Neonatal Gastric Feeding Tubes, Part 4: Clinical Management of Feeding Tubes

 

In part 3 of this blog series, we discussed several studies around bacterial growth in feeding tubes. The knowledge that this occurs in a fairly short amount of time, and can lead to feeding intolerance and perhaps clinical sepsis, requires that we evaluate our clinical practice.

Changes in practice may be indicated based on those findings. Tubes cultured in as little as 24 hours showed some bacterial biofilm formation. While this biofilm formed in all situations, it took longer to form when infants were fed human milk.1

Other studies show a decrease in the antibacterial properties of human milk when fortifiers are added – as is often necessary in order to provide adequate nutrition to high-risk premature infants.2

Clinical Implications: Feeding Tube Bacterial Management

While specific interventions to protect infants from biofilm and bacterial contamination have not been studied, it seems reasonable to:

• Promote initiation and maintenance of human milk feeds
• Limit exposure to antibiotics whenever reasonable
• Limit the potential for introduction of pathogenic bacteria

The initiation and maintenance of human milk feeds is an overarching goal for many reasons in the NICU. In relation to this concern, mother’s own milk is most important. The antibacterial activity of mother’s own milk is specific to her infant, and these effects are lost or decreased with pasteurized donor milk.3

Antibiotic stewardship is also important for other reasons, but all include decreasing the risk of resistant organisms and resulting disease in the infant.

Clinical Implications: Decreasing Feeding Tube Bacteria

Limiting the potential for introduction of pathogenic bacteria encompasses many practices and challenges how we think about feeding infants. This is not considered a sterile procedure, but perhaps incorporating some measures that are included in central line management in order to decrease infection would be useful.

Consider things such as:

• Keeping the feeding tube closed to the environment
• If used for drainage, protect the opening such that bacteria is less likely or unlikely to contaminate the tube
• Rinse a feeding tube after a feeding to avoid milk pooling in the warm, moist environment, which would otherwise provide a food source and temperature conducive to bacterial growth
• Change feeding tubes and extension tubes at regular intervals, at least per manufacturer’s recommendations
• Create a closed system such that when connecting and disconnecting an extension tube, the feeding tube is not open to air
• Avoid touch contamination and use aseptic technique
• Maintain cleanliness of the tube when inserting it and wear gloves for insertion

In addition, further research is needed. Feeding tubes in these studies were cultured at various time intervals, from 24 hours to 7 days. Changing a feeding tube can be traumatic as well leading to oral aversion and other undesirable outcomes.

Manufacturer recommendations vary, from changing the tube every 3 days to every 30 days. The material used to make the tubing is different with short- and long-term tubes, and different amongst available short-term tubes. This leads to another question and discussion: Does the material affect the amount of biofilm that is formed? How might silver-impregnated tubing effect this growth and what is the overall effect (safety) on the infant?

Tell us your thoughts below in the comments section!

References:

1. Hurrell, E., Kucerova, E., Loughlin, M., Caubilla-Barron, J., Hilton, A., Armstrong, R., … & Forsythe, S. (2009). Neonatal enteral feeding tubes as loci for colonisation by members of the Enterobacteriaceae. BMC infectious diseases, 9(1), 146.
2. Jocson MAL, Mason EO, Schanler RJ. The effects of nutrient fortification and varying storage conditions on host defense properties of human milk.  Pediatrics.  1997;100:240-243.
3. Akinbi, H., Meinzen-Derr, J., Auer, C., Ma, Y., Pullum, D., Kusano, R., … & Zimmerly, K. (2010). Alterations in the host defense properties of human milk following prolonged storage or pasteurization. Journal of pediatric gastroenterology and nutrition, 51(3), 347-352.