Delivering Full Human Milk Nutrition in the NICU (Part 1 of 2)
Are you starting to wonder how in the world you are going to keep the new ENFit connector clean?
What heroic measures are you going to have to take to keep this new hub from experiencing milk build-up?
I have heard the buzz of voices from neonatal nurses across the country talking about, and thinking through, this very valid concern of “keeping the hub clean” of the new male enteral feeding hub.
If you are one of those neonatal nurses that start your shift cleaning everything at your patient’s bedside, including outside, inside, and every piece of equipment that touches your patient, I completely understand why you would be alarmed. DO NOT let this hub change keep you up at night. There is a solution! In fact, there are three.
But first, a little back story:
Recent changes in ISO Standards for safe enteral connections (small bore connectors) require the reversal of the male and female ends for safe enteral nutrition delivery. One of these connectors is referred to as the ENFit connector (created by the Global Enteral Device Supplier Association, or GEDSA for short).
This connector change can be a safer option for the delivery of enteral nutrition because it will prohibit connectivity with any other clinical-use connector.
Unfortunately, it has also created an opportunity for milk to build up in the threads of the hub. The reversal of the connector requires the locking device to have the male connector on the feeding tube. The male connector, compared to what was previously a female connector, has a deeper well with threads that may trap and hold milk.
In other words, when milk overflows into the connector hub, and stays there, it can build up and require cleaning. To complicate this further, the feeding tube remains in use (with the patient) longer than any of the other enteral products, making milk residue build up an understandable concern. I have suggestions for you to mitigate this occurrence.
The solutions that I would like to point out are simple revisions to current practice, and will not cost any additional money.
Instead of adopting a whole new practice, these solutions will only require a small revision in how feeding tube and extension sets are handled when disconnecting or connecting them together, and will in fact reduce milk build up in the first place.
Use existing feeding tube cleaning practices
What are you currently doing to provide safe oral care related to cleaning? Does oral care in your unit include cleaning the connector of the feeding tube? If you are cleaning, then you are most likely using some application of sterile water. Whether it is with sterile water and gauze, or prepackaged sterile wipes, consider using these items to regularly clean the feeding tube hub.
Purge the line before disconnecting
If your practice is to use the feeding tube for more than one feed, a small revision can be made prior to disconnecting the extension set: purge the line. Meaning, purge the milk in the extension set tubing to the patient, clearing the connector of milk (at the end of the feed). This will require you to include the priming volume in the total feed volume. When the milk in the extension set is fed to the baby prior to disconnecting, milk overflow into the ENFit connector will be minimized.
We enlisted our product experts to complete internal tests for this theory. They found that if the extension set is purged at the end of the feed (emptied), and then disconnected, there would be less milk available to overflow into the threads and hub.
Figure 1 – Feeding tube hub disconnected before purging the line. Clearly, milk overflow collected very easily in the hub.
Figure 2 – Feeding tube disconnected after purging the line. There is less milk available to spill over, minimizing the overflow.
Following many repeated tests, it was also observed during the disconnection process (after purging the line) that milk was less likely to flow into the hub when the feeding tube was held with the connector hub facing down and the extension set connector pointed up. Any milk overflow collected into the female extension set connector well rather than the male feeding tube hub as disconnection occurred.
If this change is adopted, there is another huge benefit, especially with human milk feeds: this change will allow almost all milk to be delivered to the patient. This is significant for breast milk feeds, or if using donor breast milk, in order to reduce waste and increase all milk and nutrition to be delivered to the baby and not discarded with the extension set tubing.
When priming the extension set, stop before the connector
When starting with a new extension set (fresh out of the package), prime milk to the end and STOP immediately before reaching the connector. Stopping the milk from entering the connector will prevent overflow of milk getting into the feeding tube ENFit connector hub when you connect them.
In closing, I feel confident these solutions will help you reduce milk build up in your ENFit connectors. Instead of implementing a costly solution, consider these three ideas that may save you money and time. And, in addition, decrease milk waste for full human milk nutrition delivery.
Are you looking for more on the purging the line benefits ideas? Be sure to read part 2 of “Purging the Line: Delivering Full Human Milk Nutrition in the NICU,” to be posted next month!