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GUIDELINES ON THE HANG TIME OF ENTERAL FEEDS AND
INFUSION EQUIPMENT (PLASTICS) FOR INPATIENTS IN OLCHC.
EDITION No.
DATE OF ISSUE
REVIEW INTERVAL
AUTHORISED BY
AUTHOR
COPY
LOCATION OF COPIES
1
3rd March 2011
2 years, 3rd March 2013
Dietetic Department
Anne Marie Shine (Senior Dietitian)
Regina Keogh (Clinical Nurse Facilitator PICU)
g/dietetics/best practice guidelines
Departmental Policies, Procedures and Guidelines Folder,
Conference Room, Department Nutrition and Dietetics.
Copies available on each ward.
Hospital Bulletin Board
DOCUMENT REVIEW HISTORY
REVIEW DATE
REVIEWED BY
APRIL 2009
ITA SAUL , DIETITIAN MANAGER
NOVEMBER 2009
APRIL 2009
SIGNATURE
DR. NIAMH O SULLIVAN,
CONSULTANT MICROBIOLIOGIST
FIONNULA O NEILL, NURSE
PRACTICE DEVELOPMENT
Disclaimer & Copyright
©2010, Our Lady’s Children’s Hospital Crumlin, Dublin 12. All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system or transmitted in any form or by any means without the prior written permission of the copyright holder. Every effort has
been made to ensure that the information provided is accurate and in accord with standards accepted at the time of printing.
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TABLE OF CONTENTS
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
DOCUMENT & GUIDELINE PURPOSE................................................................................................. 3
INTRODUCTION..................................................................................................................................... 3
COMPLICATIONS ASSOCIATED WITH ENTERAL FEEDING ............................................................. 4
EQUIPMENT........................................................................................................................................... 4
PROCEDURE ........................................................................................................................................ 4
POINTS TO NOTE.................................................................................................................................. 8
SUMMARY; GUIDELINES ON THE HANG TIME OF ENTERAL FEEDS & INFUSION EQUIPMENT
(PLASTICS) FOR INPATIENTS ............................................................................................................. 8
REFERENCES........................................................................................................................................ 9
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1.0
DOCUMENT & GUIDELINE PURPOSE
Document Purpose. The development of suitable guidance material on the handling of feeds and
feeding equipment on the wards.
Guideline Purpose. These guidelines aim to minimise the risk of acquiring infection from enteral feeds
for this vulnerable group of patients
2.0
INTRODUCTION
Sick children are at nutritional risk and it is important that they receive appropriate nutritional intake to meet
requirements. It is generally accepted that whenever possible, Enteral Nutrition (EN) is preferable to
Parenteral Nutrition (PN) for adult and paediatric patients (De Oliveira Iglesias et al, 2007).
EN has many documented advantages, including improving the digestive, absorptive, immunological and
nutritional status of the patient. However enteral feeding is not without risks. Such risks include nosocomial
infections (e.g. pneumonia, bacteraemia, diarrhoea, and infectious enterocolitis ) being linked to contaminated
formulas or infusion sets (Casewell et al 1981, Levy et al 1989, Jacobs et al 1990, Navajas et al 1992, Okuma
et al 2000, Himelright et al, 2002). These risks are exacerbated in critically ill children as many are
immunocompromised (Grant, 2001).
Contamination of enteral feeds with micro-organisms can occur at any point throughout their production,
preparation, storage or administration. Manipulation of the feed and the hang time of feeds and feeding sets
contribute to the microbial load (Casewell et al, 1981). Enteral feedings can be given intermittently, as bolus
feeds or continuously via a pump over longer periods. There are considerable variations in hang time
recommendations throughout the literature with few studies conducted in the paediatric setting.
Powdered Infant Formula (PIF) contaminated with harmful bacteria has been implicated as a source of illness
in infants. In recent years, the emergence of disease associated with the bacterium Enterobacter sakazakii in
PIF has necessitated a new risk assessment. Many in-patients will receive PIF while a large proportion of
patients will receive ready to feed formula and sterile pack feeds.
Open Enteral System: PIF, Other Reconstituted Powdered Feeds and Ready to Feed Liquid Formulae are
initially all decanted into a feeding reservoir and infused via giving sets into a feeding tube (e.g. nasogastric,
nasojejunal, gastrostomy). This is known as an open enteral system.
Closed Enteral System: Sterile Pre Filled Pack Feeds can be attached directly to a giving set and are ready
to administer. This system is referred to as a closed system.
Foodborne diseases can affect all age groups in the population, however the following groups have been
identified as higher risk groups based on international risk assessment (FAO/WHO, 2006):
Vulnerable group:
All infants <12months of age
Most Vulnerable Group:
All infants <2months of age and all immunocompromised children
irrespective of age.
It is imperative that guidelines are developed on enteral feed hang times to assist all staff involved with the
delivery of EN. The American Dietetic Association (ADA) recommend that a policy for hang time for formulas
and feeding sets must be established locally for each facility (ADA, 2003).
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3.0
COMPLICATIONS ASSOCIATED WITH ENTERAL FEEDING
•
•
4.0
Microbial Contamination of feed and giving set
Nosocomial Infections
EQUIPMENT
•
•
•
Reservoirs: Nutricia™ 0.5litre Flocare (Rigid) Container, 1litre Flocare (Rigid) containers, 1.3 Litre
Flocare Top Fill Reservoir. Will be referred to as feeding reservoirs throughout this document.
Enteral feeding: Nutricia™ Flocare Infinity Pack Giving Sets. Will be referred to as feeding giving set
throughout this document.
Syringes used for Reservoir Gravity Feeding and tubing
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5.0
PROCEDURE
See separate sections below for different types of feeds ( 5.1 – 5.6 inclusive)
ACTION
RATIONALE & REFERENCE
5.1
Powdered Infant Formulae
(PIF) and Reconstituted
Powdered Feeds
Rationale to prevent contamination of feeds with bacteria.
• PIF and Reconstituted Powdered Feeds are non sterile. This
means that the feed may occasionally contain pathogens that
can cause serious illness.
• Salmonella enterica and Enterobacter sakazakii are the two
organisms present in PIF with a demonstrated causality of
illness in infants and therefore of most concern (FAO/WHO,
2006).
• The temperature of the ward will also affect the temperature
of the feed. Bacteria will grow once feeds reach a
temperature above 4°C (Food Safety Authority of Ireland,
FSAI, 2007). It is therefore necessary to restrict the time that
the feed is in this temperature range.
• When feeds reach this temperature (>4°C) bacteria could
grow to sufficient numbers in the feed to cause illness and
increase the risk of nosocomial infections (FSAI, 2007).
• The feeding set is sterile at the start of feeding but after 2
hours fat and protein deposits will build up on the feeding
equipment. Bacteria that may be present in the feed could
adhere to these deposits and grow forming a sticky layer (bio
film) that can develop in time into growing communities of
bacteria. If fresh feed is then put into the previously used
equipment then the new feed will be contaminated with
bacteria. (Anderton 1995, FSAI 2007).
• It is worth noting that build up of these biofilms can be
extremely difficult to remove during cleaning if equipment is
reused. Consequently, it is safer to use clean and sterile
feeding equipment for each fresh feed (Anderton, 1999).
• Setting the maximum hang time at 4 hours is a compromise
between practicality and the time within which bacteria could
grow. The FSAI have recommended restricting hang times to
2 hours (FSAI, 2007). The consensus for inpatients has been
to restrict hang times for PIF (feeds and equipment) to 4
hours as changing feeds and sets any more frequently than
this would not be feasible economically or practically on the
units. This concurs with ICNA 2003 guidelines, Crest 2004
Guidelines, ASPEN 2009 and the American Dietetic
Association Guidelines.
PIF and powdered
feeds that are reconstituted
in the formula room must be
used within 4 hours of
removal from the fridge.
Most standard formulae and
specialised feeds are PIF.
Always check the label and
date on bottle before using.
The feeding giving set and
feeding reservoir must be
changed every 4 hours
when infusing PIF.
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ACTION
RATIONALE & REFERENCE
Rationale to prevent contamination of feeds with bacteria.
• Ready to Feed Liquid formula is subjected to a heat
process by the manufacturer that is sufficient to kill E
sakazakii and any other bacteria that can be harmful
(FSAI, 2007).
Ready to Feed Liquid Formulae must
• When these feeds are decanted from their containers,
be used within 4 hours of removal
their sterility is decreased and therefore they become
from fridge. Always check the label
non-sterile (Anderton, 1995).
and expiry date on bottle before using.
• These feeds will equilibrate with ambient temperature
The feeding giving set and feeding
which can increase bacterial growth leading to gastroreservoir must be changed every 4
intestinal illness in the child. Therefore a maximum
hours when infusing Ready to Feed
hang time of 4 hours has been set for feeds, giving
Liquid Formulae.
sets and feeding containers (Patchell 1998, Handbook
of Paediatric Nutrition, Anderton 1995).
5. 2
Ready to Feed Liquid Formula
(decanted from a bottle or tetra
pack)
Rationale to prevent contamination of feeds with bacteria.
• To prevent colonisation of EBM with bacteria that
could cause gastro-intestinal illness of the child
EBM must be used within 4 hours of
(Balmer et al, 2001).
removal from the fridge. Always check
• Expressed Breast Milk left at room temperature can
the name on the EBM bottle and dates
be forgotten and the temperature rises above 4ºC
on label before using.
increasing the risk of bacterial growth (Guidelines for
The feeding giving set and feeding
Nursing Staff on Breastfeeding in OLCHC, 2006; UK
reservoir must be changed every 4
Association of Milk Banking 2001).
hours when infusing EBM.
• Therefore a maximum hang time of 4 hours has been
set for EBM feeds, giving sets and feeding containers
(American Dietetic Association, BDA Paediatric
Group, ASPEN 2009)
5.3
Expressed Breast Milk (EBM)
Rationale to prevent contamination of feeds with bacteria.
• Reservoir feeds via syringe are often used for
premature and low birth weight infants. This group has
been classified as the most vulnerable group
PIF, EBM or Ready to Feed Liquid
• Feed residues may remain on the syringe and provide
Formulae are often infused as gravity
a medium for bacterial growth.
infused boluses via syringe.
• These syringes are for single use only and therefore
The syringe/reservoir must be
should not be re-used (Anderton, 1999).
changed after each feed (Anderton
1999).
Rationale to prevent contamination of feeds with bacteria.
5.5
Jejunal feeds.
• When a patient is fed directly into the small intestine
PIF, EBM or Ready to Feed Liquid
they are at greater risk of developing infection as the
Formulae are occasionally fed via the
defence mechanism of the acidic stomach has been
jejunal route.
by passed (Courtney-Moore, 1985).
Jejunal feeds, giving sets and
• Therefore a maximum hang time of 4 hours has been
reservoirs must be changed every 4
set for jejunal feeds, giving sets and feeding
hours (Courtney-Moore M, 1985)
containers if using an open feeding system.
when using an Open Enteral System.
• Feeds can hang for extended periods when a Closed
Enteral System i.e. when using Sterile Pre Filled Pack
feeds (see below).
5.4
Gravity infused Feeds (via
syringe/reservoir)
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ACTION
5.6
Closed System: Sterile Pre Filled
Pack Feeds
Pre Filled Pack Feeds may be hung for
a maximum period of 24 hours if a child
is being fed continuously.
RATIONALE & REFERENCE
Rationale to prevent contamination of feeds with bacteria.
• Sterile Pre Filled Pack (Ready to feed) Feeds such
as Infatrini™, Nutrini™ and Nutrison™ have been
subjected to a heat process by the manufacturer
sufficient to kill bacteria that could cause gastrointestinal illnesses (FSAI, 2007).
• Closed Feeding Systems have lower levels of
contamination than open delivery systems. Sterile
feed
containers
remain
free
of
bacterial
contamination in closed systems for at least 24
hours. (Beattie 1996, Patchell et al 1998).
For Bolus Feeds using the pack
system.
• Always use the Infinity Pack
giving set with the drip
chamber (i.e. not the mobile
giving set). This is the giving set
used in OLCHC.
• Always leave the giving set
connected to the pack between
bolus feeds.
• Packs can be left hanging
between feeds
• Use a new giving set every time
the pack is changed.
• Minimize the number of
disconnections (i.e.
disconnection of the giving set
from the NG/PEG tube).
• When disconnecting the giving
set from the feeding tube (i.e.
NG/PEG) use non touch
aseptic technique. Replace
clear cap on the purple end of
the giving set between feeds.
Do not discard purple tip or
clear cap when setting up
feeds.
• To be conservative, before
reconnecting the giving set to
the NG/PEG tube for the next
bolus feed, press the “fill set”
button on the Infinity pump to
flush out the 10-15mls of feed in
the tube and refill with new feed
from the pack.
•
The feed or feeding set could become contaminated
with bacteria when the feeding system is interrupted
(Anderton, 1995).
•
The drip chamber prevents retrograde contamination
of the feed from the feeding tube (ASPEN 2009
Payne-James JJ).
•
There is no need to keep the pack and giving set
refrigerated between feeds as there is no evidence
to support this.
•
This will flush out possible contaminants in the distal
end of the giving set (Moffitt et al. 1997).
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6.0
POINTS TO NOTE
Additional Points to Note:
•
•
•
•
Hands must be thoroughly decontaminated prior to administering feeds.
Alcohol wipes should be used to clean the top of bottles/cans before decanting (ICNA 2003).
Avoid unnecessary handling of parts or connections as this increases the risk of introducing
bacteria into the system (ICNA 2003).
Ideally feeds should not be interrupted however if this is necessary use a non touch aseptic
technique when disconnecting and reconnecting (ICNA 2003).
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7.0
SUMMARY: GUIDELINES ON THE HANG TIME OF ENTERAL FEEDS &
PLASTICS FOR INPATIENTS
Feeds and plastics should always be handled using a non touch aseptic technique.
Always check the label and date on bottle or pack before using.
System
Max Hang
Time of
Giving Set
Pack/
Reservoir
24hours
Max Hang
Time of
Feed
Comment
24hours
Powdered infant
Formulae and other
Reconstituted
Powdered Feeds
Ready to feed infant
Formula (e.g. SMA HE /
Infatrini )
4 hours
4 hours
Pack feeds and Closed Systems
Sterile Pre Filled Pack feeds may be hung for a maximum period
of 24 hours if child is being fed continuously (ASPEN 2009).
For Bolus Feeds using the pack system.
•
Always use the Infinity Pack giving set with the drip chamber
(i.e. not the mobile giving set). The drip chamber prevents
retrograde contamination of the feed from the feeding tube
(ASPEN 2009). This is the giving set used In OLCHC.
•
Always leave the giving set connected to the pack between
bolus feeds.
•
Packs can be left hanging between feeds (i.e. there is no
need to keep the pack and giving set refrigerated between
feeds as there is no evidence to support this).
•
Use a new giving set every time the pack is changed.
•
Try to minimize the number of disconnections
•
When disconnecting the giving set from the feeding tube (i.e.
NG/PEG) use non touch aseptic technique.
•
Replace clear cap on the purple end of the giving set between
feeds. Do not discard purple tip or clear cap when setting up
feeds
•
To be conservative, before reconnecting the giving set to the
NG/PEG tube for the next bolus feed, press the “fill set”
button on the Infinity pump to flush out the 10-15mls of feed in
the tube and refill with new feed from the pack.
These feeds are non-sterile.
4 hours
4 hours
When these feeds are decanted their sterility is decreased and
therefore they become non-sterile.
Expressed Breast Milk
4 hours
4 hours
Always check the name on the EBM bottle and dates on label
before using.
Change
with each
feed.
Gravity
Infusion
Change with every feed irrespective of feed type.
4 hours
4 hours
24 hours
for Closed
Enteral
Systems
24 hours
for Closed
Enteral
Systems
When a patient is fed directly into the small intestine there is a
greater risk of developing infection as the defence mechanism of
the acidic stomach has been bypassed (Courtney-Moore, 1985).
Therefore decanted feeds and plastics should only hang for 4
hours. Sterile Pre Filled Pack feeds may be hung for a maximum
period of 24 hours if child is being fed continuously (no
disconnection of system) via jejunal route.
Sterile Pre Filled Pack
Feeds or Closed
Systems
(e.g. Infatrini™,
Nutrini™ and Nutrison
™ range of feeds)
Bolus Syringe Feeds
that remain on
Reservoir
Feeds infused via
jejunal route (naso
jejunal, jejunostomy or
gastrojejunal).
References
•
ICNA (2003) Enteral Feeding Infection Control Guidelines, Infection Control Nurses Association.
•
Crest 2004. Guidelines for the Management of Enteral Tube Feeding in Adults, Clinical Resource Efficient Support Team.
•
Anderton A. Micobial Contamination Of Tube feeds. How can we reduce the risk? Pennines 2000;16 3-8
•
American Dietetic Association. Infant Feedings: Guidelines for Preparation of Formula and Breastmilk in Health Care Facilities, 2004.
•
Aspen. 2009. Enteral Nutrition Practice Recommendations. JPEN. Special Report 1-46
•
OLCHC Breastfeeding Policy guidelines from UK Association for Milk Banking 2001.
•
Courtney-Moore M (1985) Tube feeding of infants and children. Paediatric Clinics of North America 32(2): 401-405.
Page 9 of 11
Department of Clinical Nutrition and Dietetics. Guidelines. March 2011
Department of Clinical Nutrition and Dietetics
Tel: 01 4096809
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8.0
•
REFERENCES
American Dietetic Association (2003) Infant Feedings: Guidelines for Preparation of Formula
and Breastmilk in Health Care Facilities. Paediatric Nutrition Practice Group of the American
Dietetic Association. Available from http://www.eatright.org (Accessed 27th May 2007).
•
Anderson A. (1993) Bacterial contamination of enteral feeds and feeding systems. Clinical
Nutrition 12, 16 –32 (suppl).
•
Anderton A. (1995) Reducing bacterial contamination in enteral tube feeds. British Journal of
Nursing 4 (7), 368-376.
•
Anderton A (1999) Microbial contamination of enteral feeds. How can we reduce the risk?
Birmingham, The Parenteral and Enteral Nutrition Group of the British Dietetic Association.
•
Anderton A. (2000) Microbial contamination of tube feeds. How can we reduce the risk?
Pennines 16 3-8.
•
Aspen. 2009. Enteral Nutrition Practice Recommendations. JPEN. Special Report 1-46
•
Balmer, S. E. et al (2001) Guidelines for the collection and handling of mothers’ breast milk
to be fed to her own baby on a neonatal unit. 2nd Ed. London, United Kingdom Association
for Milk Banking.
•
Casewell M.W., Cooper J.E., Webster M. (1981) Enteral feeds contaminated with
Enterobacter cloacae as a cause of septicaemia [case study]. British Medical Journal 282
973 .
•
Crest (2004) Guidelines for the Management of Enteral Tube Feeding in Adults, Clinical
Resource Efficient Support Team.
•
Courtney-Moore M (1985) Tube feeding of infants and children. Paediatric Clinics of North
America 32(2), 401-405.
•
Curtas S, Forbes B, Meguid V, Meguid M. M.(1991) Bacteriological safety of a closed
enteral nutrition delivery system. Nutrition. 7, 340 –343.
•
De Oliveira Iglesias, S. B., Pons Leite, H., Santana e Meneses, J. F. and de Carvalho, W. B.
(2007) Enteral Nutrition in Critically Ill Children: Are Prescription and Delivery According to
Their Energy Requirements? Nutrition in Clinical Practice 22 233-239.
•
FAO/WHO (2006) Enterobacter sakazakii and Salmonella in powdered infant formula.
Microbiological Risk assessment series 10.
www.fao.org/ag/agn/jemra/e_sakakazii_salmonella.pdf.
•
Food Safety Authority of Ireland (2007) Guidance Note No. 22 Information Relevant to the
Development of Guidance Material for the Safe Feeding of Reconstituted Powered Infant
Formula. www.fsai.ie (Accessed May 10th 2007).
•
Grant, M. J. C. (2001) Host Defences. In Critical Care Nursing of Infants and Children, 2nd
edn. (Curley, M.A. Q. and Moloney- Harmon, P. A. Eds), W. B. Saunders, London, 461-509.
Page 10 of 11
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Department of Clinical Nutrition and Dietetics
Tel: 01 4096809
Fax: (01) 4096146 E-mail: [email protected]
REFERENCES contd./
•
Himelright I, Harris E, Lorch V, et al. (2002) Enterobacter sakazakii infections associated
with the use of powdered infant formula: Tennessee, 2001. Morbidity and Mortality Weekly
Report. 51 297 –300.
•
Infection Control Nurses Association (2003) Enteral Feeding Infection Control Guidelines.
•
Jacobs S, Chang RW, Lee B, Bartlett FW (1990) Continuous enteral feeding: a major cause
of pneumonia among ventilated intensive care unit patients. Journal Parenteral Enteral
Nutrition.14 353 –356.
•
Lai KK. (2001) Enterobacter sakazakii infection among neonates, infants, children, and
adults: case reports and a review of the literature. Medicine 80 113--22.
•
Levy J, Van Laethem Y, Verhaegen G, Perpete C, Butzler JP, Wenzel RP. (1989)
Contaminated enteral nutrition solutions as a cause of nosocomial bloodstream infection: a
study using plasmid fingerprinting. Journal Parenteral and Enteral Nutrition 13 228 –234
•
Navajas MR-C, Chacon DJ, Solvas JFG, Vargas R.G. (1992) Bacterial contamination of
enteral feeds as a possible risk of nosocomial infection. Journal of Hospital Infection 21 111
–120.
•
Okuma T, Nakamura M, Totake H, Fukunaga Y. (2000) Microbial contamination of enteral
feeding formulas and diarrhoea. Nutrition 16 719 –722.
•
Patchell J, Anderton A, Holden C, MacDonald A, George RH, and Booth IW.
Reducing bacterial contamination of enteral feeds
Arch. Dis. Child., February 1, 1998; 78(2): 166 – 168
•
Payne-James JJ, Rana SK, Bray MJ, McSwiggan DA, Silk DB. Retrograde (Ascending)
Bacterial Contamination of Enteral Diet Systems. Journal of Parenteral and Enteral Nutrition,
Vol. 16, No. 4, 369-373 (1992)
•
Rupp M.E., Weseman R. A., Marion N., Iwen P.C. (1999) Evaluation of bacterial
contamination of a sterile, non-air-dependent enteral feeding system in
immunocompromised patients. Nutrition in Clinical Practice 14 135 –137.
•
Queen Samour. Patricia, Kathy King Helm - 2005 -Handbook of Pediatric Nutrition, Third
Edition Medical
•
Gerdts A, Maki M, Johnson J. (1990) Enteral hyper alimentation as a source of nosocomial
infection. Journal of Hospital Infection 15 203 –217.
•
Vaughan L.A., Manore M., Winston D.H. (1988) Bacterial safety of a closed-administration
system for enteral nutrition solutions. Journal of American Dietetic Association 88: 35 –37.
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