Syringe Pumps for NICU Enteral Feeding: Considerations with ENFit^® Syringes

Syringe pumps for enteral feeding in the neonatal and pediatric space have long had regulations and guidelines for safety and best performance. Making sure an enteral feeding syringe pump was not mistaken for an I.V. syringe pump has always been at the forefront of safety. Also, having a syringe pump that can be tilted to give “fats first” has always been recommended to prevent fat loss by minimizing the adherence of fats to the side of a syringe. 

But, with ENFit syringes, some new considerations should be looked at along with safety and practice. ENFit is a new design and the syringe pump needs to be ENFit-compatible and able to read the syringe.

Here are the three things to look for in enteral syringe pumps:

• Is the pump enteral only?
• Can the pump be tilted to give fats first?
• NEW - Is the pump ENFit-ready and able to read the new ENFit syringe?

A brief review of enteral-only pumps, administering fats first, and the new consideration to look for – ENFit-ready pumps – are all discussed below:

#1: Is the Pump Enteral Only?

To avoid misconnections, regulatory bodies like the Joint Commission, ADA, and ASPEN have long recommended that when using enteral pumps in the clinical setting, pumps should be clearly distinct from syringe pumps used for I.V. medications. They should look different in appearance (model, color) and act different from their I.V. counterpart devices. Highlights from these recommendations are below:

Recommendations for Enteral Only Syringe Pumps:

• Joint Commission: Do not use IV tubing or IV pumps for enteral feedings. 
  Sentinel Event Alert, Issue 53, August 20, 2014, Page:  4 #9
  
  Use distinctly different pumps for IV applications (rather than using similar pumps for intrathecal and/or epidural applications) to reduce the possibility that an intrathecal medication will accidentally be delivered intravenously and vice versa.
  The Joint Commission. “Managing Risk during Transition to New ISO Tubing Connector Standards. Sentinel Event Alert 53 (2014).
• ADA: In general, intravenous pumps should not be used for enteral feeding when enteral feeding pumps designed for infants or pediatrics are available. 
  American Dietetic Association: Infant Feedings:  Guidelines for preparation of human milk and formula in health care facilities. (2011), Page:  99
• ASPEN: When syringe pumps are used in neonatal ICUs for human milk or other feedings, they should be clearly distinct from syringe pumps used for IV or other medical purposes. Ideally, they should be a different model, color, or as different in appearance from IV pumps as possible.
  ASPEN Enteral Nutrition Practice Recommendations.  Journal of Parenteral and Enteral Nutrition. (2009), Page:  157 #9

#2: Can the Pump Administer Fats First?

Another consideration for syringe pumps for enteral feeding is whether they can be tilted to deliver fats first. The pump delivery method can result in loss of fat, with the separation of the fat layer within the container and adherence of fat to the sides of the syringe. HMBANA, ADA and ASPEN make the following recommendations below. Note under HMBANA where they say using a feeding pump with the syringe pointed up reduces fat loss from 48% to less than 8% - a significant reduction in loss of fat.

Fats First:

• HMBANA: Use of a feeding pump system with the syringe tip pointed up reduces fat loss from 48% to less than 8%. 
  HMBANA Guidelines,  Page 41
• ADA: In addition to loss of fat, loss of protein may also occur. Tilting the delivery system so that the exit point of the feedings is elevated minimizes the loss of fat.  
  ADA Guidelines, Page 101
• ASPEN: Tilting of the pump to an angle with the syringe tip elevated will prevent loss of fat.  ASPEN 2009 Guidelines , Page 152

#3: NEW - Is the ENFit Syringe Pump Ready?

Enteral syringes, despite the vendor brand name, are all made in 2 basic forms – BD or Monoject. Depending on who the vendor (like Medela) partners with, they will have one of those two syringe types. Medela uses BD, but another vendor might also use BD or Monoject. This is true for Legacy Enteral Syringes and also for the new ENFit designs.

Some vendors say they are “validated” by a pump manufacturer and that just means they will have taken their syringe (which is BD or Monoject) for further testing by that manufacturer. It is still the same basic syringe design, but this allows the pump manufacturer to put the vendor name into the library along with the BD or Monoject selections. 

The new ENFit syringe design must be able to be recognized by the enteral pump from any manufacturer and some of the older pumps are not able to do this. Upgrades sometimes can be done, but they can be expensive. Hospitals might have a combination of new and old model pumps in the unit, or newer pumps in NICU and older pumps in Pediatrics. If you implement ENFit and the syringe pumps can’t read the syringe, you can’t deliver the feeding. 

Every pump should be accounted for by version and checked with your enteral syringe vendor if this version of the pump is compatible with the new ENFit design. Or, check a sample ENFit syringe in all your devices – making sure you have programmed it for BD or Mono or the vendor name – to be sure it is really working. Doing this will avoid delays and, while upgrading or switching to newer models of syringe pumps might be costly, it will be the only way to move to ENFit and deliver pump feedings.

What's Next?

Moving to ENFit is a great time to evaluate your enteral pumps because there are safety issues with misconnections, better ways to give feedings (fats first), and the new consideration of ensuring your enteral syringe pumps are able to read and infuse the ENFit syringe. 

The new ENFit-designed syringes are all about safety, so taking a good look at your enteral pumps will be an additional safety measure and an upgrade for best possible clinical outcomes.