Your child requires a nasojejunal tube

Introduction

A nasojejunal (NJ) tube can be used when a person cannot tolerate food or drink in their stomach. It allows feed, fluid and some medication to be given directly into the small bowel.

Nasojejunal feeding is advised for patients who have a functioning small bowel, but who have an absent gag reflex, delayed stomach emptying or persistent vomiting.

What is a NJ tube?

A NJ tube is a thin plastic tube that is passed through the nostrils, down the back of the throat, and is then passed through the stomach into part of the small bowel called the jejunum.

Advantages

• No need for surgical placement.
• Can be removed easily without requiring anaesthetic.
• Provides your child with adequate nutrition.
• Reduces the anxiety of having to ensure that your child is able to take enough calories, fluids and also his/her medication.
• Greatly reduces vomiting of feed, as the tube is in the jejunum.
• May help reduce the length of time on parenteral nutrition or prevent having parenteral nutrition.

Disadvantages

• Not cosmetically pleasing.
• Can become dislodged through coughing, sneezing, retching and vomiting.
• Requires changing every ………… weeks.
• NJ tubes are more difficult to place than a nasogastric tube and will require an x-ray to confirm placement. This process can be time consuming.
• Those NJ tubes that are not able to be placed at the bedside may be placed either using x-ray (as it enables the radiologist to see the tube as it progresses through the bowel) or in endoscopy using a small flexible camera in to the small bowel to aid placement. Endoscopic placement requires a general anaesthetic.
• All feeds need to be given slowly and continuously via a feeding pump. This could mean being attached to a feeding pump up to 24 hours per day.

Passing a NJ tube

The NJ tube will be passed by either a member of the ward nursing staff or a nurse from the Paediatric Gastroenterology, Hepatology and Nutrition team.

Inserting the tube does not hurt, but it may be uncomfortable for a short while. It may make your child sneeze, cough, retch or make their eyes water.

Your child will be asked not to eat, drink, have enteral feed or take any medications for two hours prior to the tube placement to ensure that their stomach is empty to reduce the risk of vomiting.

If your child is unable to tolerate placement of the NJ at the bedside, sedation may be offered to assist this. In using sedation, the length of time that your child will not be able to eat for or have enteral nutrition for will be 6 hours prior to the sedation and 2 hours prior for drinking. One type of oral sedation used is called Chloral Hydrate which is given one hour prior to a procedure and comes in both oral liquid and suppository form. The nurses will discuss with you on the day, the best form of administration of this drug.

The procedure will be explained to you and your child by the nurse passing the tube. The hospital play specialist can help to prepare your child.

The nurse placing the tube and any staff supporting the placement will be required to wear appropriate Personal Protective Equipment for the procedure as your child may cough or sneeze during the procedure.

The length that the tube needs to be passed to will be measured in centimetres (cm) against your child before starting. The measurement is taken from the nose, to the ear, to the stomach and 15-25cm added to this in relation to the size of your child.

You or your child will be given the choice of nostril in which the tube is placed. The tube will be passed to the stomach and the contents (aspirate) will be tested for acidity on PH strips.

Once confirmed, your child will then be asked to lay on their right side with the head of the bed raised at 15-30 degrees.

The tube is slowly pushed and rotated down the nostril until it reaches the measured jejunal tube length. This may take up to 30 minutes. If it is felt that the tube is not making progress, it may be pulled back to the stomach and then slowly pushed and rotated down again.

The position of the tube will be confirmed through checking the aspirate obtained from the bowel (jejunum) using pH strips, which will be between 6-8, and then by taking an abdominal x-ray. In most cases the guide wire will be removed before x-ray but occasionally it will remain in situ until placement confirmed. The tube will be secured for x-ray.

The nurse will secure it to your child’s cheek using two different types of tape. Duoderm tape, under the tube to protect the skin and Tegaderm or Mefix tape over the tube to keep it secure.

Hand hygiene

Hand hygiene is important before and after checking the NJ tube. Jejunal feeding means the acid in the stomach does not provide a barrier against infection. Therefore strict hygiene is necessary to prevent any infection. Please follow the six stage hand washing technique below.

Testing the NJ tube

Check markings at the nose to ensure the tube has not moved. It is important to check the position of the NJ tube before administering any feed, medication or water flush and after vomiting, sneezing, retching or coughing. Aspirate from jejunal tubes should be small and have a pH of between 6 and 8 – aspirate to be attempted at least once a day. Larger than usual aspirates and pH of less than 6 may mean the tube has moved back into the stomach.

Equipment needed

• 20ml ENFit enteral purple syringe
• PH strips
• Feed
• Cooled, boiled water to flush
• Medication drawn up into syringes (if giving)

Most equipment is designed for ‘single use’ only and should be discarded after use.

Items displaying this symbol are for ‘single use’ only.

Before using any equipment it is important to check the packaging for any signs of damage and expiry dates. The expiry date will be indicated next to or below this symbol below.

Instructions:

1. Wash hands.
2. Check the measurement of the tube at the nostril for any sign of tube displacement.
3. Remove cap from NJ tube.
4. Attach a 20ml ENFit purple enteral syringe and draw back to obtain fluid (this is called aspirating).
5. Place 2-3 drops of the aspirate onto the pH strip; allow any excess aspirate on the strip to run onto a paper towel.
6. Within 10 – 60 seconds match the colour of the strip with the colour code on the pack to identify the pH.
7. Jejunal tubes should have a pH value of 6 – 8.
8. Do not feed if pH strip reads less than 6. Seek advice.

What do you do if there is no aspirate?

• Check the tube position at the nostril to see if it has moved since it was placed/ last checked.
• Commence feeds unless symptomatic e.g. vomiting.

What to do if there is a large aspirate

• If the aspirate is larger than usual and looks as though it contains feed check the pH using a pH strip. If the pH is 1 – 5.5 the tube may have moved back into the stomach.
• X-ray is required to check the tubes positioning.
• Contact your local Children’s ward or the Paediatric Nutrition Nursing Team.

Flushing

The tube can easily become blocked so requires frequent flushing with cooled, boiled water every six hours if not in use.

The tube should also be flushed:

• Before and after each feed.
• Before and after each medication and between each medication if more than one medication is given at the same time.
• When on a continuous feed every 12 hours or at the change of feed every 4 hours when a it is a feed made from powder
• At least once a day to ensure patency

General care

Look at the nostril and check:

• That the nasal passages are not red, sore, swollen or bloody.
• Check the NJ tube for any signs of deterioration, for example cracks, changes in colour or stiffness when flushing.
• It is important to ensure the NJ tube is securely fixed with tape to preventthe tube coming out.
• Observe the skin around the tapes for any signs of irritation/ reaction to the tape and that the tube is not causing any pressure.
• Ensure the nostril and tube are kept clean – carefully wash the area daily with soap and water.
• Change NJ tape when it becomes soiled or loose. Do not add more layers to loose tape. Assistance from your Children’s Community Nurse may be required.
• Mouth care is very important if your child is not eating. Plaque can build up quickly so it is important to brush teeth at least twice daily. Look into the mouth and throat for dryness, redness or any other abnormalities.
• Eating increases the production of saliva and saliva helps keep the mouth clean.
• While the NJ tube is not in use the end should be closed with the cap which is attached to the tube. This reduces the risk of infection.

What to do if the tube gets blocked?

1. Prevention is always best.
2. After each feed or medication it is important to immediately flush the NJ tube with cooled boiled water to prevent the tube from blocking.
3. If debris is noticeable in the NJ tube, try massaging the NJ tube between your fingers to dislodge any debris.
4. If the blockage does not clear try irrigating the NJ tube. Draw up some warm water into a 20ml syringe and use a push pull technique to move the water in and out of the syringe to try to dislodge the debris.
5. If this fails to remove the blockage, make up a solution of sodium bicarbonate. Mix half a teaspoon of sodium bicarbonate with 30ml of boiling water. Leave this to cool to a warm temperature then use a syringe to flush this solution down. 2‑3 ml of this solution will be sufficient for most long term feeding tubes. Leave the solution for at least two hours then flush with 20ml water.
6. If these actions fail to unblock the tube, never use excessive force or attempt to insert objects (such as wire) down the tube to unblock it.
7. Consider the reason for the blockage. Take action to avoid further problems, for example, discuss alternative medications/ route with the ward or community pharmacist.
8. To reduce risk of tube blockage, regularly massage the tube between fingers to help cleanse build-up of feed on the inside of the tube; always flush well immediately after feed and medications. Avoid giving crushed tablets where possible.

Medication

• If your child is already on any medications, the pharmacist will have checked that it is ok to administer these down a NJ tube.
• Thereafter if your child is prescribed medications it is important to remind your Doctor and Pharmacist that your child uses a NJ tube and that the medication needs to be the right preparation for this route.
• To avoid blocking feeding tubes, thick liquids should be diluted with equal amounts of water before administering.
• Please check that if you are dispersing tablets that these can be crushed or dissolved in water before administering and that the medication is completely dissolved to prevent blocking of the tube. Tablets that are enteric coated or state that they are sustained, prolonged or modified release must not be crushed.
• Do not mix medications together.

How will my child feed using the NJ tube?

The dietitian will discuss with you a feeding regime most appropriate to your child. Your child will have a prescribed liquid diet which contains all or most of the nutrients he or she needs. Please speak to your dietitian if you require further information concerning the feed.

Your child’s feed will need to be given via a feed pump continuously because they are being fed into their jejunum (tube like structure) not their stomach (bag like structure). Feed must be given slowly because if the feed goes in too quickly your child may suffer from diarrhoea and vomiting. It may also cause increased pressure resulting in feed flowing back into the stomach.

The pump contains a rechargeable battery pack, so can be put into a backpack when your child is out and about.

The Nurses on the ward will start to teach you how to look after the NJ tube.

Your child will also be referred to their local Children’s Community Nurse for support once discharged home.

Before you go home, you should feel safe and confident about all of the things on the NJ training checklist that you have been taught.

Frequently asked questions

Will my child be able to go swimming?

Swimming is possible but you should check with the swimming pool first. It is advisable that the NJ tube is coiled and secured to prevent it from being pulled. Ensure the cap is securely fixed to prevent water from entering the tube.

Are there any risks associated with having a NJ tube inserted?

Children with certain conditions may require a blood test to check their platelets before a NJ tube can be passed. There is a risk that when the tube is first inserted it may pass into the lungs or coil in the stomach. Therefore it is important to ensure the tube is in the jejunum before a feed is given.

How long will my child need a NJ tube for?

Your dietitian will provide a plan and follow-up will be arranged. This appointment may be with the dietitians at Addenbrooke’s or at your local hospital.

Can my child go to school with a NJ tube?

There is no reason why a child cannot go to school with a NJ tube in place.

How long can a NJ tube stay in place before it requires changing?

This will be confirmed before discharge. Where possible a long term feeding tube would be the tube of choice for inserting nasojejunally.

If you have any other questions or concerns about the NJ tube please contact the paediatric nutrition nursing team via the contact number below.

My child’s nasojejunal tube

……………………………… had a size ………..nasojejunal tube inserted into the ……………….. nostril on …………………

The NJ tube is at …………cm at the nares

This type of tube needs replacing every ………….. weeks.

Contacts/ Further information

Paediatric Nutrition Nursing Team (Addenbrooke’s) Monday to Friday 09:00 – 15:00 Telephone: 01223 274826

Your children’s community nursing team is ………………………………on ……………….

Your home delivery company is …………………………………………. on ………………..

Your local dietitian is ………………………………….……… on ……………………………

Addenbrooke’s dietitians: 01223 216655