Our Friends Up North: NICU Medicine & Enteral Feeding Guidelines in Canada

Annie Duchemin, R.N., is French Canadian and originally from Quebec City, now living in Mississauga, Canada. She has more than 30 years of clinical experience in NICU/Paediatric and Acute Care settings. Recently, she worked with Philips Healthcare Canada, where she spent five and a half years as a Clinical Application Specialist/Consultant for Patient Care Monitoring. She has successfully completed numerous largescale healthcare projects, which have required her to develop expertise and assume increased responsibilities in project management, team management, clinical education, the development of clinical evidence-based practice standards and policies for the NICU/Paediatric area, as well as organizational, interdisciplinary collaboration, and application of continuous improvement principles.

Since she has a unique perspective on the inner workings of NICU and enteral feeding in Canada, I wanted to take the opportunity to chat with her about how things are done in her country and where Canadians are with the enteral safety product of ENFit. 

All About Enteral Feeding Guidelines and NICU Medicine in Canada

Q: Could you briefly describe “a day in the life” of a NICU nurse in a level 2 or level 3 NICU? 

A: I started my NICU nursing career in the French speaking city of Quebec after my graduation and worked there for about 10 months before moving to Toronto, Ontario, where I continued my career at Sunnybrook Health Sciences Centre’s NICU for about 20 years. The NICU nursing practice in Canada varies from Province to Province/Territories. Sunnybrook is a Level 3 hospital and the nurses work 12 hour shifts from 7:30 -7:30 (with days and nights rotated). The NICU has 4 pods (A-D) and each pods has 12 rooms. It also has a resuscitation room with 3 beds, with each bed equipped with a camera above so the family can see the whole resuscitation. 

At the beginning of the shift, the nurse changes into her scrubs and then reports to the charge nurse who provides the R.N. with her shift assignment. The nurse may be assigned 1-4 babies, depending on the acuity and availability of staff on duty that day. In Ontario, the Registered Nurse will follow the standards of care for their nursing practice as outlined by their nursing college (CNO), the National Association of Neonatal Nurses (CANN), and by the Provincial Council for Maternal and Child Health (PCMCH). The R.N. is responsible for the assessment, nursing diagnosis expected outcomes of care, planning, implementation, evaluation, and documentation of developmentally appropriate care. They also provide support, teaching, and information to parents and coordinate the care with the multidisciplinary team. The R.N. is supporting the concepts and principles of Patient-Focused Care and the mission and values of the hospital as she or he practices within the Hospital Nursing Practice and Policies.

Q: Where are you with ENFit in Canada? 

A: ENFit connections are available to purchase in Canada from other companies. Medela Canada hasn’t launched the enteral feeding solution in Canada yet, but we are hoping for a launch in 2022.

Q: What are some safety guidelines and best practices surrounding enteral feeding (placement check, number where taped, tracing lines, etc)?

A: The nurse will use the feeding tube insertion practice guidelines outlined here by the Hospital for Sick Children in Toronto. 

Q: What are some of the vendors you use in Canada for enteral feeding? 

A: Many of the same vendors that are used in the U.S., such as:

• Atlanta BioMedical Corporation  
• ENFit^® Connection System 
• EnClean^® Single-Use and Reusable Brush
• Kangaroo
• Kendall
• McKesson
• MED-RX

Q: What colors are your enteral feeding products? 

A: Orange or purple.

Q: How do you address misconnections? 

A: Misconnections are treated like a medication error. An incident report will be completed and an investigation will be conducted to prevent the error from being repeated.

Q: What is the criteria for advancing to PO feeds from enteral? 

A: Non-nutritive sucking, which is based on readiness cues when the baby is interested and physiologically stable (not by age limitation). The baby will have been exposed to licking and sniffing at the breast during tube feeds and sucking on a pacifier with breast milk on it. Pacifiers are encouraged for self-soothing the baby and for oral stimulation. The baby will be placed at the breast just like when breastfeeding. They will start at an emptied breast, the mother will hand-express drops, and the plan is to do this once per day.

Q: What do you do for warming when enteral feeding? 

A: In most units, the Medela waterless milk warmers are being used for IPAC.

Q: What regulatory bodies watch for best practices and misconnections? 

A: Regulatory bodies include Health Canada, the Institute for Safe Medication Practices Canada ISMP Canada, and the College of Nurses of Ontario.

Q: Do most units do bolus or continuous, or is it up to physician? 

A: Most units will bolus the feeds, unless the baby is having feeding intolerances. If there are feeding intolerances, the physicians will order slow boluses over a chosen number of hours.

Q: Do you use enteral feeding pumps for NICU? What about for Peds?  

A: Yes, we do use enteral feeding pumps for both NICU and Pediatrics.

Q: Do you use Kangaroo pumps?   

A: We use the both the Medfusion and Kangaroo pumps. 

Q: Do you fortify? 

A: Yes, we do fortify.

Q: Do you use donor human milk? 

A: There are currently four Canadian human milk banks in Vancouver, Calgary, Toronto, and Montreal. Each bank follows the Human Milk Banking Association of North America guidelines for screening, processing, and dispensing donor human milk. Milk banks in Canada must meet federal, provincial, and municipal regulations.

Additionally, the sale and distribution of donor human milk is regulated by Health Canada under the Food and Drugs Act. All donors must undergo a rigorous screening process, including an interview to establish lifestyle and medical history, and a blood test to confirm they do not have any infectious diseases.

Q: Do you have prep rooms?   

A: All level 3 hospitals have milk preparation rooms with hoods and milk prep technicians. Most level 2 hospitals have a designated milk prep area, but no technicians. 

Q: Tell us about some the overall differences in healthcare between the U.S. and Canada.

A: Canada has equal healthcare for all – it's free (of course it’s paid with taxes), but no one is afraid to go to a doctor or hospital, as everything is covered and you can seek care in a timely manner. So much of our healthcare is focused on prevention that many times you can proactively eliminate the need to go to the hospital. A mom of a premature infant would have regular, no-charge follow-ups and any issues would be addressed by a hospital, physician, or clinical practice. Prevention can be the best medicine. The pandemic has actually improved access, as physicians are doing virtual presentations even for the neonatal population. 

While NICU practice is challenging everywhere, the day-to-day practice is very similar. However, the reimbursement model – meaning, private versus government – is  very different. In the enteral feeding arena, ENFit is not fully embraced in Canada (or in the U.S.), but recommendations to move fully to ENFit are in place in both countries. ENFit™ is an industry-led initiative focused on rendering enteral connections safely.

An Update on ENFit

A recent recommendation from GEDSA to both the U.S. and Canada revised some of the phase-out dates for old “legacy” enteral products. The recommendation and link to the release are below. Any ENFit information can be obtained from GEDSA.org or your enteral vendor. 

From GEDSA, April 2020:

“GEDSA and its members have decided to revise the production phase-out dates for legacy enteral connectors so that production can be dedicated to the safer ISO 80369-3 compliant connectors, commonly called ENFit^®, in the U.S. and to include Canada.”

For more information, please see below:

200914_REVISED_ENFit^®_Connector_Conversion_Schedule_U.S._Canada_Legacy_Connector_Production Phase_Out_Dates .docx (stayconnected.org)