clear instructions as to any required actions.

  • The length of the feeding tube at the nostrils or mouth at the time of x-ray.

  • If the x-ray been formally reported upon, a clinician must write in the healthcare record that they have viewed the radiologists report and that the feeding tube position is confirmed as satisfactory.

HCPs who rely on x-ray confirmation of the feeding tube’s position should confirm before feeding:

  • That the entry in the patient's healthcare record is the most recent one.

  • That the tube has not become significantly dislodged by cross-checking the length of the tube at the nostril or mouth with the entry confirming correct tube placement.

Any tubes identified to be in the lung are to be removed immediately, whether in the x-ray department or the clinical area.

Once tube position has been confirmed mark the tube with hyperfix or a permanent marker at the nose and record on the child’s jejunal Tube Testing Chart (or on ICCA Carevue) the date and time, as well as the size and type of tube that has been used. Label the tube with a label that clearly says Jejunum on it.

Record the length of tube inserted, and record that correct placement has been confirmed and record the length of visible tube from the nostril to the end (ie outside the child’s body) (Rationale 20).

Confirming the position of a NJ/OJ tube

The tube marking at the nostril and length of the jejunal tube left outside of the child’s body from the nose or mouth must be checked and documented:

  • After insertion.

  • Before any liquid, feed or medications is introduced via the tube.

  • At the change of feed if the child is receiving continuous tube feeding (this will be four-hourly for expressed breast milk and six-hourly for all other feeds).

And in the event of the child having an episode of: 

  • Retching.

  • Vomiting.

  • Excessive coughing.

  • Respiratory distress following a successful attempt to resolve a blocked tube.

  • In the event that the tube appears to have been partially dislodged (eg when visible tube length has increased/changed).

Tube management

  • Do not aspirate the NJT as it can cause collapse and recoil of the tube.

  • Do not bolus feed as the jejunum has no capacity for storage.

  • If a tube has originally been passed as an NG tube DO NOT advance it to the NJ position. It must be removed and a designated NJ tube used and re-passed.

The nasal passages should be checked regularly to insure they are kept clean and clear and checked for any signs of them being:

  • red

  • sore

  • swollen

  • bloody

If any of the above is present, an experienced nurse or doctor should be consulted regarding management of the problem and the possibility of re-siting the tube discussed (Rationale 21).

The tube should be flushed with 3-5ml of sterile water for irrigation (1-2mls for neonates) using a turbulent flush (Rationale 22):

  • 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

It should be flushed using an ANTT and standard precautions (Rationale 15).

The flushing should be recorded on the child's fluid balance chart.

Contact an experienced nurse or doctor if the tube cannot be flushed to discuss a plan.

Unblocking must not be performed using pressure (Rationale 23)

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.

Administration of feed

When feeding directly into the small bowel, feeds must be delivered continuously via a feeding pump. The small bowel cannot hold large volumes of feed (Rationale 24).

To provide a total daily intake the feed will need to be administered over a long period of time.

Feeds are ordered through a referral to the dietician (Rationale 25).

Administer only the prescribed feed.

Avoid thickened feeds (Rationale 26).

If the feed is to be administered via feed bottles, these must be changed every six hours, or every four hours for EBM.

The feeding set must be changed every 24 hours (Rationale 27).

If the child is going to be mobile during the day a portable pump may be indicated. If this is the case the contact the dietician for a backpack.

Under no circumstances should the feed be decanted from the container in which it is sent up from the special feeds unit (Rationale 27).

Where the feed is delivered by a portable pump, the bag/feeding set must be changed every six hours.

Non-specified adapters must not be used (Rationale 28).

All feeds should be monitored and recorded hourly using a fluid balance chart.

If oral feeding is appropriate, this must also be recorded.

Mouth care will be required if the child is having no oral intake (Rationale 29).

If no oral intake is permitted oral stimulation will be required (Rationale 30).

Advice can be sought from the relevant clinical nurse specialist.

The child's output should be measured and recorded (Rationale 31).

The child's fluid balance must be totalled every hour (Rationale 32).

The child's doctor and dietician should be notified if the child's fluid balance is excessively negative or positive (Rationale 33).

The child should be measured and weighed before feeding commences and then twice weekly.

Their length should then be measured monthly (Rationale 34).

The use of this feeding method should be re-assessed, evaluated and recorded daily.

Administration of medicines

Oral drug administration via a nasojejuanl tube should be discussed with the pharmacy and child's doctor (Rationale 35).

If possible the tube should not be used for the administration of medicines and if necessary syrups and suspensions should be avoided (Rationale 36).

The NJ tube should be flushed with a turbulent flush before and after drug administration using 3-5ml of sterile water (1-2mls for neonates) (Rationale 37).

An ANTT must be used (Rationale 27).

Completing treatment

When feeding using this method is no longer required, eg 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 standard precautions.

The tube must not be removed without prior discussion with the child's doctor and the nutrition support team (Rationale 38).

The child's weight and height must be recorded at the end of treatment to record the effectiveness of treatment.

The child's weight, height and enteral intake must continue to be monitored.

The removal of the tube must be recorded in the child's health care records.

Download the jejunal (oral/nasal) verification chart

Jejunal (oral/nasal) verification chart

 

Rationale

Rationale 1: To facilitate smooth and effective discharge planning and to prevent delay in the child’s discharge.
Rationale 2: 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 3: 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 4: The tube bypasses the natural microbiological defences of the stomach (Courtney-Moore, 1985). 
Rationale 5: Blocking occurs easily due to narrow lumens of jejunal tubes.
Rationale 6: The natural reservoir of the stomach is by-passed and therefore feeds are best tolerated continuously.
Rationale 7: There is a reduction in the mixing of pancreatic and stomach enzymes, which delay fat absorption (
Courtney-Moore, 1985). 
Rationale 8: To help to psychologically prepare the child.
Rationale 9: To provide a benchmark for monitoring the effectiveness of the feeding regime.
Rationale 10: checking the tube in IR or fluoroscopy exposes the patient to less radiation than conventional x rays as is quicker. 
Rationale 11: due to the risk of aspiration
Rationale 12: In case of vomiting. 
Rationale 13: To read the changes in pH aspirate as the tube passes through the gut.
Rationale 14: To aid peristalsis.
Rationale 15: Bacterial contamination is possible because the gastric juices are being by-passed.
Rationale 16: The tube can be in the lungs by mistake.
Rationale 17: To minimise the amount of radiation exposure.
Rationale 18: As fluroscopy need a guide wired tube to aid guidance through the pylorus.
Rationale 19: The tube may have passed into trachea.
Rationale 20: To provide an accurate record of the procedure and because the measurement can be used in the future to ascertain whether the tube has migrated.
Rationale 21: To determine future management of feeding method. 
Rationale 22: To prevent blockage of the fine bore and medicines can stick to the inner surface of the tube. 
Rationale 23: To prevent: splitting of the tube; accidental intubation; oesophageal trauma, gut perforation. 
Rationale 24: The small bowel cannot hold large volumes of feed. Bolus feeds can result in: diarrhoea; vomiting; abdominal discomfort (
Muscari-Lin, 1991). 
Rationale 25: A hydrolysed feed may be better absorbed (
Johnson, 2014).
Rationale 26: Thickened feeds have the potential to block the tube.
Rationale 27: To minimise the risk of infection.
Rationale 28: They may not have been approved for safety reasons in the hospital and it makes ordering of supplies difficult for the community.
Rationale 29: To maintain oral hygiene.
Rationale 30: To aid normal development.
Rationale 31: To maintain an accurate fluid balance and monitor the effectiveness of feed. 
Rationale 32: To monitor the effectiveness of the feed and to ensure the feed is being tolerated. 
Rationale 33: To reassess the feeding regime and to determine the appropriateness of the feeding method. 
Rationale 34: To assess the effectiveness of the feed and to assess the general condition of the child.
Rationale 35: Medication may not be suitable for intestinal administration and could cause harm, they may not be properly absorbed and may be incompatible with the small intestine.
Rationale 36: Medication may be incompatible with the feed and it can block the tube (
Adams, 1994).
Rationale 37: To maintain patency of tube. 
Rationale 38: To ensure the tube is not removed unnecessarily.

References

Reference 1:
Adams D (1994) Administration of drugs through a jejunostomy tube. British Journal of Intensive Care Jan: 10-17

Reference 2:
Auckland District Health Board (2014) Newborn Services Clinical Guideline. ADHB, New Zealand. [Accessed 9 July 2014]

Reference 3:
Courtney-Moore M (1985) Tube feeding of infants and children. Paediatric Clinics of North
America 32(2): pp 401-405

Reference 4:
De lucas, C (2000). Transpyloric enteral nutrition reduces the complication rate and cost in critically ill child, Journal of Pediatric gastroenterology and nutrition 30(2): 175-180

Reference 5:
Johnson T (2014) Enteral Nutrition. In: Shaw V (ed) Clinical Paediatric Dietetics, 4th Edition. Oxford, Wiley Blackwell

Reference 6:
Knox, T and Davie, J (2009) Nasogastric tube feeding-which syringe size produces lower pressure and is safest to use? Nursing Times 105(27): 24-26

Reference 7:
Muscari-Lin E (1991). Nutrition support: making the difficult decisions. Cancer Nursing 14(5): 261-269

Reference 8:
National Patient Safety Agency (NPSA) (2011). Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infantsPatient Safety Alert NPSA/2011/PSA002, London. [Accessed11 November 2014]

Reference 9:
National Patient Safety Agency (NPSA) (2005) Reducing the harm caused by misplaced naso and orogastric feeding tubes in babies under the care of neonatal unitsPatient Safety Alert NPSA/2005/9, London. [Accessed 11 November 2014]

Royal College of Nursing (2010) Restrictive physical intervention and therapeutic holding for children and young peopleLondon. [Accessed 11 November 2014]

Bibliography

McDermott A , Tomkins N , Lazonby G (2007) Nasojejunal tube placement in paediatric intensive care. Paediatric Nursing 19(2): 26-28

Ashford and St Peters Hospitals (2009) Neonatal Intensive Care Unit Clinical Guideline – Naso-jejunal (NJT) insertion

Rees RGP, Payne-James JJ, King C et al. (1998) Spontaneous transpyloric passage and
performance of fine bore polyurethane feeding tubes. A controlled clinical trial.
 J Parent
Ent Nutr, 12: 469–472

Mason S, Harris G, Blisset J (2005) Tube feeding in infancy: implications for the development of normal eating and drinking skills. Dysphagia, 20:46−61

Shaw V (2015) Clinical Paediatric Dietetics, 4th Edition. Oxford, Wiley Blackwell

Document control information

Lead Author(s)

Rachel Scott, Practice Educator
Tamsin Elwood, Clinical Site Practitioner

Additional Author(s)

Melanie Hiorns, Consultant, Radiology
Vanessa Shaw, Head of Department, Dietetics

Document owner(s)

Rachel Scott, Practice Educator

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
06 June 2005
Date approved: 
22 January 2015
Review schedule: 
Three years
Next review: 
22 January 2018
Document version: 
3.0
Previous version: 
2.0