NICU Feeding Tubes: A Source of Infection

 

How frequently are you changing feeding tubes?

Several years ago, I had the pleasure of transitioning to a clinical specialist role working for a company that is passionate about human milk, and manufactures enteral feeding products. I am frequently asked for the manufacturer’s recommendation for changing feeding tubes.

Another question is, “How long can the enteral feeding tube be left in before changing?” This is a complex question and always gives me pause. It is different from “How often should feeding tubes be changed?”

Feeding tubes (gastric tubes) are frequently used in the NICU. Most patients will have one placed for some portion of their NICU stay. The feeding tube has two primary purposes for the critically ill neonate. One is for venting and decompressing the stomach, and the second (and equally as important) is for feeding.

For many years, the dwell time for gastric tubes was based on the type of material used to make the gastric tube. Neonatal feeding tubes in general are made of three different types of products with varying recommendations for dwell time: Polyvinylchloride (PVC), 3 days, and Polyurethane and Silicone are both 30 days.

Manufactures provide information on their packages that reflect the feeding tube maximum dwell time, such as the feeding tube could be left in place when maintained for 30 days. Wallace and colleagues addressed this in their paper, reviewing the available science and examination to improve gastric tube use and care recommendation “based on the composition of the tube AND on how the material is affected by the body.”1 For example, PVC can become stiffer over time, and polyurethane becomes softer at body temperature.1

Feeding tubes and infection

For many years feeding tubes were not considered when infection was identified in neonates, although feeding tubes may dwell in patients for days and weeks before being changed. There was a tendency to look at more invasive lines and tubes such as endotracheal tubes and peripherally inserted lines. This would contribute to overlooking the feeding tube and not considering them as a source for harboring bacteria causing feeding intolerance and infection.

How often should neonatal feeding tubes dwell in neonates?

Multiple studies have been published implicating feeding tubes as a source of infection. The duration of time the feeding tube dwells increases bacterial colonization.3 However, neonatal feeding tube frequency for changing has not been clearly identified in the literature with a quantifiable dwell time or tubing change frequency for reducing the incidence of bacteria colonization.

The Academy of Nutrition and Dietetics provides a detailed, evidence-based guideline for safe preparation, handling, and administration of human milk and formula.4 As for frequency of changing hospitalized newborn feeding tubes, their recommendation is the following: It is critical to have a protocol for routine handling of the change of equipment to control the potential colonization of feeding systems.4 They do not provide a concrete frequency for changing feeding tubes.

Patel and associates published a paper reviewing their quality-improvement initiative in the Rush NICU to reduce necrotizing enterocolitis (NEC) in very low birth weight infants.2 Their results were compelling, indicating that there is a significant relationship with frequency of changing feeding tubes and bacteria growth in the feeding tube. At Rush they observed a sharp decline in the incidence of NEC by changing their feeding tube management. The improvement bundle included discontinuing the practice of prolonged gastric tube dwell duration, changing gastric tubes every 7 days (on Tuesday), and changing extension-sets between each feeding.2

The available research demonstrates that clinical practice should no longer continue with the practice of long dwell times (30 days). However, there is not enough available evidence to indicate how frequently feeding tubes should be changed. Since evidence drives practice change, and there are no clear recommendations, the next best option is to conduct a multidisciplinary committee to review current policies and available literature to develop a protocol to standardize care and maintenance and frequency for changing feeding tubes at your hospital.5

What is your current protocol, and has it been updated? Tell us in the comments below!

 

Learn more about Medela enteral feeding tubes, available in silicone, PVC, and polyurethane, and with ENFit or Twistlok connector options.

 

References

1. Wallace, T, Steward, D. Gastric tube use and care in the NICU. NAINR. 2014;14(3):103-108.
2. Patel AL, Trivedi S, Bhandari NP, Ruff A, Scala C, Witowitch G, Chen Y, Renschen C, Meier PP, Silvestri JM. Reducing necrotizing enterocolitis in very low birth weight infants using quality-improvement methods.  Jour of Perinatology. 2014. 34;850-857.
3. Mehall JR, Kite CA, Saltzman DA, Wallett T, Jackson RJ, Smith D. Prospective study of the incidence and complications of bacterial contamination of enteral feeding in neonates. J Pediatr Surg. 2002; 37: 1177-1182.
4. Academy of Nutrition and Dietetics. Infant feedings: Guidelines for preparation of human milk and formula in health care facilities. (2nd). 2011.
5. Boullata, et al. ASPEN Safe Practices for enteral nutrition therapy. Jour of Parenteral Enteral Nutrition.