A.S.P.E.N.

Enteral
Nutrition Practice
Recommendations
Kelly Tappenden, PhD, RD
Professor of Gastrointestinal Physiology & Nutrition
University of Illinois Urbana-Champaign

Outline
I.

Introduction

II.

Ordering and Labelling of EN

III.

Enteral Formula (Medical Foods) and Infant

Formula Regulation

IV.

Water and Enteral Formula Safety and

Stability

V.

Enteral Access

VI.

EN Administration

VII.

Medication Administration

VIII. Monitoring EN Administration

IX.

Summary

Glossary of Terms

Beyond-Use Date
Clinical Guidelines
Closed Enteral System
Computerized
Prescriber Order
Entry (CPOE)
Distilled Water
Drug-Nutrient
Interactions
Enteral Access Devices
Enteral Misconnection
Enteral Nutrition (EN)

Expiration Date
Fore Milk
Hang Time
Hind Milk
Medical Food
Modular Enteral
Feeding
Open Enteral System
Purified Water
Sentinel Event
Tap Water
Transitional Feeding

Objective/Goal/Methodology
Objective = establish evidence-based practice
guidelines following review of literature related
to ordering, preparation, delivery, and
monitoring of EN
Goal = identify safety issues related to EN
Grading system = modified Agency for
Healthcare Research and Quality (AHRQ) method
A. GOOD research-based evidence to support
guideline (PRCTs).
B. FAIR research-based evidence to support
guideline (well-designed studies w/out
randomization).
C. The guideline is based on EXPERT OPINION and
EDITORIAL CONSENSUS.

Formulary Selection Process

1. Facilities should establish a formulary specific
and available EN formulas. (C)
2. A specific EN formulary should be based on
patient population and estimated nutrient
needs rather than specific diagnosis. (C)
3. A clinician with expertise in nutrition support
should be involved in corporate buying of EN
products that best meets the patients nutrient
requirements. (C)

Use standardized order forms specific for

adult and pediatric EN regimens (C)
EN orders should
include (C):
1) patient info;
2) formula;
3) enteral access
site/device;
4) administration
method/rate
Incorporate EN
advancement,
transitional,
monitoring and
ancillary orders.(C)
Use generic terms,
avoid abbreviations
(C)

All orders,
even
re-orders,
must be
complete!
(C)

Labels for EN formula administration containers,

bags, or syringes should be standardized. (C)
ALL EN labels, in all
environments, shall
express clearly and
accurately what the
patient is receiving at any
time. (C)
Before administration, EN
label should be compared
with the EN order for
accuracy, hang time, and
beyond-use date. (C)

Clinician-to-clinician
communication needed to
promote the accurate EN
prescription during patient
transfers. (C)

Clearly label human breast milk with

the patients name/medical record
number to prevent delivery errors.
Preprinted labels and/or bar coding
systems helpful. (C)

Regulatory Issues
Medical food = a food which is formulated to be
consumed or administered enterally under the
supervision of a physician and which is
intended for the specific dietary management
of a disease or condition for which distinctive
nutritional requirements, based on recognized
scientific principles, are established by medical
evaluation.
Require good manufacturing practice
Exempt from regulations on labeling and health
claims that apply to conventional foods

BUYER BEWARE!!

Eliminate EN Contamination

Clean environment (A)

Aseptic technique (A)
Trained personnel (C)
Sterile, liquid>powder(A)
Controlled storage (B)
Follow manufacturer
recommendations (B)
Disposable gloves (A)
Screw cap > flip top (A)
Use recessed spikes (B)
Pump with drip chamber (A)
Peds products DEHP free (B)

Formula Hang Times Vary

1. Institution need ongoing quality control

process for EN formula prep, distribution,
storage, handling, and administration. (B)
2. Institutions need written policies and
procedures for safe EN formula and HBM
prep/handling, as well as maintain an ongoing
surveillance program for contamination. (B)

Selection of Enteral Access Device

1. Select an enteral access
device based on patient
specific factors. (C)
2. Nasojejunal route for
enteral feedings in ICU
patients are not required
unless gastric feeding
intolerance is present.
(A)
3. Patients with persistent
dysphagia should have a
long-term enteral access
device placed. (B)

Insertion of Enteral Access Device

1. Obtain radiographic confirmation of tube placement
prior to use. (B)
2. Capnography may help prevent improper placement
when inserting a gastric feeding tube. (B)
3. When inserting a small bowel feeding tube, observe for
a change in pH and appearance of aspirates as the tube
progresses from the stomach to small bowel. (B)

4. Do not rely on the ausculatory method to differentiate

between gastric and small bowel placement. (A)
5. Mark exit site of feeding tube at the time of the initial
radiograph; observe for a change during feedings. (B)
6. In pediatrics and neonates, all methods but X-ray
verification of enteral tube placement have been shown
to be inaccurate; however should be used judicious. (B)

Longterm Enteral Feeding Devices

1. Considered when EN >4 wks. (C)
2. Not for premature infants without strong justification. (C)
3. Multidisciplinary team should advise re placement to ensure
(B):
a. benefit > risk of placement;
b. placement near end of life is warranted; or
c. insertion is indicated if close to achieving oral feeding.

4. Perform abdominal imaging prior to placement. (C)

5. Gastrostomy tube placement does not mandate
fundoplication. (B)
6. Direct placement indicated in patients requiring a long-term
jejunostomy. (B)
7. Document tube type, tip location, and external markings. (C)
8. Avoid placement of catheters or tubes not intended for use
as enteral feeding devices. (B)

When to start feeding following

placement?
1. Enteral feedings should be started postoperatively
in surgical patients without waiting for flatus or a
bowel movement. The current literature indicates
that these feedings can be initiated within 24-48
hours. (A)
2. A PEG tube may be utilized for feedings within
several hours of placement: current literature
supports within 2 hours in adults and 6 hours in
infants and children. (B)

Initiation and Advancement of EN

1. Base enteral delivery method and initiation and
advancement of EN regimens on patient condition,
age, enteral route (gastric vs small bowel),
nutrition requirements, and 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)

Preterm Infant Considerations

1. For premature infants weighing < 1500 g and
at risk for NEC, it is recommended that
mothers be encouraged to supply breast milk
for their infants. (A)
2. ELBW and 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. Feeding pumps should be calibrated
periodically to assure accuracy. (B)
2. Accuracy 10% for adults (B); within 5% for
peds and neonates. (C)

3. HBM infused at low rates should be

administered via syringe pump with tip
elevated. (C)
4. Feeding pumps for home use should have
features that promote safety and minimize
sleep disturbances. (B)

Patient Positioning
1. Elevate the backrest to >30, and preferably to
45, for all patients receiving EN unless a
medical contraindication exists. (A)
2. Use the reverse Trendelenberg position to
elevate the 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 of feeding tubes

1. Flush with 30 mL water q 4h during continuous
feeding(A); before/after bolus feedings (A) and
residual volume measurements (B) in adults.
2. Use lowest volume necessary to clear tube in peds
and neonates. (C)
3. Sterile water is recommended before/after
medication administration. (C)
4. Adhere to protocols that call for proper flushing of
tubes before/after medication administration. (B)
5. Use pump when slow rates are required, such as with
neonates, and respond promptly to pump alarms. (C)
6. Use sterile water for tube flushes in
immunocompromised or critically ill patients. (C)

Enteral Misconnections
1.
2.
3.
4.
5.
6.

7.
8.

Review current systems/practices for misconnect potential. (C)

Only allow trained clinicians to reconnect, in proper lighting. (C)
Do not modify or adapt IV or feeding devices. (C)
Routinely trace lines back to origins and in standardized
directions . (C)
Recheck connections, trace all tubes in new setting/hand-off. (C)
Use standardized labels or color-code feeding tubes and
connectors. (C)
Identify and confirm the EN label. (C)
Ensure purchasing policies dictate safe products:
Avoid enteral equip that mates with female luer
connectors. (C)
Dedicated enteral pumps. (C)
Enteral feeding sets. (C)
Preoper pre-filled EN containers. (C)
Oral syringes, instead of luerlock, for enteral meds. (C)

Medication Administrion
1. Dont add meds directly to enteral formula (B)
2. Dont mix meds for EN admin (B)
3. Administer each med separately in appropriate
form (B)
4. Stop feeding flush med flush (A)
5. Hold EN < 30 min following med (A)
6. Use oral/enteral syringes labeled with for oral
use only to measure/administer enteral meds.
(B)
7. Consult pharmacist for patients who receive
medications co-administered with EN. (C)

Monitor for Refeeding Syndrome

1. Monitor fluid and electrolyte, and other
metabolic parameters as needed based on
the patients clinical situation. (B)
2. Check metabolic and nutrition parameters,
and correct depleted levels prior to the
initiation of enteral feedings. (B)

Monitor Gastric Residual Volumes

1.
2.
3.
4.
5.
6.
7.
8.

With EN, always evaluate aspiration risk. (A)

Assure tube is properly placed before use (A)
Elevate HOB 30-45(A)
During first 48h, check GRV q 4h (B); may reduce to 68h thereafter in non-critically ill (C)
If GRV is >250 mL after 2nd check, consider prokinetic
agent in adults (A)
If GRV is >500 mL, hold EN thoroughly reassess
patient tolerance (B)
If GRV is consistently >500 mL, consider tube below
loT (B)
In peds, check GRVs every 4h, hold if residual > hourly
rate. If bolus, check before next feed and hold if GRV
>50% of previous volume. (C)

Conclusions
EN is also complex and safety is
critically important
PRCTs are needed

Implications for safe EN practices

extend far beyond those providing the
nutrition support
Strong communication is essential