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Enteral nutrition

What is it?

How does it work?

Types of nasal tubes

Nasogastric tube
  • Tube inserted into a nostril and advanced down the throat to the esophagus and then the stomach.
  • Frequently used for home enteral nutrition.
  • Allows feeding and medication to be administered directly into the stomach.
  • Can be installed and replaced by the parent, depending on the child’s condition and if they have been taught by the healthcare team.
Nasoduodenal tube
  • Tube inserted into a nostril and advanced down the throat to the esophagus, the stomach and then to the first part of the small intestine (duodenum).
  • Allows feeding directly into the duodenum (bypassing the stomach).
  • Allows the administration of medication directly into the duodenum as needed.
Nasojejunal tube
  • Tube inserted through a nostril and advanced down the throat to the esophagus, the stomach and then to the second part of the small intestine (jejunum).
  • Allows feeding directly into the jejunum.
  • Allows medication to be administered directly into the jejunum as needed.
  • Can only be installed and replaced by the healthcare team.

NEVER INSTALL OR REPLACE THE BUTTON OR LONG TUBE IF YOUR CHILD HAS AN OSTOMY FOR LESS THAN 6 TO 8 WEEKS (or other length of time as recommended by your healthcare team) as the ostomy is not fully healed; all re-insertions in this time period are the responsibility of your healthcare team. 

Types of feeding buttons

Gastrostomy button
(eg, Mic-Key™, AMT MiniONE™, NutriPort™, Bard™, EntriStar™)
  • Device installed in a gastrostomy.
  • Allows feeding and medication administration directly into the stomach.
  • Can be installed and replaced by the parent only after 6 to 8 weeks after surgery (or other length of time as recommended by your healthcare team), if the model is balloon button and the parent has been taught this skill; non-balloon button models must be replaced by the healthcare team.
Gastrojejunal button
(eg, Mic-Key™J, AMT G-JET™)
  • Device installed in a gastrostomy that extends through a tube from the stomach to the jejunum.
  • Has two entry ports: one into the stomach (usually used for medications) and the second into the jejunum (usually used for continuous feeding).
  • Mostly used in children who cannot be fed directly into the stomach.
  • Can only be replaced by the healthcare team.
Jejunostomy button
  • Device installed in a jejunostomy.
  • Allows feeding directly into the jejunum.
  • Allows medication administration directly into the jejunum, as recommended by the healthcare team.
  • Mostly used in children who cannot be fed directly into the stomach.
  • Can only be replaced by the healthcare team. If the healthcare team allows the parent to change the button, they provide the necessary training.

Each type of button has its own extension set.

Types of long enterostomy feeding tubes

Gastrostomy tube 
  • Flexible tube inserted into the stomach through a gastrostomy.
  • Allows feeding and medication administration directly into the stomach.
  • Can be installed and replaced by the parent only after 6 to 8 weeks after surgery (or other length of time as recommended by your healthcare team), if the model has a balloon and the parent has been taught this skill; non-balloon tube models can only be replaced by the healthcare team.
Gastrojejunal tube
  • Flexible tube inserted into the stomach through a gastrostomy and which goes into the jejunum.
  • Has two entry ports: one into the stomach (usually used for medications) and the second into the jejunum (usually used for continuous feeding)
  • Mostly used in children who cannot be fed directly in the stomach.
  • Can only be replaced by the healthcare team.
Jejunostomy tube
  • Flexible tube inserted into the jejunum through a jejunostomy.
  • Allows feeding directly into the jejunum.
  • Allows medication to be administered directly into the jejunum, as recommended by the healthcare team.
  • Mostly used in children who cannot be fed directly into the stomach.
  • Can only be replaced by the healthcare team. If the healthcare team allows the parent to change the tube, they provide the necessary training.

Buttons are often installed in children. They have the advantage of being comfortable and safe.

The child can be fed through the urinary catheter, if recommended by the healthcare team, while waiting to have the urinary catheter replaced with a button or an enterostomy long tube.

Discuss this possibility with the healthcare team depending on your child’s condition.

A plug should be placed over the catheter opening between feeding sessions to prevent leakage.

The important thing is that the child receives the nutrients needed for energy and growth.

NOTE: For ease of reading the rest of the text, the word (nutritional) “formula” also includes “breast milk”, “fortified breast milk” or “infant formula”.

Methods of administration of the nutritional formula

By push
  • The formula is “pushed” slowly with a feeding syringe into the tube or into an extension set attached to the feeding button.
  • This method is used for bolus feeding and medication administration.
By gravity
  • The formula is poured into a bag connected to a tubing.
  • The bag must be suspended at a height above the child’s head (eg, on an IV pole).
  • The formula flows by gravity down the tubing through a drip chamber.
  • The tubing from the bag is connected to the feeding tube or to an extension set attached to the feeding button.
  • A roller clamp on the tubing adjusts the flow rate (or administration rate) of the formula.
  • This method is used for bolus feeding.
  • This method can be used as an alternative if the pump is not functioning.
By enteral feeding pump
(eg, Kangaroo™ ePump, Kangaroo™ Joey, Kangaroo™ Connect)
  • The formula is poured into a bag connected to tubing.
  • The tubing is inserted into an enteral feeding pump connected to an electrical outlet or powered by a rechargeable battery.
  • The bag and pump are suspended from an IV pole or placed in a special backpack.
  • The tubing from the bag is connected to the feeding tube or an extension set attached to the feeding button.
  • The pump controls the amount of formula dispensed and the flow rate.
  • Several models of electronic pumps are available for use in the home.
  • The pump method is used for bolus or continuous feeding.

Modalities of administration of the nutritional formula

Bolus (or intermittent)
  • Feeds are several times a day, over short periods of time, often during normal meal times.
  • Depending on the child’s specific needs, can be used as a meal replacement or as a supplement to a meal taken by mouth.
  • Each session lasts an average of 20 to 30 minutes (like the usual duration of a meal), depending on the amount to be given and the child’s tolerance. The child’s condition may require longer sessions (one hour or more).
  • Bolus feeding cannot be given in the jejunum.
  • Possible with the push, gravity or pump method of administration.
Continuous
  • Feeds run continuously at a regular pace for the prescribed number of hours/day.
  • Feeding may run throughout the day or night without interruption.
  • Mostly used with the pump delivery method.
  • Recommended for a child who:
    • has difficulty tolerating large amounts of formula at a time (does not tolerate bolus meals),
    • has slow stomach emptying,
    • needs a specific amount of formula in a given period of time,
    • is fed directly into the jejunum.
Bolus and continuous
  • Allows mixed administration of the formula (eg, bolus during the day and continuously during the night).
  • The material used for enteral nutrition (tube, button, adapter, connector, feeding bag with tubing, extension set, syringe, etc.) is reserved exclusively for this use.

Your healthcare team is available to supervise the care provided to your child, ensure the proper functioning of equipment and make recommendations to you as needed.

Refer to your healthcare team if the equipment used for your child at home is different from what is described in this section or in the methods of care.



FAQ – Enteral nutrition

When to consult your healthcare team

Nasal tube

Ostomy

Button and enterostomy long tube

Feeding sessions

General condition

Your child’s healthcare team will use your child’s regular appointments to verify the proper functioning of the enteral nutrition equipment, to answer your questions and to make adjustments to the care as required.

Do not hesitate to contact your healthcare team with any specific questions concerning your child.

WARNING: The information in this section is meant as a general guide for parents and caregivers with certain problems related to enteral nutrition. It is not intended to replace the recommendations of your child’s healthcare team.

Discuss your child’s unique needs with the healthcare team, including WHO and WHEN to contact when problems arise.

NOTE: For ease of reading the rest of the text, the word (nutritional) “formula” also includes “breast milk”, “fortified breast milk” or “infant formula”.

Problems related to nasal tube

Difficulty or inability to irrigate the nasal tube

Possible cause(s)

  • Tube blockage (eg, debris from residual formula, reflux of stomach contents, improper preparation of medication)
  • Incorrect positioning of the tube (eg, end of the tube pressing against stomach walls)
  • Pinched tube
  • Damaged tube

What to do?

  • Try to find the source of the blockage.
  • Check the tube for bends, kinks or jamming.
  • If solid particles are visible, gently roll the tube between your fingers to try to loosen them, then gently aspirate with a syringe to try and remove particles
  • Change your child’s position.
  • Try irrigating the tube again.
  • If the problem persists:
    • try to unblock the tube by slowly injecting warm water before trying to irrigate again;
    • repeat several times.
  • If the problem still persists and it is a nasogastric tube and you have been taught to use it, replace it.
  • In all other situations, rapidly contact your child’s healthcare team.

Difficulty or inability to aspirate stomach (gastric) contents from the nasal tube

Possible cause(s)

  • Blocking of the tube (eg, debris)
  • Incorrect positioning of the tube (eg, end of the tube pressed against the stomach walls or away from the accumulation of gastric fluid)
  • Collapse of the tube, causing the walls of the tube to stick together during attempt to aspirate
  • Empty stomach

What to do?

  • Check the tube location as taught by your healthcare team.
  • If the problem persists, inject 2 to 3 ml of air through the tube.
  • Try again to aspirate gastric secretions.
  • If the problem persists, reposition your child on the left side, wait 10 to 15 minutes and then try again to aspirate gastric secretions.
  • If the problem still persists and it is a nasogastric tube you have been taught to use it, replace it.
  • In all other situations, rapidly contact your child’s healthcare team.
  • Until the problem is resolved, do not use the nasogastric tube.

Displacement of the nasal tube

Possible cause(s)

  • Mishandling
  • Accident

What to do?

  • Stop the feeding session, if in progress.
  • If your child has a nasogastric tube and you can no longer see the mark on the tube and you have been taught, gently pull the tube until the mark reaches the edge of the nostril.
  • If your child has a nasogastric tube close to the nostril; make sure you have checked the location of the tube.
  • In all other situations, leave the tube in place and rapidly contact your child’s healthcare team.

Accidental removal of the nasal tube

Possible cause(s)

  • Mishandling
  • Accident

What to do?

  • If your child has a nasogastric tube and you have been taught:
    • inspect the tube for damage;
    • if the tube is in good condition, clean it, rinse it well and reinstall it.
  • In all other situations, rapidly contact your child’s healthcare team.

Difficulty or inability to insert the nasogastric tube (eg, tube coils in the mouth or comes out through the mouth)

Possible cause(s)

  • Agitated child (upset, crying)
  • Poor insertion technique
  • Nasal obstruction (eg, polyps in the nose)

What to do?

  • Remove the tube completely.
  • Make sure your child is properly positioned; have a second person help you if necessary.
  • Review the method of care (eg, lubricate the tube well before insertion).
  • Use a method to distract your child as needed. Make sure your child is calm before trying to insert the tube again.
  • If necessary, soak the tube in a container of ice water or put it in the freezer for a few moments to make it more rigid and facilitate insertion into the nostril.
  • Encourage your child to swallow or give your baby a pacifier to suck while you insert the tube.
  • If the problem persists, contact your child’s healthcare team.

Redness around the nostril in a child with a nasal tube

Possible cause(s)

  • Skin irritation
  • Nasal discharge
  • Friction from poorly secured tube
  • Pressure sore caused by the tube

What to do?

  • Check if the tube is rubbing against the nostril.
  • If necessary, reposition the tube, making sure it is securely attached.
  • If your child has a nasogastric tube and you have been taught, remove the tube and insert it into the other nostril.
  • If the redness persists, contact your child’s healthcare team.
  • In all other situations, rapidly contact your child’s healthcare team.

Breathing difficulties (severe coughing, difficulty breathing, noisy breathing, choking, bluish lips, agitation) during nasogastric tube insertion

Possible cause(s)

  • Incorrect insertion of the tube into the airway (trachea) instead of the esophagus

What to do?

  • Remove the tube immediately.
  • Let your child rest and recover: he or she should be able to breathe better quickly. If this is not the case, call 911 immediately.
  • When your child is calmer, review the method of care.
  • Encourage your child to swallow or give your baby a pacifier while you try to insert the tube again.
  • If the problem persists, rapidly contact your child’s healthcare team.

Discharge through the nasal tube

Possible cause(s)

  • Broken nasal tube
  • Broken cap
  • Forgot to put the cap on the tube
  • Worn out cap – less watertight (closes poorly or no longer closes)

What to do?

  • Discontinue feeding or irrigating, if in progress.
  • Try to find the cause of the discharge.
  • Put the cap on the end of the tube between feeding sessions, if not present.
  • Put a piece of tape on the cap to securely close it between feeding sessions, if necessary.
  • If the nasogastric tube or its cap is broken and you have been taught, change it.
  • In all other situations, leave the tube in place and rapidly contact your child’s healthcare team.

Bleeding; blood in the nasal tube

Possible cause(s)

  • Injury (eg, traumatic insertion of tube)
  • Stomach irritation
  • Stomach ulcer
  • Infection

What to do?

  • Remove the tube.
  • Rapidly contact your child’s healthcare team.

Problems related to button or enterostomy long tube

Drainage through or around the button or enterostomy long tube

Possible cause(s)

  • Button or tube breakage
  • Breakage or obstruction of the anti-reflux valve of the button
  • Improperly installed or leaking tube port covers
  • Blocking of the button or tube
  • Displacement or malposition of the button or tube
  • Balloon breakage or deflation
  • Presence of granulation tissue
  • Skin infection under the button
  • Child’s condition (eg, constipation, vomiting, slow digestion, abdominal gas, bloating, chronic cough)

What to do?

  • Discontinue feeding or irrigation, if in progress.
  • Try to find the cause of the discharge.
  • If your child has had the ostomy for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team), has a gastrostomy balloon button or tube and you have been taught, check to see if the balloon of the button or tube is properly inflated.
  • Make sure the tube or button extension set is securely attached to your child and that there is no tension on the tubing.
  • Check the location of the gastrostomy tube by gently pulling it outward until the internal retention mechanism holding the tube in place is snug against the stomach wall.
  • Irrigate the button extension set or the tube with water.
  • Place a few clean, dry compresses on the button or at the tube inlet to absorb the flow; change the compresses regularly depending on the amount of flow.
  • Keep the skin around the stoma clean and dry as much as possible.
  • Protect the healthy skin around the stoma with a barrier cream or petroleum jelly like Vaseline®.
  • If the problem persists, and if your child has an ostomy for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team), and if it is a gastrostomy balloon button or tube and you have been taught, remove the button or the tube and replace it.
  • In all other situations, rapidly contact your child’s healthcare team.

Accidental removal of the button or enterostomy long tube

Possible cause(s)

  • Mishandling
  • Accident
  • Pulled out by child
  • Too much tension on the tube (eg, incorrect use of dressings around the stoma)
  • Insufficient volume of water in the balloon or balloon bursting
  • Button or tube breakage

What to do?

  • If the stomach is too full, the contents may come out spontaneously from the ostomy, as if your child were vomiting.
  • Thoroughly clean and dry the skin around the ostomy.
  • If your child has had the ostomy for less than 6 to 8 weeks (or other length of time as recommended by your healthcare team), rapidly contact your child’s healthcare team.
  • If your child has had the ostomy for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team), has a gastrostomy balloon button or tube and you have been taught:
    • check if the button (including its balloon) is in good condition;
    • if so, clean it, rinse it well and then put it back in place.
  • If your child has had the ostomy for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team) and he has another type of button or long tube:
  • If you are unable to insert the urinary catheter, try a smaller size catheter.
  • If you are still unable to insert a urinary catheter into the ostomy, put a compress over the stoma opening and immediately contact your child’s healthcare team. A tube or button must be reinstalled very quickly to prevent the ostomy from closing.

Red, crusty, moist, thick, red tissue around the ostomy: looks like cauliflower or a turtleneck, soft to the touch, bleeds easily and may leak yellowish/brownish, sticky fluid

Possible cause(s)

Granulation tissue (or Granuloma or Hypergranulation) which is a reaction of the skin in response to irritation caused by:

  • Excessive movement of the button or tube (eg, insufficiently inflated balloon, loose external tube retention disc)
  • Incorrect adjustment of the button or tube (eg, button stem too long, tube diameter too small)
  • Rubbing of the tube or button inside the ostomy

What to do?

  • Contact your child’s healthcare team who:
    • will evaluate the most appropriate treatment for your child’s condition (eg, medicated cream, silver nitrate),
    • will treat the infection, if present,
    • will check the appropriateness of changing the button or the tube, if necessary.

While waiting to join discuss with your healthcare team:

  • If your child has had an the ostomy for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team) and you have been taught, check that the balloon of the gastrostomy button or tube is not broken and is properly inflated.
  • Make sure the tube or button extension set is securely attached to your child and that there is no tension on the tubing.
  • Put a few clean compresses around the button or tube if there is any discharge and change the compresses as soon as they get wet.

Redness of the skin around the ostomy with or without tenderness, warmth, swelling, discharge different from the usual yellowish or brownish secretions, bad smell and/or fever (≥ 38⁰C rectal or ≥ 37.5⁰C oral or ≥ 37.5⁰C armpit)

Possible cause(s)

  • Infection
  • Inadequate ostomy care
  • Gastric fluid discharge
  • Improper fit of the tube or button causing injury to the skin around the stoma
  • Incorrect attachment of the tube or extension tube
  • Pressure sore

What to do?

  • Inspect the button or the tube; check the anti-reflux valve of the button for damage.
  • If your child has had the ostomy for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team) and you have been taught, check that the balloon of the gastrostomy button or tube is not broken and is properly inflated.
  • Make sure the tube or button extension set is securely attached to your child and that there is no tension on the tubing.
  • If the problem persists, rapidly contact your healthcare team.

While waiting to discuss with your healthcare team:

  • Keep skin clean and dry and leave it exposed to air as much as possible.
  • Put a few clean compresses around the button or tube if there is any discharge and change the compresses as soon as they get wet.

Difficulty or inability to aspirate stomach (gastric) contents from the gastrostomy button or long tube

Possible cause(s)

  • Empty stomach
  • Gastrostomy tube displacement

What to do?

  • Change your child’s position and try again to aspirate.
  • Make sure the extension set is properly connected.
  • Irrigate the button extension set to the or the long tube with a small amount of water, as recommended by your healthcare team, then retry to aspirate stomach contents.
  • If the problem persists, contact your child’s healthcare team.

Difficulty or inability to irrigate the button extension set or the enterostomy long tube

Possible cause(s)

  • Blockage of the button, extension set or tube (eg, debris, reflux of stomach contents, improper preparation of medication)
  • Pinched tube or extension set
  • Button, extension set or long tube damaged (eg, wear)
  • Gastrostomy tube displacement

What to do?

  • Try to find the source of the blockage.
  • Check to see if the button extension set or the tube is bent, kinked or jammed.
  • Check if all clamps are open.
  • Roll the tube between your fingers if solid particles are visible (to try to remove them).
  • Try to aspirate with a syringe if particles are present (to try to mobilize them).
  • Disconnect the extension set, if in place, and try to irrigate it to check for blockage; change the extension set if necessary.
  • Do not use a sharp object to attempt to unblock the tube or button.
  • Do not press too hard on the syringe plunger to attempt to irrigate the button extension set, as excessive pressure may damage the extension set.
  • If the problem persists, try to unblock by slowly injecting lukewarm water.
  • If the problem persists, if your child has had the ostomy for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team), has a gastrostomy balloon button or tube and you have been taught, remove the button or the long tube and change it.
  • In all other situations, rapidly contact your child’s healthcare team.

Difficulty or inability to insert gastrostomy balloon button or long tube

Possible cause(s)

  • Agitated child
  • Poor insertion technique
  • Shrinkage of the ostomy

What to do?

  • Remove the button or the long tube.
  • Make sure your child is in the correct position; have a second person help you if necessary.
  • Review the method of care.
  • Use a method to distract your child if necessary.
  • Make sure your child is calm before trying to insert the tube or button again.
  • If the problem persists:
  • If you are still unable to insert a temporary urinary catheter into the ostomy, put a compress over the opening and contact your healthcare team immediately. A tube or long button must be reinstalled very quickly to prevent the ostomy from closing.

Button or enterostomy long tube breakage (in place)

Possible cause(s)

  • Button or tube damaged (eg, wear)
  • Manufacturing defect of the button or long tube
  • Mishandling

What to do?

  • Discontinue feeding or irrigation, if in progress.
  • If your child has had the ostomy for less than 6 to 8 weeks (or other length of time as recommended by your healthcare team):
    • do not change the button or tube;
    • contact your healthcare team.
  • If your child has had the ostomy for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team), has a gastrostomy balloon button or tube and you have been taught:
  • If your child has had the ostomy for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team) and has another type of button or long tube:
    • do not change the button or tube;
    • contact your child’s healthcare team.

Disconnection of the extension set during the feeding session

Possible cause(s)

  • Accidental disconnection
  • Wrong connection of the button extension

What to do?

  • Stop the feeding session, if in progress.
  • Try to estimate the volume of formula lost.
  • Thoroughly clean the button feeding port with soapy water and rinse it well.
  • Clean the inside of the extension set port.
  • Connect the extension set to the button and irrigate it.
  • Resume the feeding session and replace the estimated amount of formula lost during disconnection if possible.

Bleeding through or around the ostomy

Possible cause(s)

  • Injury
  • Irritation
  • Granulation tissue
  • Infection

What to do?

If the bleeding is severe:

  • Discontinue feeding or irrigating session, if in progress.
  • Apply pressure with a compress or clean cloth to the site of bleeding.
  • Contact your healthcare team immediately.

If the bleeding is light:

  • Thoroughly clean and dry the skin around the ostomy.
  • Keep the skin clean and dry and leave it exposed to air as much as possible.
  • Put a few clean compresses around the button or tube and change the compresses as soon as they get wet.
  • Contact your child’s healthcare team.

Blood in the (stomach) gastric aspirate from the button or enterostomy long tube

Possible cause(s)

  • Injury
  • Stomach irritation
  • Stomach ulcer
  • Infection

What to do?

  • Rapidly contact your child’s healthcare team.

Outward movement of the button or enterostomy long tube

Possible cause(s)

  • Insufficient volume of water in the balloon or broken balloon
  • Excess tension on the tube (eg, use of dressings around the ostomy)
  • Incorrect adjustment of the tube or button

What to do?

  • Stop the feeding session, if in progress.
  • Check the tube for excessive tension and reattach it properly, if necessary.
  • If your child has had the ostomy for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team), has a gastrostomy balloon button or tube and you have been taught:
    • check the volume of water in the balloon;
    • gently push the button stem or tube inward;
    • add the necessary amount of water missing from the balloon, if necessary.
  • In all other situations, rapidly contact your child’s healthcare team.

Inward movement of the button or enterostomy long tube

Possible cause(s)

  • External bolster (to stabilize the tube at skin level) displaced or absent
  • Incorrectly secured tube
  • Button stem too short
  • Incorrect adjustment of the tube or button

What to do?

  • Stop the feeding session, if in progress.
  • If your child has had the ostomy for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team), has a gastrostomy balloon button or tube and you have been taught:
    • gently pull the tube outward until the internal bolster is seated against the stomach wall;
    • make sure the tube’s external bolster is attached to the stomach wall, leaving a space about the thickness of a dime;
    • secure the tube to the belly.
  • If the problem persists and in all other situations, rapidly contact your child’s healthcare team.

Unable to deflate the balloon of the gastrostomy button or tube (in place)

Possible cause(s)

  • Debris in the balloon fill valve
  • Button or tube breakage

What to do?

  • Make sure that the balloon fill valve is clean and not blocked by debris from formula; clean it if necessary.
  • Then firmly insert the syringe into the valve by pushing and turning it a quarter turn; try withdrawing the syringe plunger again.
  • If the problem persists and in all other situations, contact your child’s healthcare team.

Inability to rotate the gastrostomy balloon button

Possible cause(s)

  • Incorrect button adjustment
  • Inadequate ostomy care

What to do?

  • Cleanse the skin around the button.
  • Then try turning the button again.
  • If you are unable to rotate the device, contact your child’s healthcare team.

Problems related to feeding session or general condition of the child

Feeding pump alarms

Possible cause(s)

  • Various

What to do?

  • Press the appropriate button to stop the alarm tone.
  • Look at the message on the screen.
  • Follow the instructions accordingly.
  • If a help screen is available for the alarm, follow the instructions provided.
  • If necessary, consult the pump instructions that you have been given.
  • If you still cannot resolve the problem, contact your healthcare team.

Difficulty or inability to administer formula or medication through the tube or button (eg, inability to push the plunger on the feeding syringe, blocked or slowed flow of formula by gravity or pump)

Possible cause(s)

  • Blockage of the button, extension set, tube or tubing of the bag (eg, inadequate irrigation of the button or tube before use, accumulation of debris, thick texture of the formula, nature of the medication), poor preparation of the medication, interactions between formula and medication, between medications or with gastric secretions, contaminated formula during preparation or poor maintenance of the equipment, which can change the consistency)
  • Tube, extension set or tubing clamped
  • Button, extension set or tube damaged (eg, worn out)
  • Pump malfunction
  • Poor administration technique (eg, bag hung too low)
  • Intermittent administration of the formula
  • Stomach too full

What to do?

  • Try to find the source of the blockage.
  • Make sure that all tubes are properly connected.
  • Check the button extension set, tube or bag tubing for bends, kinks or pinches.
  • Make sure clamps are fully open.
  • Reposition your child.
  • Roll the tube between your fingers if solid particles are visible.
  • Try to irrigate the tube or button extension set. Disconnect the extension and irrigate as needed before reconnecting it again.
  • Do not use a sharp object to clean the tube or button.
  • If necessary, try to unblock by slowly injecting lukewarm water.
  • Revise the technique if necessary.
  • Look at the message on the screen and if appropriate, follow the instructions accordingly.
  • If necessary, consult the pump instructions.
  • Change the pump to a back up pump if available, in case of emergency.
  • If your child has had the ostomy for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team), has a gastrostomy balloon button or tube and you have been taught, change the tube or button.
  • In all other situations, rapidly contact your child’s healthcare team.

Nausea and/or vomiting between feeding sessions

Possible cause(s)

  • Interval between feeding sessions too short
  • Formula administration speed too fast
  • Too much formula administered
  • Intolerance or allergy to the formula
  • Constipation
  • Gastric reflux (stomach contents rise up into the esophagus)
  • Dumping syndrome (or rapid gastric emptying): the stomach empties too quickly into the intestine

What to do?

  • If your child is nauseated, place the child in an upright seated position
  • If your child is vomiting, put your child’s head to the side.

In both cases:

  • Postpone the next feeding session for 30 to 60 minutes.
  • Reduce the amount or rate of formula to be administered, as recommended by your healthcare team.
  • If the problem persists, contact your child’s healthcare team.

Nausea and/or vomiting during feeding session

Possible cause(s)

  • Formula administration speed too fast
  • Excess air in the stomach
  • Too much formula administered
  • Formula too cold
  • Formula too concentrated
  • Intolerance or allergy to the formula
  • Contamination of the formula (during preparation, poor maintenance of the equipment)
  • Gastric reflux (stomach contents rise up into the esophagus)
  • Gastric emptying is fast or too slow (the stomach empties too quickly or too slowly into the intestine)
  • Change in administration schedule
  • Constipation
  • Infection

What to do?

If your child has nausea:

  • Place the child in an upright seated position, if possible.
  • Slow down or stop feeding until your child is comfortable and then resume feeding.
  • If the problem persists, contact your child’s healthcare team.

If your child vomits:

  • Turn your child’s head to the side.
  • Stop feeding for 30 to 60 minutes and then start again more slowly.
  • If the problem persists, contact your child’s healthcare team.

Breathing difficulties (eg, coughing, choking, noisy and/or wheezy breathing, increased work of breathing (retraction of the skin around the ribs and collarbones), bluish discoloration of the lips and skin) during a feeding session

Possible cause(s)

  • Aspiration (accidental entry of formula into the lungs): caused by improper positioning of the child or the nasal tube, vomiting or gastric reflux
  • Condition of the child
  • Respiratory infection

What to do?

  • Stop the feeding session immediately.
  • Stay calm and reassure your child.

If your child is in respiratory distress:

  • Call immediately 911.
  • Begin CPR as taught.

If your child is not in respiratory distress:

  • Put your child in a sitting position or turn the child onto the side to make breathing easier.
  • If your child has a nasogastric tube, check the tube location. If it is not in the stomach, remove it immediately and reinsert it when your child becomes calm again.
  • If your child has a button or another type of tube, rapidly contact your child’s healthcare team.
  • If your child has other discomforts in addition to breathing difficulties, rapidly contact your child’s healthcare team.

Bloating / swelling of the belly during feeding session

Possible cause(s)

  • Formula administration speed too fast
  • Excessive swallowing of air (eg, in children with non-invasive ventilatory support, crying)
  • Excess gas produced by digestion or infection
  • Too much formula at each feeding session
  • Intolerance to the formula
  • Poor absorption of the formula
  • Gastric emptying too slow (the stomach contents empty too slowly into the intestine)
  • Bowel obstruction
  • Condition of the child

What to do?

  • If your child has severe abdominal pain and/or other discomforts (eg, vomiting), stop the feeding session and immediately contact your child’s healthcare team.
  • If this is not the case, reduce the flow rate of the formula, according to your child’s tolerance.
  • If the problem persists:
    • stop the feeding session for 30 to 60 minutes;
    • if you have been instructed, decompress (or vent) the button or tube to let air out of the stomach.
  • If your child does not have any more discomfort afterwards, resume the feeding session by increasing the speed of flow progressively.
  • If the problem persists, contact your child’s healthcare team.

Bloating / swelling of the belly between feeding sessions

Possible cause(s)

  • Excessive swallowing of air (eg, in children with non-invasive ventilatory support, crying)
  • Excess gas produced by digestion or infection
  • Too much formula at each feeding session
  • Intolerance to the formula
  • Poor absorption of the formula
  • Gastric emptying too slow (the stomach contents empty too slowly into the intestine)
  • Bowel obstruction
  • Condition of the child

What to do?

  • If your child has severe abdominal pain and/or other discomforts (eg, vomiting), stop the feeding session and and immediately contact your child’s healthcare team.
  • If this is not the case and if you have been instructed, decompress (or vent) the button or tube to let air out of the stomach.
  • Be sure to close the tube cap tightly between feeding sessions.
  • If your child can also feed by mouth, eliminate liquids and foods that cause gas or intolerance, as recommended by your healthcare team.
  • If the problem persists, contact your child’s healthcare team.

Abdominal pain during feeding session

Possible cause(s)

  • Formula administration speed too fast
  • Too much formula at each feeding session
  • Formula too cold
  • Excess air in the stomach
  • Gastric emptying too slow (the stomach contents empty too slowly into the intestine)
  • Intolerance to the formula
  • Constipation
  • Gastrointestinal problems (eg, intestinal obstruction)
  • Infection

What to do?

  • If your child has severe abdominal pain, stop the feeding session and and immediately contact your child’s healthcare team.
  • If the pain is fairly mild, reduce the flow rate of the formula, according to your child’s tolerance
  • If the problem persists, discontinue administration for 30 to 60 minutes, which may help reduce symptoms and then gradually resume the feeding session.
  • If the problem still persists and you have been taught, decompress (or vent) the button or tube to let air out of the stomach and then gradually resume the feeding session.
  • If the problem persists, contact your child’s healthcare team.

Diarrhea (soft or liquid stools more frequent than usual) with or without cramps and/or abdominal pain

Possible cause(s)

  • Infection
  • Formula administration speed too fast
  • Use of formulas that have passed the expiry date
  • Contamination of the formula (during preparation, poor maintenance of the equipment)
  • Side effects of medication (eg, antibiotics)
  • Intolerance to the formula
  • Movement of the tube or button
  • Too much fiber in the diet
  • Food allergies or intolerances
  • Dumping syndrome (or rapid gastric emptying): the stomach contents empty too quickly into the intestine.
  • Condition of the child

What to do?

  • Discontinue feeding session if in progress.
  • If your child has bloody diarrhea, fever or episodes of diarrhea are frequent, immediately contact your child’s healthcare team.
  • If this is not the case, check your child’s hydration level (thirst, dry lips and tongue, darker urine, with a strong odour and in small quantities, weakness, dizziness).
  • If your child seems dehydrated or is having many more stools than usual, immediately contact your child’s healthcare team.
  • If your child is adequately hydrated, delay feeding for 30 to 60 minutes to relieve symptoms; resume feeding session more slowly over the next few hours.
  • Review the cleanliness guidelines for formula preparation and storage recommendations (including in the hanging bag).
  • Check the expiry date of the formula: discard products that are past their expiry date or return them to the pharmacy.
  • If the problem persists, consult your child’s healthcare team.

Constipation (infrequent and/or difficult to pass stool for more than a day) with or without nausea, vomiting, abdominal bloating, cramps and/or abdominal pain

Possible cause(s)

  • Insufficient hydration
  • Inactivity
  • Lack of fibre in the diet
  • Change of formula
  • Side effects of medication
  • Intolerance to the formula
  • Change of medication
  • Condition of the child

What to do?

  • Make sure your child gets all the fluid he or she needs.
  • Increase the amount of physical activity your child gets, if possible.
  • Contact your healthcare team for advice on nutrition (eg, increasing dietary fibre).
  • If the problem still persists, contact your child’s healthcare team.

Dry mouth

Possible cause(s)

  • Insufficient hydration
  • Lack of mouth stimulation
  • Side effects of medication
  • Condition of the child

What to do?

Yellowish or greenish vomiting (bile) or yellowish or greenish liquid visible in the feeding tube

Possible cause(s)

  • Movement of the gastrostomy tube or urinary catheter into the intestine
  • Bowel obstruction
  • Intussusception or intestinal invagination (folding of the intestines on top of each other, like a telescope: most common with nasojejunal or gastrojejunal tubes)

What to do?

  • Discontinue feeding session or irrigation, if in progress.
  • Check that the gastrostomy tube or urinary catheter is in the right place, as taught to you by your healthcare team.
  • If not, reinstall the tube or catheter correctly.
  • If the tube or catheter is in the right place and the problem persists, immediately contact your child’s healthcare team.

One or more of these symptoms between feeding sessions: Headaches; Chest pain; Vomiting; Blurred vision; Perspiration (sweating); Pallor (pale skin); Fatigue or irritability; Tremors (shakiness); Convulsions

Possible cause(s)

  • Hypoglycemia (low blood sugar)
  • Infection
  • Dumping syndrome (or rapid gastric emptying): the stomach contents empty too quickly into the intestine

What to do?

  • If your child is having a convulsion or is not responsive, immediately contact 911.
  • If not, check your child’s blood glucose, if already discussed and you have been taught by your healthcare team.
  • Rapidly give your child an additional source of sugar as recommended by your healthcare team in this situation.
  • Immediately contact your child’s healthcare team.

One or more of these symptoms during and/or after feeding session: Headaches; Chest pain; Strong thirst; Weakness; Agitation; Irritability; Abdominal cramps; Diarrhea; Urine more often than usual

Possible cause(s)

  • Hyperglycemia (high blood sugar)
  • Infection
  • Dumping syndrome (or rapid gastric emptying): the stomach contents empty too quickly into the intestine

What to do?

  • Check your child’s blood glucose, if already discussed and you have been taught by your healthcare team.
  • Immediately contact your child’s healthcare team.

One or more of these symptoms: Increased thirst; Dry and sticky tongue; Dry and chapped lips; Hollow or sunken eyes; Darker urine, strong odor and in smaller quantities than usual; Urine less often than usual; Weakness; Dizziness

Possible cause(s)

  • Dehydration because of low water intake or significant fluid loss (eg, through vomiting, diarrhea, excessive sweating, fever, certain medications)

What to do?

  • Rapidly contact your child’s healthcare team.
  • Give your child rehydration formulas (eg, Pedialyte™, Gastrolyte™), if recommended by your healthcare team.

One or more of these symptoms: Faster breathing, difficulty breathing; Swelling especially in the legs, feet and around the eyes; Quick and sudden weight gain

Possible cause(s)

  • Fluid overload in the body
  • Low protein levels in your child
  • Infection
  • Condition of the child

What to do?

  • Immediately contact your child’s healthcare team.

Please do not hesitate to refer to your healthcare team for any questions or specific advice related to your child’s condition.



Everyday tips

Clothing

  • Make sure the tube or button extension set is securely attached to your child to avoid tension.
  • Avoid clothing with a tight belt so that it does not rub against the ostomy or get caught in the tube or button.
  • Ideally, wear clothing that covers the button or enterostomy long tube (eg, long t-shirt, one-piece pyjamas, button-down sleepsuit, overalls).

Bathing and swimming

Bathing:

  • Your child can take a bath or shower with his or her feeding tube or button, unless your healthcare team advises otherwise. Make sure the cover is securely in place.
  • You can take advantage of the bath time to change the nasogastric tube; make sure the skin on the cheek is dry before reinserting the tube after the bath, if necessary.

Ostomy care:

  • Clean the skin around the ostomy with a small washcloth soaked in room temperature tap water and unscented mild soap (eg, “Dove”). Start on the inside (the area of skin closest to the ostomy) and clean outward (the area of skin furthest from the ostomy).
  • Gently lift the button or the long tube external bolster and clean the ostomy site in the same manner.
  • Observe the skin around the ostomy; it should be clean, dry, and intact (same appearance as usual: similar to the color of the belly or slightly pinkish). Check for signs of infection (redness, tenderness, swelling, discharge different from the usual yellowish or brownish discharge, bad odour).
  • It is normal for a small amount of yellowish or brownish discharge to come out of the ostomy. They may become crusty as they dry. You can easily remove them with a cotton swab. Rinse and dry the skin well.
  • If your child has had an ostomy for less than 6-8 weeks (or other length of time, as recommended by your healthcare team), check with your healthcare team to see if cleaning the ostomy site with saline solution is needed. Refer to your healthcare team for the recipe and storage of homemade saline solution, if recommended.
  • As with all children, avoid bubble baths and scented oils.
  • Do not apply cream or lotion to the skin around the ostomy unless recommended by your healthcare team.
  • If there is a small amount of milk or nutritional formula leakage, you can place a compress under the button or around the tube on the skin to absorb the leakage and protect the skin; change the compress as soon as it is wet to keep the skin clean and dry. You can purchase button pads, made for children, from many online retailers (eg, www.feedingtubeawareness.org/g-gj-tube-pads/). Discuss this with your healthcare team.

Mouth care:

  • Even if your child is not eating, your child’s mouth should be cleaned at least twice a day.
  • If your child has no teeth, use a small face cloth or a compress dampened with water and rolled around your index finger, to gently rub your child’s gums and tongue.
  • Once teeth start to appear, brush your child’s teeth after each meal and at bedtime. Since young children have a tendency to swallow toothpaste instead of spitting it out, use only the size of a small grain of rice in children under 2 years old and the size of a small pea in children up to 6 years old. Use this time to also gently massage their gums with the toothbrush.
  • As your child matures, teach and supervise brushing of the teeth.
  • Apply, if required, a hydrating lip balm.

Nasal hygiene:

  • In all children, secretions, along with bacteria and viruses collect in the nose. Keeping your child’s nose clean helps prevent lung infections.
  • If your child cannot blow his/her nose effectively, refer to your healthcare team for the appropriate technique for nasal hygiene with a saline solution that will allow your child to clear his/her nose properly (recipe and storage of the “homemade” saline solution, quantity to use, how to proceed according to your child’s age, etc.). To this end, you can refer to the brochure published by the Centre hospitalier universitaire Ste-Justine that explains the technique of nasal hygiene: Nasal hygiene.

Swimming:

  • Immediately following tube placement, your child can bathe according to the recommendations of the healthcare team.
  • Unplug your child from the feeding system and remove the extension set, if in place, before swimming.
  • Make sure the tube is securely fastened so that it will not get snagged or ripped off while swimming.
  • Make sure the cover on the nasal tube, button feeding port or enterostomy long tube ports is securely closed.
  • Consult your healthcare team for recommendations specific to your child.

Sleeping

  • As with all children under one year of age, lay your baby on his or her back to sleep.
  • If applicable, refer to your healthcare team to obtain an IV pole for overnight feedings.

Nutrition and hydration

  • Your healthcare team is responsible for identifying the specific type of nutritional formula for your child. Follow their instructions for preparation, if applicable, and for the amount to give according to the feeding schedule agreed upon with you.
  • Always check the expiry date on the original container or package before preparing or using the product; do not use products that are past their expiry date.

For ease of reading the rest of the text, the word (nutritional) “formula” also includes “breast milk”, “fortified breast milk” or “infant formula”.

  • Preparation of the nutritional formula:
    • Follow the manufacturer’s or your healthcare team’s instructions carefully.
    • Confirm with your healthcare team the type of water, if any, to be used for preparation: tap water, sterile water or cooled boiled water. The type of water varies according to the age and condition of your child.
  • Conservation of the nutritional formula:
    • Follow the manufacturer’s or your healthcare team’s instructions carefully.
    • The conservation time of the formula depends on how it is prepared (ready-to-use or reconstituted from liquid concentrate or powder).
    • Unopened original containers or packaging may be stored until their expiry date.
    • Remaining portions should be stored in a clean, airtight container.
    • Administer the formula at the temperature your child can tolerate, as recommended by your healthcare team.
    • Do not reheat the container in the microwave.
    • The length of time the formula is kept in the feeding bag varies according to several factors (eg, the form of the product used, whether or not supplements have been added, etc.). Follow the instructions of the manufacturer or your healthcare team. Pour only the amount needed for the feeding session and discard the formula that remains in the bag afterwards.

The following are general recommendations for the preparation and storage of the nutritional formula:

Preparation and conservation of the nutritional formula

Formats Preparation Conservation: Remaining portion of the prepared formula Conservation: Remaining portion of the original container 
Ready to serve
  • Wipe the top of the container with a clean cloth;
  • Shake container well before opening;
  • Do not add water or other ingredients unless your healthcare team advises you to do so;
  • Pour the required amount into the feeding bag.
X
  • Store in a clean container
  • 24 hours maximum in the refrigerator
Liquid concentrate
  • Wipe the top of the container with a clean cloth;
  • Shake container well before opening;
  • Empty the necessary concentrate into a clean, dry container;
  • Add the required amount of water for the recipe;
  • Mix well until the formula is homogeneous (smooth);
  • Pour the required amount into the feeding bag.
  • 4 hours at room temperature
  • 24 hours in the refrigerator
  • Store in a clean, airtight container
  • 48 hours maximum in the refrigerator
Powder
  • Take a clean and try container;
  • Prepare water at the temperature specified by your healthcare team;
  • Measure the amount of water and powder needed for the recipe;
  • Carefully follow the manufacturer’s or your healthcare team’s instructions for further recipe preparation;
  • Pour the required amount into the feeding bag.
  • 4 hours at room temperature
  • 24 hours in the refrigerator
  • Store in the original container
  • One month at room temperature (powder)

  • Precautions for the content of the feeding bag:
    • Check that the feeding bag and tubing have been rinsed thoroughly before use.
    • Do not add new formula to the bag if there is any left over from the previous feeding session.
    • Check with your healthcare team as to how much formula to put in the feeding bag to ensure that it will keep for the correct conservation time.
    • Always check that the formula is at the temperature your child can tolerate, as recommended by your healthcare team, before transferring it to the feeding bag.
    • Never place the filled feeding bag near a source of heat (eg, a furnace) or in a sunny place.
    • Follow the recommended conservation time for the formula in the feeding bag to avoid contamination and the development of an infection in your child.
  • Your healthcare team may recommend pureed (blenderized) tube or button feeding for your child. If this is the case, they will give you the appropriate details.
  • Discuss with your healthcare team whether your child’s condition also allows for drinking and/or eating by mouth.
  • Even if your child is receiving enteral feeding, you can encourage your child to sit at the table while other family members eat their meal. It is important that your child participates in the meals at the table. Mealtime is a social activity for the whole family. If your child can eat by mouth, take advantage of these opportunities to encourage your child to touch and taste the food.
  • You can hold your baby in your arms during feeding sessions as if you were feeding by breast or bottle.
  • Discuss with your healthcare team the best position for your child during feeding to help ease digestion, avoid discomfort (eg, nausea, vomiting, reflux) and the risk of aspiration (accidental entry of formula into the lungs).
  • You can burp your baby after feeding.
  • If your child has an ostomy, you can also decompress (or vent) the stomach prior to feeds, as taught by your healthcare team; this will help release gas and relieve bloating.

Activities

  • Your child can continue regular daily activities, according to the limits of your child’s health conditions. Make sure that the button or enterostomy long tube is always well protected. Discuss this with your healthcare team.
  • However, your child should avoid:
    • activities that may cause the tube or button to move accidentally (eg, pulling, contact sports),
    • the use of scissors near the tube and tubings,
    • having pets in contact with the pump and tubings, which could cause damage.
  • Your child can return to school or daycare if otherwise well. If necessary, discuss your child’s equipment, care and feeding needs with school or daycare staff. Discuss your child’s return to school or daycare with your healthcare team.
  • Your child can be placed on his or her stomach for play and placed in a baby carrier or car seat.

Travel and transportation

  • Always bring with you the equipment needed to administer enteral nutrition and medications when you are not at home, including a “troubleshooting kit” in case of complications. This equipment contains at least:
    • the nutritional formula (with ice packs if necessary) or the ingredients required to prepare it,
    • medications and a device to crush tablets to powder, if necessary,
    • an oral/enteral feeding syringe or feeding bags,
    • an oral/enteral syringe (to administer medication),
    • an oral/enteral syringe (for irrigation or flushing, after medication administration or feeding),
    • two button extension sets, if applicable,
    • the enteral feeding pump and backpack, if applicable,
    • the power cable for wall outlet, if necessary,
    • a spare nasogastric tube, gastrostomy balloon button or tube for replacement,
    • two urinary catheters, if your child has an ostomy: one the same size and one smaller than your child’s tube or button,
    • water-soluble lubricant,
    • a syringe (for the button balloon or urinary catheter),
    • a thin protective bandage, if appropriate,
    • adhesive bandages,
    • water (for irrigation),
    • towels.
  • Always have an up-to-date list of materials and equipment needed in the travel bag; replace used or missing items. Confirm the frequency of checking expiry dates and equipment status with your healthcare team.
  • Keep the specific instructions of the enteral pump used by your child, if applicable, handy.
  • Keep a resource list close at hand with the names and telephone numbers of hospital, doctors, other members of your child’s healthcare team and equipment providers. Make sure you know how to contact these resources outside of regular hours and during vacations.
  • Before leaving on a trip:
    • always check with your insurance company to see if travel to your destination is covered;
    • check that the appropriate voltage for the enteral feeding pump is available at your destination;
    • make sure you have a document from your healthcare team describing your child’s condition and your child’s needs regarding enteral nutrition along with a complete list of medications;
    • bring enough supplies to last for the duration of the trip and add a bit extra as a reserve;
    • be aware of the presence of suppliers and other resources that may be required while traveling to or from the destination, in case there is equipment breakdown or other health need;
    • plan what to do in case of an emergency (eg, unintentional removal of the tube or button that you cannot change yourself, broken pump, lack of nutritional formula).
  • For travel by airplane:
    • contact the airline company to inquire about their policy concerning the transport of equipment and formula;
    • keep all equipment, formula, medications and documents from your healthcare team with you in the cabin.
  • While traveling: make sure the battery of the enteral feeding pump is fully charged.
  • Discuss with your healthcare team the possibility of using an alternative method of feeding (push, gravity) while traveling.

Others

Oral stimulation:

  • Even if your child’s feeding is partially or not at all possible through the mouth, stimulation of the lips, gums and tongue is important for speech development and to maintain a normal feeling of touch, temperature and taste.
  • You can encourage your child to develop these skills by:
    • Playing with toys and objects of different sizes and textures that are appropriate for age and developmental level and intended for use in the mouth (eg, sponges, terry towels, rubber toys, small soft toothbrushes),
    • Playing with cold rattles or cooled teething toys to stimulate the inside of the mouth,
    • Using a pacifier during feeding sessions so that sucking can be combined with the pleasure brought by the food.
  • As your child grows older, find more opportunities for sucking and chewing. Oral stimulation should always be pleasant and safe.
  • Maintaining this type of stimulation can help prevent your child from developing an oral aversion (not wanting to put anything near the mouth or lips, gagging easily).
  • Depending on certain conditions, some children may need more specific techniques or exercises. Discuss this with your healthcare team.

Care of feeding tubes and buttons:

  • COMMON care for all types of tubes and buttons:
    • Checking the location of the tube or button is essential to ensure that it is used safely (to avoid administering the formula or medication in the wrong place). Several methods are used (eg, measuring external length, checking for stomach contents, checking pH, etc.). Confirm the most appropriate methods for your child’s situation with your healthcare team.
      It is essential to verify the correct location of the tube or button in all of the following circumstances:

      • after installing a nasogastric tube, gastrostomy balloon button or tube (the healthcare team will check the location of other types of tubes and buttons when they are installed),
      • before using them (feeding session, medication administration),
      • every 4 hours if your child is receiving continuous feeding,
      • if your child has certain symptoms (eg, difficulty breathing, coughing, choking, vomiting, reflux, discomfort during feeding, etc.),
      • if there are signs that the tube or button is displaced (eg, change in the length of the outer portion of the tube or button stem, detachment of the adhesive bandage or other fastening system, etc.),
      • daily, if the tube or button is not used on a regular basis,
      • if the tube is blocked, leaking or at the request of your healthcare team.
    • Irrigation of the tube and button is very important to maintain proper functioning and to avoid blockages (eg, removing traces of formula or medication). Never irrigate the button directly with a syringe as this may damage the anti-reflux valve; always connect an extension set to the button.
      It is essential to irrigate the tube or button in all of the following circumstances:

      • after installing a nasogastric tube, gastrostomy balloon button or tube,
      • before and after use (feeding session, medication administration)
      • in-between the administration of each medication,
      • after aspirating gastric contents to check the pH,
      • every 4 hours during continuous feeding,
      • daily, if the tube or button is not used on a regular basis,
      • in all other circumstances, at the request of your healthcare team.

The quantity and type of water used for irrigation (eg, tap water or cooled boiled water) depends on the model of tube or button (including the extension set) and on the child (eg, age, health condition, etc.). Always follow the instructions of your healthcare team. Each irrigation should be done with the smallest amount of water recommended to prevent the tube or button from becoming blocked.

Other solutions may be recommended for irrigation if the button/tube becomes blocked.

The same care recommendations apply to the urinary catheter (until it is replaced by a button or a enterostomy long tube).

  • SPECIFIC care for nasal tubes:
    • Before each use: Monitor the condition of your child’s nostrils and check that the reference point is always in the same place on the tube.
    • Every day: Perform nasal hygiene and check that the dressing securing the tube is clean and securely in place; change it if necessary.
  • SPECIFIC care for buttons and enterostomy long feeding tubes:
    • NEVER INSTALL OR REPLACE THE BUTTON OR LONG TUBE IF YOUR CHILD HAS A OSTOMY FOR LESS THAN 6 TO 8 WEEKS (or other length of time as recommended by your healthcare team) as the ostomy is not fully healed; all re-insertions in this time period are the responsibility of your healthcare team.
    • It is normal for a small amount of yellowish or brownish secretions to come out of the ostomy.
    • Keep the ostomy site as open to air as possible, unless a dressing is recommended by your healthcare team (eg, heavy drainage).
    • Every day:
      • Clean the skin around the ostomy with a small washcloth soaked in room temperature tap water and unscented mild soap (eg, “Dove”). Start on the inside (the area of skin closest to the ostomy) and clean outward (the area of skin furthest from the ostomy).
      • Gently lift the button or the long tube external bolster and clean the ostomy site in the same manner. Secretions may become crusty as they dry. You can easily remove them with a cotton swab. Rinse and dry the skin well.
      • If your child has an ostomy for less than 6-8 weeks (or other length of time as recommended by your healthcare team), check with your healthcare team to see if the cleaning should be done with saline solution. Refer to your healthcare team for the recipe and storage of homemade saline solution.
      • After removing the cover, clean the feeding port of the button or tube with a cotton swab soaked in soapy water to remove any remains of formula. Also clean the anti-reflux valve on the button that is accessible when you open the feeding port. Close the cover tightly.
      • Observe the condition of the skin around the ostomy; it should be clean, dry and intact (same appearance as usual: similar to the color of the belly or a little pinkish). Check for signs of infection (redness, tenderness, swelling, discharge different from the usual yellowish or brownish discharge, bad odor).
      • Check that there is not too much tension on the long tube and that the external bolster is well adjusted to the abdominal wall, as directed by your healthcare team.
      • As recommended by your healthcare team, gently rotate the gastrostomy/jejunostomy button to check for mobility and avoid skin irritation.
      • Never turn the gastrojejunal button as you could move the portion that is in the jejunum.
      • Check with your healthcare team for specifics for gastrostomy and jejunostomy tube care.
    • After each feeding session (or minimally every day if the tube or button is not used on a regular basis):
      • Observe the condition of the skin around the ostomy; it should be clean, dry and intact (same appearance as usual: similar to the color of the belly or a little pinkish). Check for signs of infection (redness, tenderness, swelling, discharge different from the usual yellowish or brownish discharge, bad odor).
      • Check if there is any leakage of milk or nutritional formula; if so, place a compress under the button or the external bolster of the tube to absorb it and protect the skin; change the compress as soon as it is wet to keep the skin clean and dry. Discuss this with your healthcare team.
    • Weekly for balloon models but only after 6 to 8 weeks following surgery (or other duration as recommended by your healthcare team): Check the amount of water in the balloon to ensure that there are no leaks and that the balloon is functioning properly.
      • Connect the specific syringe for this purpose into the balloon port.
      • Remove all water and discard. The water may not be colourless.
      • Inject the required amount of water into the balloon.
      • It is normal to take out a little less water than the amount you put in initially. The water may have evaporated from the balloon. If the difference is more than 0.5 ml, the balloon may be defective.
      • If there is not enough water in the balloon when you try to deflate it, inject the usual amount of water into the balloon. Wait 3 to 4 hours and then try to remove the water. a) If the amount has not changed, check after a few days to make sure the balloon is working properly. b) If the balloon is empty, the balloon is probably broken; the tube or button needs to be changed.

Preparation of medications for enteral administration

  • Refer to your healthcare team for specifics regarding the preparation and expiration date of medications.
  • Medications should always be given in liquid form to avoid blocking the tube or button:
    • Use the liquid form of the medication if available.
    • If the medication is in tablet form, check with your healthcare team to see if you can crush it into a fine powder and mix it with a little water.

    • If the medication is in a capsule, check with your healthcare team to see if you can open it and mix the contents with a little water.
    • Coated or extended-release medications cannot be crushed as this may interfere with their effectiveness.
  • Never mix medications with the formula to prevent them from reacting with each other and clogging the button or tube.
  • Never mix medications in the same syringe. Give one medication at a time.

Frequency of equipment replacement:

  • Follow your healthcare team’s recommendations about how often equipment should be replaced.
  • Any part must be changed if it appears damaged or does not function properly (eg, breakage, color change, stains, rigidity, etc.).

Maintenance and cleaning of material and equipment:

  • Always refer to the manufacturer’s recommendations and those provided by your healthcare team if they are different from the following. Your healthcare team will be able to take various factors into consideration (eg, your child’s health condition, comfort, safety, environment, etc.) to provide specific advice for the cleaning and maintenance of materials and equipment.
  • Proper cleaning and quick rinsing after use prevents milk or formula remains from drying and accumulating in the equipment.
  • We suggest the following way of cleaning the equipment that can be used as a general guide:
    • Always wash your hands before providing care to your child.
    • Disassemble all equipment (bag with tubing, extension set, syringe body and plunger, etc.).
    • Always clean and rinse with lukewarm water as hot water can damage the quality of the plastic: it can make it stiff, erase the numbers on the syringes and make the plungers sticky.
    • Never use bleach, alcohol, alcohol-based products, peroxide or strongly scented products to clean the equipment. These products can damage the equipment.
    • Do not put any parts in the dishwasher.
    • After each feeding session:
      • Rinse each piece with warm tap water. Make sure the draining water runs clear (no residue).
      • Bags and tubing: Use a bottle brush to clean the inside of the bag. If gravity feed: Hang the bag from a hook or the IV pole to clean the tubing; stand over the sink or a large bowl; put 500 ml of warm water in the bag and run it through the tubing until it is clean.
      • If pump feeding: leave the tubing in place in the pump; refer to your healthcare team’s or manufacturer’s instructions for rinsing the tubing.
      • Extension sets: Fill a syringe with warm water, connect it to the extension set and inject water through the ports until drains out cleanly.
      • Drain and air-dry all parts on a clean cloth and place them so that the water drains well; air dry the tubing and the hanging bag without the cap on.
      • Reassemble the pieces when they are completely dry. Make sure that the black rubber tip of the plunger is completely dry before putting it back into the syringe barrel; otherwise, it may stretch and crack and the syringe will be unusable.
      • Store unused equipment in a clean container with a lid until the next use.
    • Every day or more often, if necessary:
      • Prepare soapy water: 15 ml of dishwasher soap diluted in 125 ml of boiling water. Let it cool before using it.
      • Bags and tubing: Put 250 ml of warm water and 1 ml of soapy water in the bag. Use a bottle brush to clean the inside. Run the water through the tubing to clean it.
      • If residues remain stuck to the walls of the bag, tubing or nasogastric tube or if odours persist: fill with a solution of 1/2 white vinegar – 1/2 warm tap water. Let stand with the solution in a sink or other container for 10 minutes; then empty the contents of the bag, tubing and nasogastric tube; rinse with clear warm water at least twice to remove any vinegar odour.
      • Extension sets: Clean with a syringe of soapy water diluted with warm water; roll the extension set between your fingers to dislodge any sticky residue; thoroughly clean the inside of the feeding and medication port.
      • Syringes: Clean the body and plunger with soap and water diluted with warm water.
      • Thoroughly rinse all parts with warm tap water until the return water is clear (no soap residue); repeat this rinse as many times as necessary.
      • Pay special attention to the connection points.
      • Drain and air-dry all parts on a clean cloth and place them so that the water drains well; air dry the tubing and hanging bag without the cap on.
      • Reassemble the parts when they are completely dry; make sure that the black rubber tip of the plunger is completely dry before putting it back into the syringe barrel; otherwise, it could stretch and crack and the syringe would be unusable.
      • Store unused equipment in a clean container with a lid until the next use.
    • When changing the nasogastric tube: fill a syringe with warm soapy water and inject the water into the tube until it comes out clear.
  • If formula is given continuously, clean the equipment before adding formula to the bag; some families find it advantageous to use a second bag (eg, when one bag is cleaned, the second bag can be set up to continue enteral feeding).
  • The following are specific recommendations for the maintenance and cleaning of the enteral pump after each feeding session:
    • Unplug the pump from the electrical outlet before cleaning.
    • Clean the exterior surface with a damp cloth.
    • Check with the manufacturer or your healthcare team for maintenance and cleaning specifications for the interior.
    • Clean the outside of the power cord thoroughly with a damp cloth.
    • Never immerse the pump or power cord in water or any other cleaning solution.
    • Make sure all parts are dry, including the power cord, before reconnecting the pump.
    • Your healthcare team will advise you of the procedures for periodic inspection of the pump (recertification/recalibration) to ensure proper operation and safety.

Charging the enteral pump:

  • The pump can be recharged in different ways:
    • by electricity in a wall outlet or in a power strip extension equipped with a circuit breaker,
    • by an integrated rechargeable battery, if present in the device.
  • Do not plug the unit into a wall outlet controlled by a wall switch.
  • It is not recommended to use a portable charger (eg, power bank) to operate the pump.
  • When a battery is used, make sure it is sufficiently charged for the expected operating time of the pump.

Emergencies:

  • Always have a telephone nearby in case of an emergency. Make sure your cell phone is charged at all times.
  • Make sure that the pump, if used, is always charged.
  • Have the necessary equipment available in case of a power failure (eg, ice-packs and cooler for the formula).
  • Have the equipment available to administer the nutritional formula or milk and medications by push (feeding syringe) or gravity (gravity feed bag with tubing) in the event of a problem with the pump (eg, malfunction, inability to recharge).
  • Keep a resource list close at hand with the names and telephone numbers of hospital, doctors, other members of your child’s healthcare team and equipment providers. Make sure you know how to contact these resources outside of regular hours and during vacations.

Accident prevention:

  • Do not use over-the-counter medications without a doctor’s advice.
  • Never leave your child alone during the feeding session; it is important to check that your child is tolerating the formula, is not vomiting, is not accidentally disconnected, etc.
  • Attach and secure the tube or button extension set as directed by your healthcare team.
  • Make sure the tubing is out of your child’s reach (eg, under clothing) during gravity or pump feeding; if your baby pulls on the tube often, cover the hands in mittens or socks.
  • Verify the correct location of the tube or button at these times:
    • after installing a nasogastric tube, gastrostomy balloon button or tube (the healthcare team will check the location of all other types of tubes and buttons when they are installed),
    • before use (feeding session, medication administration),
    • every 4 hours during continuous feeding,
    • if your child has certain symptoms (eg, difficulty breathing, coughing, choking, vomiting, reflux, discomfort with feeds etc.),
    • if there are signs that the tube or button is displaced (eg, change in length in the outer portion of the tube or button stem, detachment of the adhesive bandage or other fastening system, etc.),
    • daily, if the tube or button is not used on a regular basis,
    • in all other circumstances, at the request of your healthcare team (eg, blocked tube).
  • If your child moves around with an IV pole supporting the bag with or without the pump, it is important to make a few changes around the house to avoid obstacles (eg, move some furniture to provide more space, attach a ramp to allow easy access to the bathroom, remove carpets).

Infection prevention:

  • Always wash your hands before providing care to your child and have your child wash his hands before and after all meals and frequently during the day.
  • Properly clean the work surface for preparing the milk or nutritional formula to be administered.
  • Refer to the section “Conservation of the nutritional formula” to avoid contamination of the food given and the development of infections in your child.
  • Follow your healthcare team’s recommendations on how often to change the equipment used at home.
  • Make sure to clean and maintain the equipment and materials as recommended. Discuss special cleaning and maintenance measures if your child is immunosuppressed.

Daycare and school:

  • Your child’s healthcare team will evaluate your child’s needs and will support you in the planning of integration to daycare or to school.
  • Advise school staff of the treatment and care that your child requires.

Additional information and tips can be found on the following sites:
https://www.feedingtubeawareness.org

https://www.friendshipcircle.org/blog/2017/02/10/online-resources-parents-children-who-need-feeding-tube/



Methods of care


Methods of care : Insertion and removal of a nasogastric tube

Indications

Considerations:

Frequency

Required materials

If needed:

Refer to your healthcare team if the material used at home or the sequence of steps taught is different from what is described in the method of care.

Depending on your child’s age and condition, always encourage your child’s autonomy in carrying out the method of care.


Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

  • Create the right moment: integrate the care in a routine.
  • Alert your child to the needed care and communicate together.
  • Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

  • Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
  • Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
  • Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

  • Safety: Carefully follow the care practice steps as you have been taught.
  • Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
  • Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the material

  • Set up on a flat surface or a well-cleaned table.
  • Gather the necessary equipment.
  • Remove the tube from its packaging or container.
  • Inspect the tube to ensure that it is not damaged or soiled.
  • Cut the appropriate size of the protective dressing, if applied.
  • Cut the appropriate size of the adhesive bandage that will secure the tube to the cheek.
  • Open the lubricant packet; place a small amount of lubricant on the open tube package.
Why ?

This step ensures that the required materials are on hand in order to start the procedure.

Step 5: Prepare your child

  • Ask your child to blow his or her nose, if possible.
  • If he or she is unable to do so, remove secretions from your child’s nose with a tissue or suction nasal secretions, as instructed by your healthcare team.
  • Choose which side the tube will be inserted.
  • Make sure the skin on the cheek on the same side as that nostril is clean and dry.
  • If the tube will be left in place for a long period of time, attach the protective dressing to the cheek where the adhesive bandage will be placed.

Why ?

Clean nostrils make it easier to insert the tube.

The protective dressing minimizes irritation to the cheek.

Step 6: Position your child

  • Place your child in a lying down position.
  • Swaddle the baby in a blanket if necessary, depending on the baby’s age and degree of collaboration.
  • If your child is older, position your child in a seated or semi-seated position and tilt your child’s head slightly forward.
Why ?

This position facilitates swallowing as well as the progression of the tube through the nose into the stomach and reduces the risk of aspiration into the lungs.

Swaddling the baby increases the safety of the procedure.

Step 7: Determine the tube insertion length

  • Take the end of the tube and put it on the tip of your child’s nose.
  • Holding the end of the tube in place, measure the distance from the tip of the nose (1) ⇒ to the base of the earlobe (2) ⇒ to the base of the sternum breastbone) (3) ⇒ to halfway between the base of the sternum and the navel (belly button) (4).
  • Make a mark at this point on the tube with a permanent marker pen or note the number on the tube if it is graduated (numbers pre-marked).

Why ?

Measuring the insertion length of the tube helps ensure that, once fully inserted, the tube will be correctly positioned for use.

Step 8: Lubricate the tube

If you use a water-soluble lubricant:

  • Spread the lubricant (size of a pea) on the first 3 cm of the tube.
  • Roll the end of the tube on in the lubricant. 

If you use water:

  • Dip the end of the tube into the glass or water container.
  • Shake slightly to remove excess water drops.
Why ?

Lubrication of the tube makes it easier to insert and more comfortable for your child.

Step 9: Insert the tube

  • Give your baby a pacifier to suck on or if your child is older, ask your child to swallow or sip water from a glass with a straw.
  • Hold the pre-measured, lubricated tube like a pencil about 3-4 cm from the tip.
  • Slowly insert the tube into one nostril while your child swallows; gently but quickly push the tube backwards and down. Do not force.
  • Continue to insert the tube until the mark reaches the edge of the nostril.

Why ?

This method of insertion follows the natural curves inside the nose and the back of the throat and avoids injury.

Swallowing, drinking or sucking while inserting the tube helps advance it into the back of the throat.

Inserting the tube quickly will minimize gagging and discomfort.

Inserting the tube up to the mark allows placement in the stomach.

Step 10: Secure the tube

  • If the tube is going to be removed after the feeding session: attach the tube to your child’s cheek with the adhesive bandage.
  • If the tube will be left in place for a longer period of time: place the tube over the protective dressing already stuck on the cheek and secure it by placing the adhesive dressing over it.
  • Make sure that the pen mark on the tube is clearly visible on the edge of the nostril.
  • Make sure that the position of the tube does not compress the edge of the nostril.
Why ?

This step reduces the risk of accidental removal of the tube.

Do not put too much pressure on the nostril to avoid injury from the tube.

Step 11: Check the tube location

  • With one hand, bend the tube near the outside end of it.
  • With your other hand, remove the cap from the end of the tube, if in place.
  • Connect the syringe.
  • Stop bending the tube.
  • Gently pull on the plunger to withdraw some gastric secretions (liquid from the stomach, usually clear or light yellow in colour) into the syringe.
  • Bend the tube again.
  • Disconnect the syringe.
  • Replace the cap at the end of the tube.

  • Stop bending the tube.
  • Check the pH of the gastric secretions: soak the pH indicator paper with a few drops of the liquid collected in the syringe.
    • If the result is 5.5 or less, the tube is in the correct position.
    • If the result is 6 or higher, the tube may not be in the correct place; remove the tube and reinsert it.
  • Discard any gastric fluid remaining in the syringe.
Why ?

This step is used to check if the tube is in the stomach. If so, the pH indicator paper will confirm the acidity of the gastric liquid.

Bending the tube prevents the gastric secretions from leaking out if there is no cap at the end of the tube.

Step 12: Irrigate the tube

  • Put the tip of the syringe into the water container.
  • Withdraw the plunger and fill the syringe with the amount of water recommended by your healthcare team to irrigate the tube.
  • With one hand, bend the tube.
  • With the other hand, remove the cap in place from the end of the tube.
  • Connect the syringe.
  • Stop bending the tube.
  • Slowly depress the plunger of the syringe to push the water into the tube.
  • Bend the tube again.
  • Disconnect the syringe.
  • Replace the cap at the end of the tube.

  • Stop bending the tube.
Why ?

This step clears the tube and prevents blockage.

Step 13: Secure the tube

  • Put the tube behind your child’s ear, if this is what your healthcare team recommends.
  • The tube should be positioned so that it does not put pressure on your child’s nostril and allows your child to move his or her head.
  • Attach the tube according to your healthcare team’s instructions: slide it under clothing or roll it up and tape it to your child’s back with adhesive tape.
Why ?

This step prevents unintentional removal of the tube, minimizes the risk of strangulation and promotes your child’s comfort.

Step 14: Administer the formula, if applicable

Go to the next step if you want to give your child medication instead.

  • Proceed with the administration of the nutritional formula as planned for your child.
  • Observe your child for any signs of discomfort when the feeding session is started (eg, nausea, vomiting, difficulty breathing, abdominal pain, sweating, etc.).

Step 15: Administer medication, if appropriate

Proceed with the administration of the medication as planned for your child.

Step 16: Remove the tube, if agreed

  • Wash your hands again.
  • Make sure the cap is securely in place at the end of the tube.
  • Carefully peel off the adhesive dressing that holds the tube in place on the cheek.
  • Place your child’s head slightly tilted back.
  • Firmly pinch the tube a few inches near the nose.

  • Pull on the tube with a quick and continuous movement, without forcing.
  • Peel off the protective bandage if present on the cheek.
Why ?

Pinching the tube prevents fluid (contained in the tube) from entering the lungs when removing it.

Step 17: Clean and store equipment

Clean, maintain and store equipment as recommended.

Why ?

This step is necessary to ensure cleanliness and proper functioning of the equipment for the next use.

Step 18: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

  • Listen to what your child says about the parts of the procedure that were difficult or painful.
  • Comfort your child and recognize your child’s collaboration with positive feedback.
  • Highlight your child’s  specific strengths that helped make the procedure positive.
  • Discuss with your child what might be done the same or differently the next time the care is needed.
  • Keep your promises if you have promised a reward, follow through.
  • Reward yourself too.
.Reviser : NRoss .Version : 1.0

Methods of care : Change of the gastrostomy balloon button

Indications

Considerations:

Frequency

Required materials

If needed:

Refer to your healthcare team if the material used at home or the sequence of steps taught is different from what is described in the method of care.

Depending on your child’s age and condition, always encourage your child’s autonomy in carrying out the method of care. 

The steps described in the method of care refer to the use of the Mic-Key® gastrostomy button.


Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

  • Create the right moment: integrate the care in a routine.
  • Alert your child to the needed care and communicate together.
  • Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

  • Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
  • Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
  • Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

  • Safety: Carefully follow the care practice steps as you have been taught.
  • Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
  • Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the material

  • Set up on a flat surface or a well-cleaned table.
  • Gather the necessary equipment.
  • Remove the new button from its packaging.
  • Remove the extension set from its packaging or container.
  • Inspect the button and extension set for damage.
  • Open the lubricant packet; place a small amount of lubricant on the open package of the button.
  • Fill syringe #1 with the amount of water needed to inflate the new button balloon, according to the manufacturer’s recommendations or as directed by your healthcare team.
  • Fill syringe #2 with the amount of water needed to irrigate the extension set as recommended by your healthcare team.
Why ?

This step ensures that the required materials are on hand in order to start the procedure.

Step 5: Check the function of the new button balloon

  • Hold the sides of the button with one hand.
  • With the other hand, connect the tip of syringe #1 into the balloon port until the connection is solid.
  • Depress the plunger of the syringe to inject the full amount of water into the balloon.
  • While leaving the syringe connected and maintaining pressure on the plunger, check that the balloon is intact and properly inflated.
  • If the balloon does not leak, remove the water from the balloon by withdrawing the plunger.
  • Leave the syringe filled with water connected to the balloon port.
Why ?

This step is used to check if the balloon is functioning properly and has no leaks.

Holding the sides of the button will stabilize it during this step.

Screwing the tip of the syringe into the balloon port opens the balloon fill valve.

Step 6: Position your child

Lay your baby down or ask your child to lie on his or her back.

Why ?

The lying down position makes the procedure easier because it provides better access to the ostomy site.

Step 7: Lubricate the new button

Spread a sufficient amount of lubricant on the tip of the new button.

Why ?

Lubrication makes the button insertion easier and more comfortable for your child.

Step 8: Deflate the balloon from the old button

If the old button is not in place, go to step 10.

  • Hold the sides of the button with one hand until the end of the step.
  • With the other hand, connect the tip of syringe #3 into the balloon port of the old button until securely connected.
  • Remove water from the balloon by withdrawing the plunger.
  • If the water does not return, there may be no water left or the syringe may not be inserted deep enough; push the syringe a little more into the balloon port and try to remove the water again.
  • When all the water has been removed, disconnect the syringe.
  • Set the syringe aside.
Why ?

This step is necessary to avoid injuring the ostomy while removing the old button.

Holding the sides of the button helps stabilize the button during the step.

Screwing the tip of the syringe into the balloon port opens the balloon fill valve.

Step 9: Remove the old button

  • Put one hand on your child’s belly and then slowly remove the button pulling vertically with the other hand.
  • Even if you feel a little resistance, continue gently but DO NOT FORCE.
  • Use this time to observe the ostomy and the skin around it.
  • Wipe the skin with the towel if any gastric secretions come out of the ostomy.
Why ?

This step is necessary to install the new button.

There may be a small amount of resistance as the old button is removed, even if the balloon is correctly deflated.

Step 10: Inserting the new button in the gastrostomy

  • Gently insert the button vertically through the stoma until it is flush with the stomach wall.
  • Try inserting the button as your child takes in a breath, when your child is usually more relaxed.
  • Slight pressure may be needed to insert the button, especially if your child cries during the procedure, but NEVER FORCE TO INSERT THE BUTTON. Try to calm your child down before continuing.
Why ?

This prevents injury to the gastrostomy during insertion of the button.

There may be a small amount of resistance as the new button is inserted, even if the balloon is correctly deflated.

It may be a little difficult to insert the button if your child is crying because this causes the abdominal muscles to contract.

Step 11: Inflate the button balloon

  • When the button is properly inserted, hold the sides with one hand until the end of the step.
  • Depress the plunger of syringe #1 (already connected to the balloon port) with the other hand to inject the full amount of water into the balloon.
  • Disconnect the syringe from the balloon port by holding the plunger.
  • Set the syringe aside.
  • Make sure there is a distance of about a dime between the button and the belly.
  • Turn the button at skin level; you should be able to do this without any problem.
Why ?

Inflating the balloon properly ensures that the button remains in place in the gastrostomy.

Holding the sides of the button helps to stabilize it during the step.

Holding the plunger when disconnecting the syringe prevents water from coming out of the balloon.

The ability to rotate the button confirms that it is not too deeply inserted into the gastrostomy.

Step 12: Irrigate the button extension set

  • Remove the cover from the extension set feeding port, if in place.
  • If the extension set has two ports, make sure the medication port is closed.
  • Connect the syringe #2 to the end of the extension set.
  • Make sure the extension set clamp is open.
  • Depress the plunger of the syringe to inject water all the way to the end of the extension set.
  • Close the clamp on the extension set.
  • Leave the syringe connected to the extension set.
Why ?

This step ensures that the extension set tubing is filled with water and ready to flush into the button feeding port.

Step 13: Connect the extension set to the button

  • Remove the cover from the button feeding port, if closed.
  • Hold the sides of the button and insert the extension set into the feeding port.
  • Lock the extension set into the button, according to the manufacturer’s instructions or those of your healthcare team.
Why ?

This step prepares for verification of the button location and irrigation.

Holding the sides of the button helps to stabilize it during the installation of the extension set.

Step 14: Check the location of the button

  • Open the clamp of the extension set.
  • Gently withdraw the plunger of the syringe #2 (already connected to the extension set) to draw some gastric secretions into the syringe.
Why ?

This step confirms that the button is installed correctly in the stomach.

Step 15: Irrigate the button

  • Slowly depress the plunger of syringe #2 to push back the gastric secretions and flush water from the extension set into the button.
  • When the syringe is empty, close the clamp of the extension set.
  • Disconnect the syringe.
Why ?

This step ensures that the button is patent, ready to use and reduces the risk of the button being blocked with debris.

Step 16: Administer the formula, if applicable

Go to the next step if you want to give your child medication instead.

  • Proceed with the administration of the nutritional formula as planned for your child.
  • Observe your child for any signs of discomfort when the feeding session is started (eg, nausea, vomiting, difficulty breathing, abdominal pain, sweating, etc.).

Step 17: Administer medication, if appropriate

Go to the next step if the button is not used immediately. 

Step 18: Disconnect the button extension set

If you do not use the button immediately:

  • Hold the sides of the button.
  • Unlock the button extension set, as directed by the manufacturer or your healthcare team.
  • Remove the extension set from the button feeding port.
  • Put the cover on the button feeding port.

Why ?

Removing the extension set prevents your child from accidentally pulling on it, moving the button and causing irritation at the insertion site. In addition, an unused extension set is cumbersome.

Holding the sides of the button helps stabilize the button while the extension set is being removed.

Closing the cover prevents leakage of the stomach contents through the button in between feeding sessions.

Step 19: Clean and store equipment

Clean, maintain and store equipment as recommended.

Why ?

This step is necessary to ensure cleanliness and proper functioning of the equipment for the next use.

Step 20: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

  • Listen to what your child says about the parts of the procedure that were difficult or painful.
  • Comfort your child and recognize your child’s collaboration with positive feedback.
  • Highlight your child’s  specific strengths that helped make the procedure positive.
  • Discuss with your child what might be done the same or differently the next time the care is needed.
  • Keep your promises if you have promised a reward, follow through.
  • Reward yourself too.
.Reviser : NRoss .Version : 1.0

Methods of care : Temporary installation of a urinary catheter per ostomy

Indications

Considerations:

Frequency

Required materials

If needed:

Refer to your healthcare team if the material used at home or the sequence of steps taught is different from what is described in the method of care. 

Depending on your child’s age and condition, always encourage your child’s autonomy in carrying out the care method of care.


Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

  • Create the right moment: integrate the care in a routine.
  • Alert your child to the needed care and communicate together.
  • Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

  • Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
  • Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
  • Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

  • Safety: Carefully follow the care practice steps as you have been taught.
  • Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
  • Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the material

  • Set up on a flat surface or a well-cleaned table.
  • Gather the necessary equipment.
  • Open the package of the urinary catheter and inspect it to make sure it is not damaged or soiled.
  • Put the plug on the end of the catheter.
  • Cut out the appropriate size of adhesive bandage that will secure the catheter to the belly.
  • Open the bag of lubricant and pour a small amount onto the opened catheter package.
  • Fill syringe #1 with the amount of water needed to inflate the catheter balloon, according to the manufacturer’s recommendations or as directed by your healthcare team.
  • Fill syringe #2 with the amount of water recommended by your healthcare team to irrigate the catheter.
Why ?

This step ensures that the required materials are on hand in order to start the procedure.

Step 5: Check the function of the catheter balloon

  • Grasp the balloon port of the catheter with one hand.
  • With the other hand, connect the tip of syringe #1 into this port until securely connected.
  • Depress the plunger of the syringe to inject the full amount of water into the balloon.
  • While leaving the syringe connected and maintaining pressure on the plunger, check that the balloon is intact and properly inflated.
  • If the balloon does not leak, remove the water from the balloon by withdrawing the plunger.
  • Leave the syringe, filled with water, connected to the catheter.
Why ?

This step is used to check if the balloon is functioning properly and has no leaks.

Screwing the tip of the syringe into the balloon port opens the balloon fill valve.

Step 6: Position your child

Lay your baby down or ask your child to lie on his or her back.

Why ?

The lying down position makes the procedure easier because it provides better access to the ostomy site.

Step 7: Lubricate the catheter

  • Spread enough lubricant over the first 3 cm of the tip of the catheter.
  • Roll the tip of the catheter in the lubricant.
Why ?

Lubrication makes the catheter insertion easier and more comfortable for your child.

Step 8: Insert the catheter into the ostomy

  • With one hand, hold the catheter about 7-10 cm from its tip.
  • Gently insert the tip of the catheter into the ostomy; gently push the catheter all the way to the end of this length.
  • Some pressure may be needed to insert the catheter, especially if your child cries during the procedure; take time to calm your child NEVER FORCE THE CATHETER IN.
  • If you are unable to insert the catheter, try a smaller size catheter.
  • Wipe the skin with the towel if any stomach contents come out of the ostomy.
  • Thoroughly clean and dry the skin around the ostomy.
Why ?

This prevents injury to the ostomy during insertion of the catheter.

There may be a small amount of resistance as the catheter is inserted, even if the balloon is correctly deflated.

It may be a little difficult to insert the catheter if your child is crying because this causes the abdominal muscles to contract.

Step 9: Inflate the catheter balloon

  • Take the balloon opening with one hand.
  • Depress the plunger of syringe #1 (already connected in the balloon port) to inject the entire amount of water into the balloon.
  • While maintaining pressure on the plunger, disconnect the syringe.
  • Set the syringe aside.
  • Gently pull the catheter until you feel a slight resistance.

Why ?

Balloon inflation ensures that the catheter remains in place in the ostomy.

Pulling slightly on the catheter positions balloon against the stomach wall.

Step 10: Attach and secure the catheter

  • Secure the catheter in place on the belly with tape to prevent it from moving, according to the method suggested by your healthcare team.
  • You can hold it in place using the “H” technique: form an “H” with tape and attach it to the catheter and then to the skin.
Why ?

Attaching the catheter securely prevents the catheter from moving and irritating the ostomy.

Step 11: Clean and store equipment

Clean, maintain and store equipment as recommended.

Why ?

This step is necessary to ensure cleanliness and proper functioning of the equipment for the next use.

Step 12: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

  • Listen to what your child says about the parts of the procedure that were difficult or painful.
  • Comfort your child and recognize your child’s collaboration with positive feedback.
  • Highlight your child’s  specific strengths that helped make the procedure positive.
  • Discuss with your child what might be done the same or differently the next time the care is needed.
  • Keep your promises if you have promised a reward, follow through.
  • Reward yourself too.
.Reviser : NRoss .Version : 1.0

Methods of care : Administration of nutritional formula: Nasal tube

Indications

NOTE: For ease of reading the rest of the text, the word (nutritional) “formula” also includes “breast milk”, “fortified breast milk” or “infant formula”.

Considerations:

Frequency

Required materials

Push method:

Gravity method:

Pump method:

Refer to your healthcare team:

Depending on your child’s age and condition, always encourage your child’s autonomy in carrying out the care method of care.

The steps of the methods of care are illustrated by a nasogastric tube.

The steps of the “By pump” method of care are illustrated by a Kangaroo Joey pump ™.

By push


Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

  • Create the right moment: integrate the care in a routine.
  • Alert your child to the needed care and communicate together.
  • Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

  • Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
  • Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
  • Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

  • Safety: Carefully follow the care practice steps as you have been taught.
  • Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
  • Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the material

  • Set up on a flat surface or a well-cleaned table.
  • Gather and inspect all equipment to ensure that it is not damaged.
  • Fill the irrigation syringe with the amount of water recommended by your healthcare team.
Why ?

This step ensures that the required materials are on hand in order to start the procedure.

Step 5: Position your child

Place your child in a seated or semi-seated position according to your child’s comfort and capacity.

Why ?

This position facilitates digestion and avoids aspiration of the formula into the lungs.

Step 6: Check the location of the nasal tube

  • Make a visual inspection of your child’s tube; check to see if it is intact.
  • Check to see if there are any changes in the outer portion of the tube, if the mark is still in the same place and if the adhesive bandage is securely in place.
  • Aspirate some gastric secretions, if recommended by your healthcare team: first inject air to empty the tube and then aspirate to get a sample directly from the stomach.
  • Afterwards, check the pH of this gastric fluid, if recommended by your healthcare team.
Why ?

This step ensures the safe use of the tube.

Step 7: Irrigate the nasal tube

  • Bend the tube and remove its cap.
  • Connect the syringe to the end of the tube.
  • Release the tube.
  • Slowly depress the plunger of the syringe to push the water into the tube.
  • When the syringe is empty, bend the tube.
  • Disconnect the syringe.
  • Replace the cap at the end of the tube.
  • Release the tube.
Why ?

This step clears the tube and prevents blockage.

Step 8: Aspirate the formula into the feeding syringe

  • Remove the protective cap from the feeding syringe.
  • Dip the end of the syringe into the container and withdraw up the formula by pulling the plunger.
  • Fill the syringe with the required amount of formula.
  • Hold the syringe with the pointed end upwards and remove the air from the syringe by pushing gently on the plunger until a drop of formula comes out of the tip of the syringe.
Why ?

This step fills the syringe with the amount of formula to be administered and removes the air from the syringe.

Step 9: Connect the feeding syringe to the nasal tube

  • Bend the tube and remove its cap.
  • Connect the syringe to the end of the tube.
  • Release the tube.
Why ?

Connecting the filled syringe allows for administration of the formula by push.

Step 10: Administer the formula

  • Slowly depress the plunger of the feeding syringe and push a small amount of formula at a time, at the speed recommended by your healthcare team.
  • Every time the syringe is empty:
    • bend the tube,
    • disconnect the syringe,
    • put the cap at the end of the tube,
    • release the tube,
    • fill the syringe with formula,
    • bend the tube again,
    • remove the cap from the tube,
    • reconnect the syringe to the end of the tube,
    • continue the administration.
  • Administer the formula for 20-30 minutes until your child has received the required amount or for the length of time agreed upon with your healthcare team.
  • Observe your child for any signs of discomfort when the feeding session is started (eg, nausea, vomiting, difficulty breathing, abdominal pain, sweating, etc.).
Why ?

This ensures that the formula reaches the stomach safely.

The length of the feeding session depends on the amount of formula required and your child’s tolerance.

Step 11: Disconnect the feeding syringe from the nasal tube

When the feeding session is over:

  • Bend the tube.
  • Disconnect the feeding syringe from the tube.
  • Replace the cap at the end of the tube.
  • Release the tube.
Why ?

This step prepares the tube for irrigation.

Step 12: Irrigate the nasal tube

  • Bend the tube and remove its cap.
  • Connect the syringe to the end of the tube.
  • Release the tube.
  • Slowly depress the plunger of the syringe to push the water into the tube.
  • When the syringe is empty, bend the tube.
  • Disconnect the syringe.
  • Replace the cap at the end of the tube.
  • Release the tube.
Why ?

Irrigation ensures that your child has received all of the formula and prevents debris from sticking to the tube and blocking it.

Step 13: Keep your child in the same position after the session

  • Leave your child in a seated or semi-seated position for at least 30 minutes after formula administration, if possible.
  • Burp your baby after feeding, as needed.
Why ?

This position facilitates digestion and reduces regurgitation.

Burping your baby avoids abdominal pain (bloating and swelling).

Step 14: Clean and store the equipment

Clean, maintain and store equipment as recommended.

Why ?

This step is necessary to ensure cleanliness and proper functioning of the equipment for the next use.

Step 15: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

  • Listen to what your child says about the parts of the procedure that were difficult or painful.
  • Comfort your child and recognize your child’s collaboration with positive feedback.
  • Highlight your child’s  specific strengths that helped make the procedure positive.
  • Discuss with your child what might be done the same or differently the next time the care is needed.
  • Keep your promises if you have promised a reward, follow through.
  • Reward yourself too.

By gravity


Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

  • Create the right moment: integrate the care in a routine.
  • Alert your child to the needed care and communicate together.
  • Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

  • Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
  • Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
  • Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

  • Safety: Carefully follow the care practice steps as you have been taught.
  • Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
  • Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the material

  • Set up on a flat surface or a well-cleaned table.
  • Gather and inspect all equipment to ensure that it is not damaged.
  • Fill the irrigation syringe with the amount of water recommended by your healthcare team.
  • Check that the roller clamp on the bag tubing is securely closed.

Why ?

This step ensures that the required materials are on hand in order to start the procedure.

Step 5: Position your child

Place your child in a seated or semi-seated position according to your child’s comfort and capacity.

Why ?

This position facilitates digestion and avoids aspiration of the formula into the lungs.

Step 6: Check the location of the nasal tube

  • Make a visual inspection of your child’s tube; check to see if it is intact.
  • Check to see if there are any changes in the outer portion of the tube, if the mark is still in the same place and if the adhesive bandage is securely in place.
  • Aspirate some gastric secretions, if recommended by your healthcare team: first inject air to empty the tube and then aspirate to get a sample directly from the stomach.
  • Afterwards, check the pH of this gastric fluid, if recommended by your healthcare team.
Why ?

This step ensures the safe use of the tube.

Step 7: Irrigate the nasal tube

  • Fold the tube and remove its cap.
  • Connect the syringe to the end of the tube.
  • Release the tube.
  • Slowly depress the plunger of the syringe to push the water into the tube.
  • When the syringe is empty, fold the tube.
  • Disconnect the syringe.
  • Replace the cap at the end of the tube.
  • Release the tube.
Why ?

This step clears the tube and prevents blockage.

Step 8: Pour the formula into the bag

  • Open the cap of the feeding bag.
  • Pour the formula into the bag, adding about 30 ml more than the amount to be given to get rid of the the air in the tubing.
  • Close the cap of the bag.
Why ?

This step allows you to fill the bag with the formula.

Step 9: Hang the bag

  • Hang the bag at a height of 45 to 90 cm above your child’s head.
  • Hang it from a coat rack, a wall hook, or place it on the IV pole.
Why ?

The correct positioning of the bag promotes the safe administration of the formula.

Step 10: Empty the air out of the bag tubing

  • Compress the drip chamber to fill it with formula to 1/3 or 1/2 of its capacity.
  • Remove the cap from the end of the tubing.
  • Then open the roller clamp to allow the formula to flow down through the tubing and get rid of air from the rest of the tubing.
  • Direct the end of the tubing into a container to catch the few drops of formula that will drip out of the tubing.

  • When the tubing is filled with formula, close the roller clamp.
Why ?

This step avoids the entry of air into the stomach and prevents swelling of the belly from excess air.

Step 11: Connect the tubing to the nasal tube

  • Bend the tube and remove its cap.
  • Connect the tubing to the end of the tube.
  • Release the tube.
Why ?

Once the feeding bag tubing is connected to the nasal tube, the feeding can begin.

Step 12: Administer the formula

  • Open the roller clamp and slowly roll the roller up or down until you get the flow rate agreed upon with your healthcare team.

Feeding volume

Drop rate
60 ml / hour 16 drops / minute
80 ml / hour 20 drops / minute
100 ml / hour 24 drops / minute
120 ml / hour 28 drops / minute
140 ml / hour

32 drops / minute

  • Observe your child for any signs of discomfort when the feeding session is started (eg, nausea, vomiting, difficulty breathing, abdominal pain, sweating, etc.).

If the formula is administered over a long period of time or continuously:

  • Every 4 hours: Irrigate the tube.
  • Every 4 hours and after adding formula to the bag: Shake the bag for 10 seconds.
Why ?

This sets a rate for the formula to be fed into the stomach.

Irrigation of the tube prevents blockage.

Step 13: Close the roller clamp on the tubing

When the feeding session is over, close the roller clamp on the bag tubing.

Why ?

This step ends the feeding session.

Step 14: Disconnect the tubing from the nasal tube

  • Bend the tube.
  • Disconnect the tubing from the tube.
  • Replace the cap at the end of the tube.
  • Release the tube.
Why ?

This step clears the tube for irrigation.

Step 15: Irrigate the nasal tube

  • Bend the tube and remove its cap.
  • Connect the syringe to the end of the tube.
  • Release the tube.
  • Slowly depress the plunger of the syringe to push the water into the tube.
  • When the syringe is empty, bend the tube.
  • Disconnect the syringe.
  • Replace the cap at the end of the tube.
  • Release the tube.
Why ?

Irrigation ensures that your child has received all of the formula and prevents debris from sticking to the tube and blocking it.

Step 16: Keep your child in the same position after the session

  • Leave your child in a seated or semi-seated position for at least 30 minutes after formula administration, if possible
  • Burp your baby after feeding, as needed.
Why ?

This position facilitates digestion and reduces regurgitation.

Burping your baby avoids abdominal pain (bloating and swelling).

Step 17: Clean and store the equipment

Clean, maintain and store equipment as recommended.

Why ?

This step is necessary to ensure cleanliness and proper functioning of the equipment for the next use.

Step 18: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

  • Listen to what your child says about the parts of the procedure that were difficult or painful.
  • Comfort your child and recognize your child’s collaboration with positive feedback.
  • Highlight your child’s  specific strengths that helped make the procedure positive.
  • Discuss with your child what might be done the same or differently the next time the care is needed.
  • Keep your promises if you have promised a reward, follow through.
  • Reward yourself too.

By pump


Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

  • Create the right moment: integrate the care in a routine.
  • Alert your child to the needed care and communicate together.
  • Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

  • Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
  • Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
  • Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

  • Safety: Carefully follow the care practice steps as you have been taught.
  • Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
  • Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the material

  • Set up on a flat surface or a well-cleaned table.
  • Gather and inspect all equipment to ensure that it is not damaged.
  • Fill the irrigation syringe with the amount of water recommended by your healthcare team.
  • Make sure the pump is properly charged or plugged into a wall outlet.
  • Place the pump on a solid surface (eg, chest of drawers, bedside table or kitchen table), on an IV pole or in a backpack.
Why ?

This step ensures that the required materials are on hand in order to start the procedure.

Step 5: Position your child

Place your child in a seated or semi-seated position according to your child’s comfort and capacity.

Why ?

This position facilitates digestion and avoids aspiration of the formula into the lungs.

Step 6: Check the location of the nasal tube

  • Make a visual inspection of your child’s tube; check to see if it is intact.
  • Check to see if there are any changes in the outer portion of the tube, if the mark is still in the same place and if the adhesive bandage is securely in place.
  • Aspirate some gastric secretions, if recommended by your healthcare team: first inject air to empty the tube and then aspirate to get a sample directly from the stomach.
  • Afterwards, check the pH of this gastric fluid, if recommended by your healthcare team.
Why ?

This step ensures the safe use of the tube.

Step 7: Irrigate the nasal tube

  • Bend the tube and remove its cap.
  • Connect the syringe to the end of the tube.
  • Release the tube.
  • Slowly depress the plunger of the syringe to push the water into the tube.
  • When the syringe is empty, bend the tube.
  • Disconnect the syringe.
  • Replace the cap at the end of the tube.
  • Release the tube.
Why ?

This step clears the tube and prevents blockage.

Step 8: Pour the formula into the bag

  • Open the cap of the feeding bag.
  • Pour the formula into the bag, adding about 30 ml more than the amount to be given to get rid of the the air in the tubing.
  • Close the cap of the bag.
Why ?

This step allows you to fill the bag with the formula.

Step 9: Hang the bag

  • Install the bag so that the highest level of the formula is about 15 cm above the pump.
  • Hang it from a coat rack, a wall hook, or place it on the IV pole.
  • If the bag is put in a backpack, keep the bag upright.

Why ?

The correct positioning of the bag promotes the safe administration of the formula.

Step 10: Prepare the pump

As directed by the manufacturer or your healthcare team:

  • Turn on the pump.
  • Verify that the prescribed delivery parameters (eg, volume, flow rate) are set.
  • Insert the bag tubing onto the pump.
Why ?

This step ensures secure administration of the formula.

Step 11: Empty the air out of the bag tubing

  • Remove the cap from the end of the tubing.
  • Get rid of the air from the bag tubing, as instructed by the manufacturer or your healthcare team.
Why ?

This step avoids the entry of air into the stomach and prevents swelling of the belly from excess air.

Step 12: Connect the tubing to the nasal tube

  • Bend the tube and remove its cap.
  • Connect the tubing to the end of the tube.
  • Release the tube.
Why ?

Once the bag tubing is connected to the nasal tube, the feeding can begin.

Step 13: Start the pump

Start the pump as directed by the manufacturer or your healthcare team.

Why ?

This step starts the delivery of the formula.

Step 14: Administer the formula

  • Observe your child for any signs of discomfort when the feeding session is started (eg, nausea, vomiting, difficulty breathing, abdominal pain, sweating, etc.).

If the formula is administered over a long period of time or continuously:

  • Every 4 hours: Irrigate the tube.
  • Every 4 hours and after adding formula to the bag: Shake the bag for 10 seconds.
Why ?

This allows delivery of formula at a set rate into the stomach.

Step 15: Stop the pump

When the feeding session is over, turn off the pump as instructed by the manufacturer or your healthcare team.

Why ?

This step ends the administration of the formula.

Step 16: Disconnect the tubing from the nasal tube

  • Bend the tube.
  • Disconnect the tubing from the tube.
  • Replace the cap at the end of the tube.
  • Release the tube.
Why ?

This step clears the tube for irrigation.

Step 17: Irrigate the nasal tube

  • Bend the tube and remove its cap.
  • Connect the syringe to the end of the tube.
  • Release the tube.
  • Slowly depress the plunger of the syringe to push the water into the tube.
  • When the syringe is empty, bend the tube.
  • Disconnect the syringe.
  • Replace the cap at the end of the tube.
  • Release the tube.
Why ?

Irrigation ensures that your child has received all of the formula and prevents debris from sticking to the tube and blocking it.

Step 18: Keep your child in the same position after the session

  • Leave your child in a seated or semi-seated position for at least 30 minutes after formula administration, if possible.
  • Burp your baby after feeding, as needed.
Why ?

This position facilitates digestion and reduces regurgitation.

Burping your baby avoids abdominal pain (bloating and swelling).

Step 19: Clean and store equipment

  • Leave the tubing in place in the pump and follow your healthcare team’s or manufacturer’s instructions for cleaning.
  • Clean all other materials and equipment and store as recommended.
Why ?

This step is necessary to ensure cleanliness and proper functioning of the equipment for the next use.

Step 20: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

  • Listen to what your child says about the parts of the procedure that were difficult or painful.
  • Comfort your child and recognize your child’s collaboration with positive feedback.
  • Highlight your child’s  specific strengths that helped make the procedure positive.
  • Discuss with your child what might be done the same or differently the next time the care is needed.
  • Keep your promises if you have promised a reward, follow through.
  • Reward yourself too.
.Reviser : NRoss .Version : 1.0

Methods of care : Administration of nutritional formula: Button

Indications

NOTE: For ease of reading the rest of the text, the word (nutritional) “formula” also includes “breast milk”, “fortified breast milk” or “infant formula”.

The formula is given to your child through the enteral route to provide nutrients and calories to meet their nutritional needs.

Considerations:

Frequency

Required materials

Push method:

Gravity method:

Pump method:

Refer to your healthcare team:

Depending on your child’s age and condition, always encourage your child’s autonomy in carrying out the care method of care.

The steps of the methods of care are illustrated by a Mic-Key® gastrostomy button.

The steps of the “By pump” method of care are illustrated by a Kangaroo Joey pump ™.

By push


Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

  • Create the right moment: integrate the care in a routine.
  • Alert your child to the needed care and communicate together.
  • Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

  • Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
  • Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
  • Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

  • Safety: Carefully follow the care practice steps as you have been taught.
  • Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
  • Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the material

  • Set up on a flat surface or a well-cleaned table.
  • Gather and inspect all equipment to ensure that it is not damaged.
  • Fill the irrigation syringe with the amount of water recommended by your healthcare team.
Why ?

This step ensures that the required materials are on hand in order to start the procedure.

Step 5: Position your child

Place your child in a seated or semi-seated position according to your child’s comfort and capacity

Why ?

This position facilitates digestion and avoids aspiration of the formula into the lungs.

Step 6: Check the location of the button

  • Make a visual inspection your child’s button; check to see if it is intact.
  • Check to see if the button is correctly in place and not pushed into the stoma, or too far out of the stoma.
Why ?

This step ensures the safe use of the button.

Step 7: Irrigate the button extension set

  • Remove the cover from the extension set feeding port.
  • If the extension set has two ports, make sure that the medication port remains closed throughout the procedure.
  • Connect the syringe to the end of the extension set.
  • Make sure the extension set clamp is open.
  • Depress the plunger of the syringe to inject water all the way to the end of the extension set.
  • Close the clamp on the extension set.
  • Leave the syringe connected to the extension set.
Why ?

This step ensures that the extension set tubing is filled with water and ready to flush into the button feeding port.

Step 8: Connect the extension set to the button

  • Remove the cover from the button feeding port, if closed.
  • Make sure the port is clean.
  • Hold the sides of the button and insert the extension set into the feeding port.
  • Lock the extension set into the button, according to the manufacturer’s instructions or those of your healthcare team.
Why ?

This step prepares for verification of the button location and irrigation.

Holding the sides of the button helps to stabilize it during the installation of the extension set.

Step 9: Irrigate the button

  • Open the clamp of the extension set.
  • Slowly depress the plunger of the syringe (already connected to the extension set) to push the water into the button
  • When the syringe is empty, close the clamp of the extension set.
  • Disconnect the syringe.
  • Replace the cover on the feeding port of the extension set.
Why ?

This step ensures that the button is patent, ready to use and reduces the risk of the button being blocked with debris.

Step 10: Aspirate the formula into the feeding syringe

  • Remove the protective cap from the feeding syringe.
  • Dip the end of the syringe into the container and withdraw up the formula by pulling the plunger.
  • Fill the syringe with the required amount of formula.
  • Hold the syringe with the pointed end upwards and remove the air from the syringe by pushing gently on the plunger until a drop of formula comes out of the tip of the syringe.
Why ?

This step fills the syringe with the amount of formula to be administered and removes the air from the syringe.

Step 11: Connect the feeding syringe to the button extension set

  • Remove the cover from the extension set feeding port.
  • Connect the supply syringe into the extension port.
  • Open the extension set clamp.
Why ?

Connecting the feeding syringe makes it possible to administer the formula by push.

Step 12: Administer the formula

  • Slowly depress the plunger of the feeding syringe and push a small amount of formula at a time, at the speed recommended by your healthcare team.
  • Every time the syringe is empty:
    • close the extension set clamp,
    • disconnect the syringe,
    • put the cover on the extension feeding port,
    • fill the syringe with formula,
    • remove the cover from the feeding port,
    • reconnect the syringe from the extension port,
    • open the extension clamp,
    • continue the administration.
  • Administer the formula for 20-30 minutes until your child has received the required amount or for the length of time agreed upon with your healthcare team.
  • Observe your child for signs of discomfort when the feeding session is started (eg, nausea, vomiting, difficulty breathing, abdominal pain, sweating, etc.).
Why ?

This ensures that the formula reaches the stomach safely.

The length of the feeding session depends on the amount of formula required and your child’s tolerance.

Step 13: Disconnect the feeding syringe from the button extension set

When the feeding session is over:

  • Close the button extension set clamp.
  • Disconnect the feeding syringe from the extension set.
  • Replace the cover on the extension set.
Why ?

This step clears the extension for irrigation.

Step 14: Irrigate the button

  • Remove the cover from the extension set.
  • Connect the syringe to the end of the extension set.
  • Open the clamp of the extension set.
  • Slowly depress the plunger of the syringe to push the water into the button.
  • When the syringe is empty, close the clamp of the extension set.
  • Disconnect the syringe.
  • Replace the cover on the feeding port of the extension set.
Why ?

This step ensures that all of the formula was given and reduces the risk of the button being blocked with left over traces of formula.

Step 15: Disconnect the button extension set

  • Hold the sides of the button.
  • Unlock the button extension set, as directed by the manufacturer or your healthcare team.
  • Remove the extension set from the button feeding port.
  • Put the cover on the button feeding port.

Why ?

If the extension set is kept in place, your child may accidentally pull on it and move the button, in addition to it being cumbersome.

Holding the sides of the button helps stabilize the button while the extension set is being removed.

Closing the cover prevents leakage of the stomach contents through the button in between feeding sessions.

Step 16: Keep your child in the same position after the session

  • Leave your child in a seated or semi-seated position for at least 30 minutes after formula administration, if possible.
  • Burp your baby after feeding, as needed.
Why ?

This position facilitates digestion and reduces regurgitation.

Burping your baby avoids abdominal pain (bloating and swelling).

Step 17: Clean and store equipment

Clean, maintain and store equipment as recommended.

Why ?

This step is necessary to ensure cleanliness and proper functioning of the equipment for the next use.

Step 18: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

  • Listen to what your child says about the parts of the procedure that were difficult or painful.
  • Comfort your child and recognize your child’s collaboration with positive feedback.
  • Highlight your child’s  specific strengths that helped make the procedure positive.
  • Discuss with your child what might be done the same or differently the next time the care is needed.
  • Keep your promises if you have promised a reward, follow through.
  • Reward yourself too.

By gravity


Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

  • Create the right moment: integrate the care in a routine.
  • Alert your child to the needed care and communicate together.
  • Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

  • Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
  • Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
  • Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

  • Safety: Carefully follow the care practice steps as you have been taught.
  • Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
  • Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the material

  • Set up on a flat surface or a well-cleaned table.
  • Gather and inspect all equipment to ensure that it is not damaged.
  • Fill the irrigation syringe with the amount of water recommended by your healthcare team
  • Check that the roller clamp on the bag tubing is securely closed.

Why ?

This step ensures that the required materials are on hand in order to start the procedure.

Step 5: Position your child

Place your child in a seated or semi-seated position according to your child’s comfort and capacity.

Why ?

This position facilitates digestion and avoids aspiration of the formula into the lungs.

Step 6: Check the location of the button

  • Make a visual inspection your child’s button; check to see if it is intact.
  • Check to see if the button is correctly in place and not pushed into the stoma, or too far out of the stoma.
Why ?

This step ensures the safe use of the button.

Step 7: Irrigate the button extension set

  • Remove the cover from the extension set feeding port.
  • If the extension set has two ports, make sure that the medication port remains closed throughout the procedure.
  • Connect the syringe to the end of the extension set.
  • Make sure the extension set clamp is open.
  • Depress the plunger of the syringe to inject water all the way to the end of the extension set.
  • Close the clamp on the extension set.
  • Leave the syringe connected to the extension set.
Why ?

This step ensures that the extension set tubing is filled with water and ready to flush into the button feeding port.

Step 8: Connect the extension set to the button

  • Remove the cover from the button feeding port, if closed.
  • Make sure the port is clean.
  • Hold the sides of the button and insert the extension set into the feeding port.
  • Lock the extension set into the button, according to the manufacturer’s instructions or those of your healthcare team.
Why ?

This step prepares for verification of the button location and irrigation.

Holding the sides of the button helps to stabilize it during the installation of the extension set.

Step 9: Irrigate the button

  • Open the clamp of the extension set.
  • Slowly depress the plunger of the syringe (already connected to the extension set) to push the water into the button
  • When the syringe is empty, close the clamp of the extension set.
  • Disconnect the syringe.
  • Replace the cover on the feeding port of the extension set.
Why ?

This step ensures that the button is patent, ready to use and reduces the risk of the button being blocked with debris.

Step 10: Pour the formula into the bag

  • Open the cap of the feeding bag.
  • Pour the formula into the bag, adding about 30 ml more than the amount to be given to get rid of the the air in the tubing.
  • Close the cap of the bag.
Why ?

This step allows you to fill the bag with the formula.

Step 11: Hang the bag

  • Hang the bag at a height of 45 to 90 cm above your child’s head.
  • Hang it from a coat rack, a wall hook, or place it on the IV pole.
Why ?

The correct positioning of the bag promotes the safe administration of the formula.

Step 12: Empty the air out of the bag tubing

  • Compress the drip chamber to fill it with formula to 1/3 or 1/2 of its capacity.
  • Remove the cap from the end of the tubing.
  • Then open the roller clamp to allow the formula to flow down through the tubing and get rid of air from the rest of the tubing.
  • Direct the end of the tubing into a container to catch the few drops of formula that will drip out of the tubing.

  • When the tubing and extension set are filled with formula, close the roller clamp.
Why ?

This step avoids the entry of air into the stomach and prevents swelling of the belly from excess air.

Step 13: Connect the tubing to the button extension set

  • Remove the cover from the extension set port.
  • Connect the tubing to the end of the extension set.
  • Open the extension set clamp.
Why ?

Once the feeding bag tubing is connected to the button extension set, the feeding can begin.

Step 14: Administer the formula

  • Open the roller clamp and slowly roll the roller up or down until you get the flow rate agreed upon with your healthcare team.
Feeding volume Drop rate
60 ml / hour 16 drops / minute
80 ml / hour 20 drops / minute
100 ml / hour 24 drops / minute
120 ml / hour 28 drops / minute
140 ml / hour 32 drops / minute
  • Observe your child for signs of discomfort when the feeding session is started (eg, nausea, vomiting, difficulty breathing, abdominal pain, sweating, etc.).

If the formula is administered over a long period of time or continuously:

  • Every 4 hours: Irrigate the tube.
  • Every 4 hours and after adding formula to the bag: Shake the bag for 10 seconds.
Why ?

This ensures that the formula reaches the stomach.

Irrigation of the button extension set during continuous administration of the formula prevents blockage.

Step 15: Close the roller clamp on the tubing

When the feeding session is over, close the roller clamp on the bag tubing.

Why ?

This step ends the feeding session.

Step 16: Disconnect the tubing from the button extension set

  • Close the button extension set clamp.
  • Disconnect the tubing from the extension set.
  • Replace the cover on the extension set.
Why ?

This step clears the extension for irrigation.

Step 17: Irrigate the button

  • Remove the cover from the extension set.
  • Connect the syringe to the end of the extension set.
  • Open the clamp of the extension set.
  • Slowly depress the plunger of the syringe to push the water into the button.
  • When the syringe is empty, close the clamp of the extension set.
  • Disconnect the syringe.
  • Replace the cover on the feeding port of the extension set.
Why ?

This step ensures that all of the formula was given and reduces the risk of the button being blocked with left over traces of formula.

Step 18: Disconnect the button extension set

  • Hold the sides of the button.
  • Unlock the button extension set, as directed by the manufacturer or your healthcare team.
  • Remove the extension set from the button feeding port.
  • Put the cover on the button feeding port.

Why ?

If the extension set is held in place, your child may accidentally pull on it and move the button, in addition to it being cumbersome. 

Holding the sides of the button helps stabilize the button while the extension set is being removed.

Closing the cover prevents leakage of the stomach contents through the button in between feeding sessions.

Step 19: Keep your child in the same position after the session

  • Leave your child in a seated or semi-seated position for at least 30 minutes after formula administration, if possible.
  • Burp your baby after feeding, as needed.
Why ?

This position facilitates digestion and reduces regurgitation.

Burping your baby avoids abdominal pain (bloating and swelling).

Step 20: Clean and store equipment

Clean, maintain and store equipment as recommended.

Why ?

This step is necessary to ensure cleanliness and proper functioning of the equipment for the next use.

Step 21: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

  • Listen to what your child says about the parts of the procedure that were difficult or painful.
  • Comfort your child and recognize your child’s collaboration with positive feedback.
  • Highlight your child’s  specific strengths that helped make the procedure positive.
  • Discuss with your child what might be done the same or differently the next time the care is needed.
  • Keep your promises if you have promised a reward, follow through.
  • Reward yourself too.

By pump


Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

  • Create the right moment: integrate the care in a routine.
  • Alert your child to the needed care and communicate together.
  • Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

  • Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
  • Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
  • Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

  • Safety: Carefully follow the care practice steps as you have been taught.
  • Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
  • Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the material

  • Set up on a flat surface or a well-cleaned table.
  • Gather and inspect all equipment to ensure that it is not damaged.
  • Fill the irrigation syringe with the amount of water recommended by your healthcare team.
  • Make sure the pump is properly charged or plugged into a wall outlet.
  • Place the pump on a solid surface (eg, chest of drawers, bedside table or kitchen table), on an IV pole or in its backpack.
Why ?

This step ensures that the required materials are on hand in order to start the procedure.

Step 5: Position your child

Place your child in a seated or semi-seated position according to your child’s comfort and capacity.

Why ?

This position facilitates digestion and avoids aspiration of the formula into the lungs.

Step 6: Check the location of the button

  • Make a visual inspection your child’s button; check to see if it is intact.
  • Check to see if the button is correctly in place and not pushed into the stoma, or too far out of the stoma.
Why ?

This step ensures the safe use of the button.

Step 7: Irrigate the button extension set

  • Remove the cover from the extension set feeding port.
  • If the extension set has two ports, make sure that the medication port remains closed throughout the procedure.
  • Connect the syringe to the end of the extension set.
  • Make sure the extension set clamp is open.
  • Depress the plunger of the syringe to inject water all the way to the end of the extension set.
  • Close the clamp on the extension set.
  • Leave the syringe connected to the extension set.
Why ?

This step ensures that the extension set tubing is filled with water and ready to flush into the button feeding port.

Step 8: Connect the extension set to the button

  • Remove the cover from the button feeding port, if closed.
  • Make sure the port is clean.
  • Hold the sides of the button and insert the extension set into the feeding port.
  • Lock the extension set into the button, according to the manufacturer’s instructions or those of your healthcare team.
Why ?

This step prepares for verification of the button location and irrigation.

Holding the sides of the button helps to stabilize it during the installation of the extension set.

Step 9: Irrigate the button

  • Open the clamp of the extension set.
  • Slowly depress the plunger of the syringe (already connected to the extension set) to push the water into the button.
  • When the syringe is empty, close the clamp of the extension set.
  • Disconnect the syringe.
  • Replace the cover on the feeding port of the extension set.
Why ?

This step ensures that the button is patent, ready to use and reduces the risk of the button being blocked with debris.

Step 10: Pour the formula into the bag

  • Open the cap of the feeding bag.
  • Pour the formula into the bag, adding about 30 ml more than the amount to be given to get rid of the the air in the tubing.
  • Close the cap of the bag.
Why ?

This step allows you to fill the bag with the formula.

Step 11: Hang the bag

  • Install the bag so that the highest level of the formula is about 15 cm above the pump.
  • Hang it from a coat rack, a wall hook, or place it on the IV pole.
  • If the bag is put in a backpack, keep the bag upright.

Why ?

The correct positioning of the bag promotes the safe administration of the formula.

Step 12: Prepare the pump

As directed by the manufacturer or your healthcare team:

  • Turn on the pump.
  • Verify that the prescribed delivery parameters (eg, volume, flow rate) are set.
  • Insert the bag tubing onto the pump.
Why ?

This step ensures secure administration of the formula.

Step 13: Empty the air out of the bag tubing

  • Remove the cap from the end of the tubing.
  • Get rid of the air from the bag tubing, as instructed by the manufacturer or your healthcare team.
Why ?

This step avoids the entry of air into the stomach and prevents swelling of the belly from excess air.

Step 14: Connect the tubing to the button extension set

  • Remove the cover from the extension set port.
  • Connect the tubing to the end of the extension set.
  • Open the extension set clamp.
Why ?

Once the bag tubing is connected to the button extension set, the feeding can begin.

Step 15: Start the pump

Start the pump as directed by the manufacturer or your healthcare team.

Why ?

This step starts the delivery of the formula.

Step 16: Administer the formula

  • Open the extension set clamp.
  • Observe your child for signs of discomfort when the feeding session is started (eg, nausea, vomiting, difficulty breathing, abdominal pain, sweating, etc.).

If the formula is administered over a long period of time or continuously:

Why ?

This allows delivery of formula at a set rate into the stomach.

Step 17: Stop the pump

When the feeding session is over, turn off the pump as instructed by the manufacturer or your healthcare team.

Why ?

This step ends the administration of the formula.

Step 18: Disconnect the tubing from the button extension set

  • Close the button extension set clamp.
  • Disconnect the tubing from the extension set.
  • Replace the cover on the extension set.
Why ?

This step clears the extension for irrigation.

Step 19: Irrigate the button

  • Remove the cover from the extension set.
  • Connect the syringe to the end of the extension set.
  • Open the clamp of the extension set.
  • Slowly depress the plunger of the syringe to push the water into the button.
  • When the syringe is empty, close the clamp of the extension set.
  • Disconnect the syringe.
  • Replace the cover on the feeding port of the extension set.
Why ?

This step ensures that all of the formula was given and reduces the risk of the button being blocked with left over traces of formula.

Step 20: Disconnect the button extension set

  • Hold the sides of the button.
  • Unlock the button extension set, as directed by the manufacturer or your healthcare team.
  • Remove the extension set from the button feeding port.
  • Put the cover on the button feeding port.

Why ?

If the extension set is held in place, your child may accidentally pull on it and move the button, in addition to it being cumbersome. 

Holding the sides of the button helps stabilize the button while the extension set is being removed.

Closing the cover prevents leakage of the stomach contents through the button in between feeding sessions.

Step 21: Keep your child in the same position after the session

  • Leave your child in a seated or semi-seated position for at least 30 minutes after formula administration, if possible.
  • Burp your baby after feeding, as needed.
Why ?

This position facilitates digestion and reduces regurgitation.

Burping your baby avoids abdominal pain (bloating and swelling).

Step 22: Clean and store equipment

  • Leave the tubing in place in the pump and follow your healthcare team’s or manufacturer’s instructions for cleaning.
  • Clean all other materials and equipment and store as recommended.
Why ?

This step is necessary to ensure cleanliness and proper functioning of the equipment for the next use.

Step 23: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

  • Listen to what your child says about the parts of the procedure that were difficult or painful.
  • Comfort your child and recognize your child’s collaboration with positive feedback.
  • Highlight your child’s  specific strengths that helped make the procedure positive.
  • Discuss with your child what might be done the same or differently the next time the care is needed.
  • Keep your promises if you have promised a reward, follow through.
  • Reward yourself too.
.Reviser : NRoss .Version : 1.0

Methods of care : Administration of nutritional formula: Enterostomy long tube

Indications

NOTE: For ease of reading the rest of the text, the word (nutritional) “formula” also includes “breast milk”, “fortified breast milk” or “infant formula”.

Considerations:

Frequency

Required materials

Push method:

Gravity method:

Pump method:

Refer to your healthcare team:

Depending on your child’s age and condition, always encourage your child’s autonomy in carrying out the care method of care.

The steps of the “By pump” method of care are illustrated by a Kangaroo Joey pump ™.

By push


Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

  • Create the right moment: integrate the care in a routine.
  • Alert your child to the needed care and communicate together.
  • Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

  • Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
  • Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
  • Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

  • Safety: Carefully follow the care practice steps as you have been taught.
  • Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
  • Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the material

  • Set up on a flat surface or a well-cleaned table.
  • Gather and inspect all equipment to ensure that it is not damaged.
  • Fill the irrigation syringe with the amount of water recommended by your healthcare team.
Why ?

This step ensures that the required materials are on hand in order to start the procedure.

Step 5: Position your child

Place your child in a seated or semi-seated position according to your child’s comfort and capacity.

Why ?

This position facilitates digestion and avoids aspiration of the formula into the lungs.

Step 6: Check the location of the long tube

  • Make a visual inspection of your child’s long tube; check to see if it is intact.
  • Check to see if there are any changes in the outer portion of the tube.
Why ?

This step ensures the safe use of the long tube.

Step 7: Irrigate the long tube

  • Bend the tube and remove its cover.
  • Connect the syringe to the tube.
  • Release the tube.
  • Slowly depress the plunger of the syringe to push the water into the tube.
  • When the syringe is empty, bend the tube.
  • Disconnect the syringe.
  • Replace the cover on the tube.
  • Release the tube.
Why ?

This step clears the long tube of any debris and prevents blockage.

Step 8: Aspirate the formula into the feeding syringe

  • Remove the protective cap from the feeding syringe.
  • Dip the end of the syringe into the container and withdraw up the formula by pulling the plunger.
  • Fill the syringe with the required amount of formula.
  • Hold the syringe with the pointed end upwards and remove the air from the syringe by pushing gently on the plunger until a drop of formula comes out of the tip of the syringe.
Why ?

This step fills the syringe with the amount of formula to be administered and removes the air from the syringe.

Step 9: Connect the feeding syringe to the long tube

  • Bend the tube and remove its cover.
  • Connect the syringe to the tube.
  • Release the tube.
Why ?

The installation of the syringe makes it possible to administer the formula by push.

Step 10: Administer the formula

  • Slowly depress the plunger of the feeding syringe and push a small amount of formula at a time, at the speed recommended by your healthcare team.
  • Every time the syringe is empty:
    • bend the tube,
    • disconnect the syringe,
    • put the cover on the tube,
    • release the tube,
    • fill the syringe with formula,
    • bend the tube again,
    • remove the cover from the tube,
    • reconnect the syringe to the tube,
    • continue the administration.
  • Administer the formula for 20-30 minutes until your child has received the required amount or for the length of time agreed upon with your healthcare team.
  • Observe your child for signs of discomfort when the feeding session is started (eg, nausea, vomiting, difficulty breathing, abdominal pain, sweating, etc.).
Why ?

This ensures that the formula reaches the stomach safely.

The length of the feeding session depends on the amount of formula required and your child’s tolerance.

Step 11: Disconnect the feeding syringe from the long tube

When the feeding session is over:

  • Bend the tube.
  • Disconnect the feeding syringe from the tube.
  • Replace the cover on the tube.
  • Release the tube.
Why ?

This step clears the long tube for irrigation.

Step 12: Irrigate the long tube

  • Bend the tube and remove its cover.
  • Connect the syringe to the tube.
  • Release the tube.
  • Slowly depress the plunger of the syringe to push the water into the tube.
  • When the syringe is empty, bend the tube.
  • Disconnect the syringe.
  • Replace the cover on the tube.
  • Release the tube.
Why ?

Irrigation ensures that your child has received all of the formula and prevents debris from sticking to the long tube and blocking it.

Step 13: Keep your child in the same position after the session

  • Leave your child in a seated or semi-seated position for at least 30 minutes after formula administration, if possible.
  • Burp your baby after feeding, as needed.
Why ?

This position facilitates digestion and reduces regurgitation.

Burping your baby avoids abdominal pain (bloating and swelling).

Step 14: Clean and store equipment

Clean, maintain and store equipment as recommended.

Why ?

This step is necessary to ensure cleanliness and proper functioning of the equipment for the next use.

Step 15: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

  • Listen to what your child says about the parts of the procedure that were difficult or painful.
  • Comfort your child and recognize your child’s collaboration with positive feedback.
  • Highlight your child’s  specific strengths that helped make the procedure positive.
  • Discuss with your child what might be done the same or differently the next time the care is needed.
  • Keep your promises if you have promised a reward, follow through.
  • Reward yourself too.

By gravity


Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

  • Create the right moment: integrate the care in a routine.
  • Alert your child to the needed care and communicate together.
  • Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

  • Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
  • Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
  • Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

  • Safety: Carefully follow the care practice steps as you have been taught.
  • Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
  • Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the material

  • Set up on a flat surface or a well-cleaned table.
  • Gather and inspect all equipment to ensure that it is not damaged.
  • Fill the irrigation syringe with the amount of water recommended by your healthcare team.
  • Check that the roller clamp on the bag tubing is securely closed.

Why ?

This step ensures that the required materials are on hand in order to start the procedure.

Step 5: Position your child

Place your child in a seated or semi-seated position according to your child’s comfort and capacity.

Why ?

This position facilitates digestion and avoids aspiration of the formula into the lungs.

Step 6: Check the location of the long tube

  • Make a visual inspection of your child’s long tube; check to see if it is intact.
  • Check to see if there are any changes in the outer portion of the tube.
Why ?

This step ensures the safe use of the long tube.

Step 7: Irrigate the long tube

  • Bend the tube and remove its cover.
  • Connect the syringe to the tube.
  • Release the tube.
  • Slowly depress the plunger of the syringe to push the water into the tube.
  • When the syringe is empty, bend the tube.
  • Disconnect the syringe.
  • Replace the cover on the
  • Release the tube.
Why ?

This step clears the long tube of any debris and prevents blockage.

Step 8: Pour the formula into the bag

  • Open the cap of the feeding bag.
  • Pour the formula into the bag, adding about 30 ml more than the amount to be given to get rid of the the air in the tubing.
  • Close the cap of the bag.
Why ?

This step allows you to fill the bag with the formula.

Step 9: Hang the bag

  • Hang the bag at a height of 45 to 90 cm above your child’s head.
  • Hang it from a coat rack, a wall hook, or place it on the IV pole.
Why ?

The correct positioning of the bag promotes the safe administration of the formula.

Step 10: Empty the air out of the bag tubing

  • Compress the drip chamber to fill it with formula to 1/3 or 1/2 of its capacity.
  • Remove the cap from the end of the tubing.
  • Then open the roller clamp to allow the formula to flow down through the tubing and get rid of air from the rest of the tubing.
  • Direct the end of the tubing into a container to catch the few drops of formula that will drip out of the tubing.

  • When the tubing is filled with formula, close the roller clamp.
Why ?

This step avoids the entry of air into the stomach and prevents swelling of the belly from excess air.

Step 11: Connect the tubing to the long tube

  • Bend the tube and remove its cover.
  • Connect the tubing to the end of the tube.
  • Release the tube.
Why ?

Once the feeding bag tubing is connected to the long tube, the feeding can begin.

Step 12: Administer the formula

  • Open the roller clamp and slowly roll the roller up or down until you get the flow rate agreed upon with your healthcare team.
Feeding volume Drop rate
60 ml / hour 16 drops / minute
80 ml / hour 20 drops / minute
100 ml / hour 24 drops / minute
120 ml / hour 28 drops / minute
140 ml / hour 32 drops / minute
  • Observe your child for signs of discomfort when the feeding session is started (eg, nausea, vomiting, difficulty breathing, abdominal pain, sweating, etc.).

If the formula is administered over a long period of time or continuously:

Why ?

This ensures that the formula reaches the stomach.

Irrigation of the long tube during continuous administration of the formula prevents blockage.

Step 13: Close the roller clamp on the tubing

When the feeding session is over, close the roller clamp on the bag tubing.

Why ?

This step ends the feeding session.

Step 14: Disconnect the tubing from the long tube

  • Bend the tube.
  • Disconnect the tubing from the tube.
  • Replace the cover at the end of the tube.
  • Release the tube.
Why ?

This step clears the long tube for irrigation.

Step 15: Irrigate the long tube

  • Bend the tube and remove its cover.
  • Connect the syringe to the tube.
  • Release the tube.
  • Slowly depress the plunger of the syringe to push the water into the tube.
  • When the syringe is empty, bend the tube.
  • Disconnect the syringe.
  • Replace the cover on the tube.
  • Release the tube.
Why ?

Irrigation ensures that your child has received all the formula and prevents debris from sticking to the long tube and blocking it.

Step 16: Keep your child in the same position after the session

  • Leave your child in a seated or semi-seated position for at least 30 minutes after formula administration, if possible.
  • Burp your baby after feeding, as needed.
Why ?

This position facilitates digestion and reduces regurgitation.

Burping your baby avoids abdominal pain (bloating and swelling).

Step 17: Clean and store equipment

Clean, maintain and store equipment as recommended.

Why ?

This step is necessary to ensure cleanliness and proper functioning of the equipment for the next use.

Step 18: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

  • Listen to what your child says about the parts of the procedure that were difficult or painful.
  • Comfort your child and recognize your child’s collaboration with positive feedback.
  • Highlight your child’s  specific strengths that helped make the procedure positive.
  • Discuss with your child what might be done the same or differently the next time the care is needed.
  • Keep your promises if you have promised a reward, follow through.
  • Reward yourself too.

By pump


Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

  • Create the right moment: integrate the care in a routine.
  • Alert your child to the needed care and communicate together.
  • Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

  • Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
  • Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
  • Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

  • Safety: Carefully follow the care practice steps as you have been taught.
  • Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
  • Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the material

  • Set up on a flat surface or a well-cleaned table.
  • Gather and inspect all equipment to ensure that it is not damaged.
  • Fill the irrigation syringe with the amount of water recommended by your healthcare team.
  • Make sure the pump is properly charged or plugged into a wall outlet.
  • Place the pump on a solid surface (eg, chest of drawers, bedside table or kitchen table), on an IV pole or in its backpack.
Why ?

This step ensures that the required materials are on hand in order to start the procedure.

Step 5: Position your child

Place your child in a seated or semi-seated position according to your child’s comfort and capacity.

Why ?

This position facilitates digestion and avoids aspiration of the formula into the lungs.

Step 6: Check the location of the long tube

  • Make a visual inspection of your child’s long tube; check to see if it is intact.
  • Check to see if there are any changes in the outer portion of the tube.
Why ?

This step ensures the safe use of the tube.

Step 7: Irrigate the long tube

  • Bend the tube and remove its cap.
  • Connect the syringe to the end of the tube.
  • Release the tube.
  • Slowly depress the plunger of the syringe to push the water into the tube.
  • When the syringe is empty, bend the tube.
  • Disconnect the syringe.
  • Replace the cap at the end of the tube.
  • Release the tube.
Why ?

This step clears the long tube of any debris and prevents blockage.

Step 8: Pour the formula into the bag

  • Open the cap of the feeding bag.
  • Pour the formula into the bag, adding about 30 ml more than the amount to be given to get rid of the the air in the tubing.
  • Close the cap of the bag.
Why ?

This step allows you to fill the bag with the formula.

Step 9: Hang the bag

  • Install the bag so that the highest level of the formula is about 15 cm above the pump.
  • Hang it from a coat rack, a wall hook, or place it on the IV pole.
  • If the bag is put in a backpack, keep the bag upright.

Why ?

The correct positioning of the bag promotes the safe administration of the formula.

Step 10: Prepare the pump

As directed by the manufacturer or your healthcare team:

  • Turn on the pump.
  • Verify that the prescribed delivery parameters (eg, volume, flow rate) are set.
  • Insert the bag tubing onto the pump.
Why ?

This step ensures secure administration of the formula.

Step 11: Empty the air out of the bag tubing

  • Remove the cap from the end of the tubing.
  • Get rid of the air from the tubing, as instructed by the manufacturer or your healthcare team.
Why ?

This step avoids the entry of air into the stomach and prevents swelling of the belly from excess air.

Step 12: Connect the tubing to the long tube

  • Bend the tube and remove its cover.
  • Connect the tubing to the end of the tube.
  • Release the tube.
Why ?

Once the feeding bag tubing is connected to the long tube, the feeding can begin.

Step 13: Start the pump

Start the pump as directed by the manufacturer or your healthcare team.

Why ?

This step starts the administration of the formula.

Step 14: Administer the formula

  • Open the extension set clamp.
  • Observe your child for signs of discomfort when the feeding session is started (eg, nausea, vomiting, difficulty breathing, abdominal pain, sweating, etc.).

If the formula is administered over a long period of time or continuously:

  • Every 4 hours: Irrigate the long tube.
  • Every 4 hours and after adding formula to the bag: Shake the bag for 10 seconds.
Why ?

This ensures that the formula reaches the stomach.

Step 15: Stop the pump

  • When the feeding session is over, turn off the pump as instructed by the manufacturer or your healthcare team.
Why ?

This step ends the administration of the formula.

Step 16: Disconnect the tubing from the long tube

  • Bend the tube.
  • Disconnect the tubing from the tube.
  • Replace the cover at the end of the tube.
  • Release the tube.
Why ?

This step clears the long tube for irrigation.

Step 17: Irrigate the long tube

  • Bend the tube and remove its cover.
  • Connect the syringe to the tube.
  • Release the tube.
  • Slowly depress the plunger of the syringe to push the water into the tube.
  • When the syringe is empty, bend the tube.
  • Disconnect the syringe.
  • Replace the cover on the tube.
  • Release the tube.
Why ?

Irrigation ensures that your child has received all the formula and prevents debris from sticking to the long tube and blocking it.

Step 18: Keep your child in the same position after the session

  • Leave your child in a seated or semi-seated position for at least 30 minutes after formula administration, if possible.
  • Burp your baby after feeding, as needed.
Why ?

This position facilitates digestion and reduces regurgitation.

Burping your baby avoids abdominal pain (bloating and swelling).

Step 19: Clean and store equipment

  • Leave the tubing in place in the pump and follow your healthcare team’s or manufacturer’s instructions for cleaning.
  • Clean all other materials and equipment and store as recommended.
Why ?

This step is necessary to ensure cleanliness and proper functioning of the equipment for the next use.

Step 20: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

  • Listen to what your child says about the parts of the procedure that were difficult or painful.
  • Comfort your child and recognize your child’s collaboration with positive feedback.
  • Highlight your child’s  specific strengths that helped make the procedure positive.
  • Discuss with your child what might be done the same or differently the next time the care is needed.
  • Keep your promises if you have promised a reward, follow through.
  • Reward yourself too.
.Reviser : NRoss .Version : 1.0

Methods of care : Medication administration

Indications

NOTE: For ease of reading the rest of the text, the word (nutritional) “formula” also includes “breast milk”, “fortified breast milk” or “infant formula”.

Considerations:

Frequency

According to the medical prescription.

Required materials

If needed:

Refer to your healthcare team if the material used at home or the sequence of steps taught is different from what is described in the method of care. 

Depending on your child’s age and condition, always encourage your child’s autonomy in carrying out the care method of care.

The steps of the methods of care are illustrated by a nasogastric tube.

The steps of the “By pump” method of care are illustrated by a Kangaroo Joey pump ™.

Nasal tube


Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

  • Create the right moment: integrate the care in a routine.
  • Alert your child to the needed care and communicate together.
  • Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

  • Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
  • Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
  • Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

  • Safety: Carefully follow the care practice steps as you have been taught.
  • Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
  • Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the material

  • Set up on a flat surface or a well-cleaned table.
  • Gather and inspect all equipment to ensure that it is not damaged.
  • Fill the syringe #1 with the amount of water recommended by your healthcare team.
Why ?

This step ensures that the required materials are on hand in order to start the procedure.

Step 5: Position your child

Place your child in a seated or semi-seated position according to your child’s comfort and capacity

Why ?

This position facilitates digestion and avoids aspiration of the medication into the lungs.

Step 6: Discontinue feeding session, if in progress

If the feeding session is not in progress, go to the next step. 

  • Turn off the pump.
  • Bend the nasal tube.
  • Disconnect the tubing from the tube.
  • Replace the cap at the end of the tube.
  • Release the tube.
  • Put a cap on the end of the tubing or place the end of the tubing on a clean compress.
  • Then proceed to step 8.
Why ?

Mixing medications and formula may cause problems such as:  changing the effect of the medication or causing blockages.  Temporarily stopping the formula feeding to give medications reduces these risks.

Step 7: Check the location of the nasal tube

  • Make a visual inspection of your child’s tube; check to see if it is intact.
  • Check to see if there are any changes in the outer portion of the tube, if the mark is still in the same place and if the adhesive bandage is securely in place.
  • Aspirate some gastric secretions, if recommended by your healthcare team: first inject air to empty the tube and then aspirate to get a sample directly from the stomach.
  • Afterwards, check the pH of this gastric fluid, if recommended by your healthcare team.
Why ?

This step ensures the safe use of the tube.

Step 8: Irrigate the nasal tube

  • Bend the tube and remove its cap.
  • Connect the syringe to the end of the tube.
  • Release the tube.
  • Slowly depress the plunger of the syringe to push the water into the tube.
  • When the syringe is empty, bend the tube.
  • Disconnect the syringe.
  • Replace the cap at the end of the tube.
  • Release the tube.
Why ?

This step clears the tube and prevents blockage and possible interactions between the formula remaining in the tube and the medication.

Step 9: Aspirate the medication into the medication syringe

  • Remove the protective cap from the feeding syringe #2.
  • Dip the end of the syringe into the container and draw up the medication by pulling the plunger.
  • Fill the syringe with the required amount of medication.
  • Hold the syringe with the pointed end upwards and remove the air from the syringe by gently depressing the plunger until a drop of medication comes out of the tip of the syringe.
Why ?

This step fills the syringe with the amount of medication to be given and removes the air from the syringe.

Step 10: Connect the syringe to the nasal tube

  • Bend the tube and remove its cap.
  • Connect the syringe to the end of the tube.
  • Release the tube.
Why ?

Connecting the syringe to the nasal tube allows the medication to be given by push.

Step 11: Administer the medication

  • Slowly depress the plunger of the syringe #2.
  • Continue until your child has received all the medication.
Why ?

This ensures that the medication reaches the stomach safely.

Step 12: Disconnect the syringe from the nasal tube

When all the medication is administered:

  • Bend the tube.
  • Disconnect the syringe #2 from the tube.
  • Replace the cap at the end of the tube.
  • Release the tube.
Why ?

This step clears the tube for irrigation.

Step 13: Irrigate the nasal tube

  • Bend the tube and remove its cap.
  • Connect the syringe #1 to the end of the tube.
  • Release the tube.
  • Slowly depress the plunger of the syringe to push the water into the tube.
  • When the syringe is empty, bend the tube.
  • Disconnect the syringe #1.
  • Replace the cap at the end of the tube.
  • Release the tube.
Why ?

This step ensures that all of the medication was given and reduces the risk of the tube being blocked with left over traces of medication.

Step 14: Resume the feeding session, if necessary

Taking into account the time required after the administration of the medication, as indicated by your healthcare team:

  • Reconnect the tubing to the nasal tube.
  • Start the pump.
Why ?

This step allows you to continue the temporarily stopped feeding session.

Step 15: Clean and store equipment

Clean, maintain and store equipment as recommended.

Why ?

This step is necessary to ensure cleanliness and proper functioning of the equipment for the next use.

Step 16: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

  • Listen to what your child says about the parts of the procedure that were difficult or painful.
  • Comfort your child and recognize your child’s collaboration with positive feedback.
  • Highlight your child’s  specific strengths that helped make the procedure positive.
  • Discuss with your child what might be done the same or differently the next time the care is needed.
  • Keep your promises if you have promised a reward, follow through.
  • Reward yourself too.

Button


Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

  • Create the right moment: integrate the care in a routine.
  • Alert your child to the needed care and communicate together.
  • Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

  • Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
  • Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
  • Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

  • Safety: Carefully follow the care practice steps as you have been taught.
  • Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
  • Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the material

  • Set up on a flat surface or a well-cleaned table.
  • Gather and inspect all equipment to ensure that it is not damaged.
  • Fill the syringe #1 with the amount of water recommended by your healthcare team.
Why ?

This step ensures that the required materials are on hand in order to start the procedure.

Step 5: Position your child

Place your child in a seated or semi-seated position according to your child’s comfort and capacity.

Why ?

This position facilitates digestion and avoids aspiration of the medication into the lungs.

Step 6: Discontinue feeding session, if in progress

If the feeding session is not in progress, go to the next step. 

  • Turn off the pump.
  • Bend the nasal tube.
  • Disconnect the tubing from the tube.
  • Replace the cap at the end of the tube.
  • Release the tube.
  • Put a cap on the end of the tubing or place the end of the tubing on a clean compress.
  • Then proceed to step 10.
Why ?

Mixing medications and formula may cause problems such as: changing the effect of the medication or causing blockages.  Temporarily stopping the formula feeding to give medications reduces these risks.

Step 7: Check the location of the button

  • Make a visual inspection your child’s button; check to see if it is intact.
  • Check to see if the button is correctly in place and not pushed into the stoma, or too far out of the stoma.
Why ?

This step ensures the safe use of the button.

Step 8: Irrigate the button extension set

  • Remove the cover from the feeding port or medication port, depending on the type of extension set.
  • If the extension set has two ports, ensure that the feeding port remains closed throughout the procedure.
  • Connect the #1 syringe to the end of the extension set.
  • Make sure the extension set clamp is open.
  • Depress the plunger of the syringe to inject water all the way to the end of the extension set.
  • Close the clamp on the extension set.
  • Leave the syringe connected to the extension set.
Why ?

This step ensures that the extension set tubing is filled with water and ready to flush into the button feeding port.

Step 9: Connect the extension set to the button

  • Remove the cover from the button feeding port, if closed.
  • Make sure the port is clean.
  • Hold the sides of the button and insert the extension set into the feeding port.
  • Lock the extension set into the button, according to the manufacturer’s instructions or those of your healthcare team.
Why ?

This step prepares for verification of the button location and irrigation.

Holding the sides of the button helps to stabilize it during the installation of the extension set.

Step 10: Irrigate the button

  • Open the clamp of the extension set.
  • Slowly depress the plunger of the syringe #1 (already connected to the extension set) to push the water into the button.
  • When the syringe is empty, close the clamp of the extension set.
  • Disconnect the syringe #1.
  • Replace the cover on the feeding port of the extension set.
Why ?

This step clears the button and prevents blockage and possible interactions between the formula remaining in the button and the medication.

Step 11: Aspirate the medication into the syringe for the medication

  • Remove the protective cap from the feeding syringe #2.
  • Dip the end of the syringe into the container and draw up the medication by pulling the plunger.
  • Fill the syringe with the required amount of medication.
  • Hold the syringe with the pointed end upwards and remove the air from the syringe by gently depressing the plunger until a drop of medication comes out of the tip of the syringe.
Why ?

This step fills the syringe with the amount of medication to be given and removes the air from the syringe.

Step 12: Connect the syringe to the button extension set

  • Remove the cover from the appropriate port of the extension set.
  • Connect the #2 syringe into the extension port.
  • Open the extension set clamp.
Why ?

Connecting the syringe to the button extension set allows the medication to be given by push.

Step 13: Administer the medication

  • Slowly depress the plunger of the syringe #2.
  • Continue until your child has received all the medication.
Why ?

This ensures that the medication reaches the stomach safely.

Step 14: Disconnect the feeding syringe from the button extension set

When all the medication is administered:

  • Close the button extension set clamp.
  • Disconnect the syringe #2 from the extension set.
  • Replace the cover on the extension set
Why ?

This step clears the extension for irrigation.

Step 15: Irrigate the button

  • Remove the cover from the extension set.
  • Connect the syringe #1 to the end of the extension set.
  • Open the clamp of the extension set.
  • Slowly depress the plunger of the syringe #1 to push the water into the button.
  • When the syringe is empty, close the clamp of the extension set.
  • Disconnect the syringe #1.
  • Replace the cover on the feeding port of the extension set.
Why ?

This step ensures that all of the medication was given and reduces the risk of the button being blocked with left over traces of medication.

Step 16: Resume the feeding session, if necessary

Taking into account the time required after the administration of the medication, as indicated by your healthcare team:

  • Reconnect the tubing to the nasal tube.
  • Start the pump.
Why ?

This step allows you to continue the temporarily stopped feeding session.

Step 17: Disconnect the button extension set

  • Hold the sides of the button.
  • Unlock the button extension set, as directed by the manufacturer or your healthcare team.
  • Remove the extension set from the button feeding port.
  • Put the cover on the button feeding port.

Why ?

If the extension set is held in place, your child may accidentally pull on it and move the button, in addition to being cumbersome.

Holding the sides of the button helps stabilize the button while the extension set is being removed.

Closing the cover prevents leakage of the stomach contents through the button in between feeding sessions.

Step 18: Clean and store equipment

Clean, maintain and store equipment as recommended.

Why ?

This step is necessary to ensure cleanliness and proper functioning of the equipment for the next use.

Step 19: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

  • Listen to what your child says about the parts of the procedure that were difficult or painful.
  • Comfort your child and recognize your child’s collaboration with positive feedback.
  • Highlight your child’s  specific strengths that helped make the procedure positive.
  • Discuss with your child what might be done the same or differently the next time the care is needed.
  • Keep your promises if you have promised a reward, follow through.
  • Reward yourself too.

Enterostomy long tube


Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

  • Create the right moment: integrate the care in a routine.
  • Alert your child to the needed care and communicate together.
  • Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

  • Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
  • Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
  • Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

  • Safety: Carefully follow the care practice steps as you have been taught.
  • Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
  • Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the material

  • Set up on a flat surface or a well-cleaned table.
  • Gather and inspect all equipment to ensure that it is not damaged.
  • Fill the syringe #1 with the amount of water recommended by your healthcare team.
Why ?

This step ensures that the required materials are on hand in order to start the procedure.

Step 5: Position your child

Place your child in a seated or semi-seated position according to your child’s comfort and capacity.

Why ?

This position facilitates digestion and avoids aspiration of the formula into the lungs.

Step 6: Discontinue feeding session, if in progress

If the feeding session is not in progress, go to the next step. 

  • Turn off the pump.
  • Bend the tube.
  • Disconnect the tubing from the long tube feeding port.
  • Replace the cover at the end of the feeding port.
  • Release the tube.
  • Put a cap on the end of the tubing or place the end of the tubing on a clean compress.
  • Then proceed to step 8.
Why ?

Mixing medications and formula may cause problems such as: changing the effect of the medication or causing blockages.  Temporarily stopping the formula feeding to give medications reduces these risks.

Step 7: Check the location of the long tube

  • Make a visual inspection of your child’s long tube; check to see if it is intact.
  • Check to see if there are any changes in the outer portion of the tube.
Why ?

This step ensures the safe use of the long tube.

Step 8: Irrigate the long tube

  • Bend the tube and remove its cover.
  • Connect the syringe #1 to the tube.
  • Release the tube.
  • Slowly depress the plunger of the syringe to push the water into the tube.
  • When the syringe is empty, bend the tube.
  • Disconnect the syringe #1.
  • Replace the cover on the tube.
  • Release the tube.
Why ?

This step clears the tube and prevents blockage and possible interactions between the formula remaining in the long tube and the medication.

Step 9: Aspirate the medication into the medication syringe

  • Remove the protective cap from the feeding syringe #2.
  • Dip the end of the syringe into the container and draw up the medication by pulling the plunger.
  • Fill the syringe with the required amount of medication.
  • Hold the syringe with the pointed end upwards and remove the air from the syringe by gently depressing the plunger until a drop of medication comes out of the tip of the syringe.
Why ?

This step fills the syringe with the amount of medication to be given and removes the air from the syringe.

Step 10: Connect the feeding syringe to the long tube

  • Bend the tube and remove its cover.
  • Connect the syringe #2 to the tube.
  • Release the tube.
Why ?

Connecting the syringe to the long tube allows the medication to be given by push.

Step 11: Administer the medication

  • Slowly press the plunger of the syringe #2.
  • Continue until your child has received all the medication.
Why ?

This ensures that the medication reaches the stomach safely.

Step 12: Disconnect the syringe from the long tube

When all the medication is administered:

  • Bend the tube.
  • Disconnect the syringe #2 from the tube.
  • Replace the cover on the tube.
  • Release the tube.
Why ?

This step clears the long tube for irrigation.

Step 13: Irrigate the long tube

  • Bend the tube and remove its cover.
  • Connect the syringe #1 to the tube.
  • Release the tube.
  • Slowly depress the plunger of the syringe to push the water into the tube.
  • When the syringe is empty, bend the tube.
  • Disconnect the syringe #1.
  • Replace the cover on the tube.
  • Release the tube.
Why ?

This step ensures that all of the medication was given and reduces the risk of the long tube being blocked with left over traces of medication.

Step 14: Resume the feeding session, if necessary

Taking into account the time required after the administration of the medication, as indicated by your healthcare team:

  • Reconnect the tubing to the long tube feeding port.
  • Start the pump.
Why ?

This step allows you to continue the temporarily stopped feeding session.

Step 15: Clean and store equipment

Clean, maintain and store equipment as recommended.

Why ?

This step is necessary to ensure cleanliness and proper functioning of the equipment for the next use.

Step 16: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

  • Listen to what your child says about the parts of the procedure that were difficult or painful.
  • Comfort your child and recognize your child’s collaboration with positive feedback.
  • Highlight your child’s  specific strengths that helped make the procedure positive.
  • Discuss with your child what might be done the same or differently the next time the care is needed.
  • Keep your promises if you have promised a reward, follow through.
  • Reward yourself too.
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https://complexcareathomeforchildren.com/enteral-nutrition/

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