ENFit® and blenderized tube feeding: Do they mix?

In 2006, The Joint Commission published a sentinel event alert regarding unintentional medical device misconnections (i.e., delivering medications, oxygen, or tube feeding/fluid to the wrong place). This sparked the development of new connectors that would physically prevent these dangerous misconnections. The ENFit® was the first new connector to be developed.^1,2 Because the ENFit® inner diameter is narrower than current enteral connectors, there is concern about whether blenderized tube feeding (BTF) formulas will pass through safely. Here’s what you need to know.

Testing ENFit® with blenderized tube feeding

Bolus tube feeding, regardless of type of formula or blended food, is typically administered in one of two ways: syringe pushes or gravity feeding. During product testing, ENFit® was compared to existing enteral connectors by studying both the force required for syringe pushes and the time required to deliver gravity feeding. Studies have been ongoing since 2014 with mixed results, which has only added to the concern and confusion. We sorted through it all.

• 2014: No significant difference. The Global Enteral Device Supplier Association (GEDSA) tested refrigerated commercially prepared BTF in order to reflect actual practices at home. They found minimal difference between the existing enteral connectors and ENFit® with regard to both the pressure required to deliver 60 mL of formula through a syringe and the time to deliver a gravity feed.³
• 2016: Size matters. GEDSA collected reports from outside users (not a clinical controlled trial) on both commercially prepared BTF and also homemade BTF using recipes from the Mayo Clinic and the Oley Foundation. As it turns out, the feeding tube French size might make a difference when gravity feeding with commercially prepared BTF. Fourteen French and 24 French tubes had slower rates with the ENFit® design compared to existing enteral connectors, but no difference in rate with the 18 French and 20 French tubes. For homemade BTF, researchers were not able to isolate the impact of the ENFit® given the multiple variables of home blended tube feeding (viscosity, technique, etc).⁴
• 2016: Thick and thin. An independent study compared the existing enteral connectors to the then-prototype ENFit® connector, looking specifically at the impact on two different commercially prepared BTF and a homemade BTF. Researchers found that while one commercial BTF required only slightly more force when administered through the ENFit®, other commercial BTF and the homemade BTF required significantly more force using the ENFit®.⁵It seems that the viscosity of BTF may be a significant factor when determining the ease of delivery with the new ENFit®.
• 2018: Speed of the feed. Using existing enteral connectors and ENFit®, researchers compared a “faster” syringe push (five seconds), a “longer” syringe push (60 seconds), and a gravity feed. Interestingly enough, the 5-second push required significantly more force through the ENFit® versus existing enteral connectors, however almost no difference in force was needed during the 60-second push. Gravity feeds took significantly longer through ENFit® systems using both thick and thin BTF.⁶

Can we use BTF with ENFit®?

While ENFit® has been designed to work with all current tube feeding regimens, research shows that the ENFit® does impact the delivery method of BTF. If your patients or clients are currently using BTF, it would be helpful to thin the recipe with added fluid and be prepared to add time to current gravity feeding regimens or mimic the 60-second syringe push so that additional force is not required. BTF is still possible with ENFit® tubes, but it may require additional adjustments to the feeding regimen.

It is important to note that the ENFit® developers recommend regular cleaning of the ENFit® with either a toothbrush or the manufactured brush designed for the system.² Due to the emphasis on safe food handling practices with BTF, it should be encouraged to clean the system often in order to prevent buildup and other foodborne bacteria.

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References

Nutritioncare.org. (2019). ASPEN | Reduce the Risk of Tubing Misconnections and Learn more about the New ENFit Connector. [online] Available at: http://www.nutritioncare.org/News/General_News/Reduce_the_Risk_of_Tubing_Misconnections_and_Learn_more_about_the_New_ENFit_Connector/ [Accessed 10 Jul. 2019].

StayConnected by GEDSA. (2019). SC Home Page – StayConnected by GEDSA. [online] Available at: http://stayconnected.org/[Accessed 19 Jul. 2019].

Guenter P, McMichael D. Further Updates on Blenderized Diet Use with the New Enteral Connectors. Oley Foundation. https://oley.org/page/UpdateBlenderDiet. Published July 2014. Accessed July 20, 2019.

Blenderized Tube Feeding ENFit® Connector Testing. Blenderized Tube Feeding ENFit® Connector Testing. http://stayconnected.org/wp-content/uploads/2017/02/Flow-Rates-Pressure-Testing-Fred-Reuning.pdf. Accessed July 20, 2019.

Mundi MS, Epp L, Hurt RT. Increased Force Required With Proposed Standardized Enteral Feed Connector in Blenderized Tube Feeding. Nutrition in Clinical Practice. 2016;31(6):795-798. doi:10.1177/0884533616639126.

Guha S, Bouhrira N, Antonino MJ, Silverstein JS, Cooper J, Myers MR. Impact of Design Changes in Gastrostomy Tube (G-tube) Devices for Patients Who Rely on Home-Based Blenderized Diets for Enteral Nutrition. Journal of the American College of Nutrition. 2019;38(4):311-317. doi:10.1080/07315724.2018.1509247.