Raising the Head of the Bed With Peg Tube Feedings

Ways to give tube feedings

There are 3 ways to give tube feedings to your child:

• Bolus feeding – Bolus feedings give large doses of formula several times a day. The formula is poured slowly into at least a 35 ml catheter tip syringe attached to your child's feeding tube or button.
• Continuous feeding – Continuous feedings use a pump to slowly drip small amounts of formula through the feeding tube over several hours. Your child's dietitian will decide how long the feeding should last.
• Gravity feeding – Gravity feedings use a feeding bag that hangs from an IV pole. The feeding bag is set to drip an ordered amount of formula into the stomach by gravity several times a day.

The dietitian and St. Jude team will decide on the best formula for your child's nutritional needs. The dietitian will also choose the best way to give your child tube feedings. St. Jude patients usually do best with continuous feedings.

Tips for giving tube feedings

Make sure your child is sitting up. He can be in your arms, a high chair, or in bed with the head of the bed raised 30–45 degrees. Ask the dietitian or clinical nurse specialist to show you how far to raise the head of the bed.

If your child fusses or cries during a bolus feeding, pinch the tube with your fingers or lower the syringe to slow or stop the feeding until your child is calmer and quieter. Feedings often will not infuse while your child is fussing or crying.

Preparing formula

Most formula comes ready to feed. It is in a can that you open and pour directly into a measuring container or a formula bag that goes with your child's feeding tube. Some formula comes in a powder or liquid concentrate you mix with water. Your child's dietitian will tell you how to mix it, if needed.

Formula that has been opened or mixed can be stored in the refrigerator for 24 hours. Throw away any unused formula after 24 hours.

How to give bolus feedings

Your child needs ______ ml of ____________ every ______ hours.

The formula should be at room temperature. If you keep it in the refrigerator, take it out about one (1) hour before feeding time. Pour enough formula for one (1) feeding into a clean container. Cover it and let it warm up to room temperature on the counter. Put any extra formula back in the refrigerator. Throw out any canned or mixed formula that has been open more than 24 hours.

Supplies for bolus feedings

Gather supplies in a clean work area.

• Enough formula for one (1) feeding, warmed to room temperature
  
• Water ______ ml
• _____ml syringe (at least a 35 ml syringe)
• Feeding adapter tube (only if your child has a button)

Putting in the feeding adapter (if your child has a button)

• Wash your hands with soap and water. Dry them well. See "Do You Know… Clean Hands."
• Fill the adapter with water and clamp.
• Pull the cover back from the button.
• Insert the tip of the adapter into the small hole in the middle of the button. Make sure the lines on the adapter line up with the lines on the button.
• Gently push in the adapter as far as it will go and twist to lock. It might be tight and hard to push in the first time. Putting the adapter in the first time will probably be uncomfortable for your child, but it should not hurt after the skin has healed completely.

Giving the bolus feeding

• Make sure your child's head is higher than his stomach. You can hold a small child on your lap or have him sit in a high chair. If your child is older, have him sit in a chair or high chair or raise the head of his bed 30–45 degrees. You can put pillows behind your child's head to help him sit up in bed.
• Take the plunger out of the syringe. Take the plug out of the opening of the feeding tube or adapter tube. Attach the tip of the syringe to the tube.
• Hold the syringe upright (tip facing down) and slightly above your child's stomach. Unclamp the feeding tube or adapter.
• Put ____ ml of water into the syringe.

Add water

Add formula

Add water

Clamp the tube

• Slowly pour ______ml of formula into the syringe. Let it drain into the tube by itself (by gravity). Never use the plunger of the syringe to force the formula into the tube. You can make the formula go in faster or slower by raising or lowering the syringe. The higher above your child's stomach you hold the syringe, the faster the formula will go into your child's stomach. If the formula will not go in, you may put gentle pressure on the formula with the syringe plunger.
• Do not let the syringe get completely empty during the feeding. Air can get into your child's stomach through an empty syringe. This can puff up your child's stomach and cause discomfort.
• When all the formula has gone in, put _____ ml of water in the syringe to rinse the feeding tube or adapter tube. Clamp or plug the tube after the water has gone through.
• Disconnect the syringe from the tubing.
• Remove the adapter tubing, if needed.
• Wash your hands again with soap and water.
• Keep your child's head higher than his stomach for one (1) hour after the feeding.
• Watch your child for any signs of pain, nausea, or vomiting during the feeding and right afterward. If any of these things happen, stop the feeding and call your St. Jude team. Wash the syringe (and adapter, if you used one) with warm water and dishwashing soap. Rinse them and let them air dry between feedings. You may use the syringe and adapter for up to 2 weeks. Throw them out earlier if you cannot get them completely clean.

How to give continuous feedings

Your child needs ______ml of ______________ for ____ hours each day between the hours of ____________ and ____________.

Supplies for continuous feedings

• Gather supplies in a clean work area.
• Enough formula for the feeding, in a feeding container with tubing
• Feeding adapter tube (only if your child has a button)
• Feeding pump
• Water ____ml
• _____ ml syringe (at least a 35 ml syringe)

Putting in the feeding adapter (if your child has a button)

• Wash your hands with soap and water. Dry them well. See "Do You Know … Clean Hands."
• Pull the cover back from the button.
• Insert the tip of the adapter into the small hole in the middle of the button. Make sure the lines on the adapter line up with the lines on the button.
• Gently push in the adapter as far as it will go and twist to lock. It might be tight and hard to get in the first time. Putting the adapter in the first time will probably be uncomfortable for your child, but it should not hurt after the skin has healed completely.

Giving the continuous feeding

Flush with water

• Make sure your child's head is higher than his stomach. You can hold a small child on your lap or have him sit in a high chair. If your child is older, have him sit in a chair or high chair or raise the head of his bed 30–45 degrees. You can put pillows behind your child's head to help him sit up in bed.
• Take the plug out of the feeding tube or adapter. Connect the feeding tube or adapter to the syringe and flush it with ____ ml of water.
• Connect the feeding tube or adapter to the pump tubing.

• To work the pump, read the instructions for your pump and start the pump. It is a good idea to read the pump instructions before you need to give the first feeding. Ask your dietitian or another member of the St. Jude team if you have questions about how to work the pump. Make sure the pump is set for the correct rate per hour. Change the pump settings if needed.
• Watch your child for signs of nausea, vomiting, stomach swelling, or irritability (being cranky or fussy). These signs might mean your child cannot digest the formula at the rate it is going in. If this happens, stop the feeding and call your child's doctor right away.

How to change the formula bags and tubing

Change the pump tubing and feeding container (bag or bottle) at least every 12 hours unless the staff tells you something different. For your child, change the tubing and container every ______ hours.

To change the tubing and container, follow these steps:

• Gather supplies in a clean work area.
  
  •  ______ml of formula (_________________)
  • Formula bag with tubing
  • Water ___ ml
  • _____ ml syringe (at least a 35 ml syringe)
  • Feeding pump

• Wash your hands with soap and water. See "Do You Know … Clean Hands."
• Open the formula bag and tubing package. Close the clamp on the tubing.
• Pour the formula into the new container. Open the clamp and prime the tubing.
• Put the container in place and connect the tubing to the pump. Follow the specific instructions for your pump when you do this.
• When you are ready to connect the pump tubing to the feeding tube or adapter, take off any old tubing. Throw away the old formula bag and tubing. Save the adapter tube for the button.
• Attach your syringe to the feeding tube or adapter and flush with ______ml of water to flush the feeding tube clean.
• Connect the new pump tubing to the feeding tube or adapter tube. Open the clamp and start the feeding.
• Wash your hands again.
• While your child is receiving continuous feedings, you must flush the feeding tube or button adapter tube with water every 4–6 hours. This helps keep the tube from clogging.

Helpful Note

The dietitian will decide how much water your child needs each day. Use this amount of water to flush the tube as needed during the day. Your child might need more or less water on certain days depending on his condition and environment.

How to vent or burp the tube

Your child's belly might sometimes get hard or swollen during or after a feeding. Venting or burping the tube or button might help. To vent or burp the tube:

• Stop the feeding, if this happens during a feeding. Disconnect the feeding bag tubing from the feeding tube.
• Attach a 60 ml syringe with the plunger removed to the feeding tube. If your child has a button, attach a primed extension set before attaching the syringe.

• Pour some water into the syringe. Hold the syringe lower than your child's belly and unclamp the tube or extension set to let air flow out. If air comes out of the belly, it will make the water in the syringe bubble.
• After the air comes out, let the formula and stomach contents that came out go slowly back into the stomach.
• Clamp the feeding tube again or take off the button extension set. Restart feedings if your child is on continuous feedings.

Your child might need to have the tube vented or burped several times a day.

Gastroesophageal reflux

Food and acid sometimes flow from the stomach back into the esophagus (the tube between the throat and stomach). This is called gastroesophageal reflux, acid reflux, or just reflux. It happens to some children more than others.

Reflux can cause health problems for your child, such as:

• Gagging or vomiting,
  
• Stomach pain or burning,
• Pain or nausea when your child lies down,
• Colds, bronchitis, or other infections, and
• Trouble gaining weight.

When a child has a feeding tube, the gastric port is sometimes opened and attached to a drain bag. This lets stomach contents flow out the tube instead of back into the esophagus.

If your child has severe reflux, a surgery may be needed. If your child needs this surgery, your St. Jude team will give you more information.

Getting supplies from an infusion company

St. Jude patients get tube feeding supplies and formula from an infusion company. There are several different infusion companies. Your child's clinical nurse specialist will decide which company will give you the supplies while you are in Memphis and, if needed, when you go home. The infusion company will send a nurse to talk with you about how to work the feeding pump and the services the company offers. After you have met with the infusion company nurse, you will have the company's contact information. When you need more supplies, please call the infusion company directly, and they will deliver the supplies to you.

Your infusion company is: _______________________________________________________________

Phone number ________________________________________

Questions?

To learn more about tube feedings, venting, and reflux, please talk to your child's clinical nurse specialist.

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Source: https://www.stjude.org/treatment/patient-resources/caregiver-resources/patient-family-education-sheets/feeding-tube-information/feedings-venting-and-reflux.html