Corona 7 ways to protect your baby

Safety & instructions on product use

Corona 7 ways to protect your baby

Oral nutritional supplements / tube feeding products are sold in the pharmacies. Could there be COVID -19 virus on the products? Could someone be infected due to COVID -19 virus on ONS / tube feeding products?

Nutricia is taking all necessary precautions and measures to ensure product safety by applying high product safety standards and quality controls throughout the value chain, from the sourcing of our raw material and packaging to the delivery of our products. The risk of infections arising from contact with food ingredients or packaging coming from affected areas, sourced from commercial suppliers, is considered negligible as stated by expert organizations (like the World Health Organization, European Food Safety Authority and the European Center for Disease Control).

Coronaviruses are generally thought to be spread from person-to-person through respiratory droplets. Currently there is no evidence to suggest transmission of COVID-19 associated with food or medical nutrition products. Before preparing/consuming/ delivering tube feeding products it is important to always wash hands with soap and water for 30 seconds for general food safety.

For more information see also the following websites:

WHO Q&A on COVID-19

FAQ on Centers for Disease Control and Prevention

Is there any extra precaution for using tube-feeding pumps at home during the COVID -19 virus spread?

Before preparing and delivering tube feeding products, practice respiratory hygiene, wash hands thoroughly with soap and water for at least 30 seconds. At all times, carefully follow the recommendations that you have been given for safe and proper handling of feeding tubes and devices according to the product instruction manual.
On a regular basis thoroughly clean all surfaces of the pump with warm soapy water, a multipurpose disinfectant cleaner or a soft cloth. Always follow the instructions according to the product manual.

COVID-19 viruses are generally thought to be spread from person-to-person through respiratory droplets. Currently there is no evidence to suggest transmission of COVID-19 associated with food or medical nutrition products.
It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads.

For more information see also the following websites:

FAQ on Centers for Disease Control and Prevention

Nutricia Flocare

Is nasogastric (NG) feeding possible if patients are ventilated in prone position?

Based on most up to date publicly available information, gastric feeding is not contraindicated in these patients. Nasogastric (NG) feeding can in principle be continued during prone positioning if there are no concerns regarding gastrointestinal intolerance (GI) (e.g. high gastric residual volumes (GRVs), vomiting).

Critical care specialist group (CCSG) makes the following recommendations:

  • Nasogastric (NG) feeding should continue during prone positioning if there are no concerns regarding gastrointestinal intolerance (GI) (e.g. high gastric residual volumes (GRVs), vomiting).
  • If your unit GRV threshold is more than 300 ml / 4 hours, consider revising this to be a maximum of 300 ml/4 hours in proned patients to reduce the risk of aspiration/regurgitation.
  • Consider the use of early or prophylactic prokinetics in patients who have high GRVs (e.g. >300ml/4 hours or using your local cut-off).
  • Avoid 2 kcal/ml enteral feeds if possible as these may exacerbate high GRVs, although it is acknowledged that these may be required for the management of potassium or fluid restrictions.
  • Aim to avoid large volumes / high rates of enteral feed. Consider 1.3/1.5kcal/ml feeds.
  • If high GRVs persist for more than 48-72 hours consider bedside placement of post-pyloric feeding tube when patient is supine if able in line with infection control policies.
  • If post-pyloric feeding is not available, consider alternative options such as a semi-elemental enteral feeds or Parenteral Nutrition (PN).
  • If enteral feeding is stopped during proning, ensure insulin infusion is adjusted if this is being given. 

For more information see also the following websites:

Critical Care Specialist Group (CCSG) of the BDA Guidance on management of nutrition and dietetic services during the COVID-19 pandemic

Publication: Administration of enteral nutrition to adult patients in the prone position

Publication: Enteral feeding in the critically ill: comparison between the supine and prone positions: a prospective crossover study in mechanically ventilated patients

How many COVID-19 patients have gastrointestinal symptoms?

As per publicly available information, about 20% of COVID-19 patients have gastrointestinal (GI) symptoms (such as abdominal pain and diarrhea) due to direct viral infection of the intestinal mucosa or antiviral and anti-infective drugs. The balance of the bacterial microbiome in the gut seems to be disturbed. Some COVID-19 patients seem to experience GI tolerance issues due to the high level of sedative drugs used, which can have an impact on the smooth muscle of the GI tract causing gastric stasis.

For more information see also the following website:

BDA (The Association of UK Dieticians) Critical Care Group COVID-19 Guidance

Is there any feed that is better tolerated than others in the prone position patients?

Since the tolerance issues are mainly related to a delayed gastric emptying, the recommendation is to start standard high protein feeds from 1.3kcal-1.5kcal/ml if fluid restricted.

There are publications suggesting that a special 4 proteins (whey, casein, soy and pea) blend called P4 provides better tolerance/ faster gastric volume emptying as compared to casein-based products. Casein dominant enteral nutrition coagulates in the stomach due to its precipitation by gastric acid. The P4 blend has been shown to be non-coagulating.

The British Dietetic Association (BDA) Critical Care Group has specified that 2.0kcal/ml feeds may not be well tolerated, however this could be due to the high concentration/ being casein based. They can be useful for severe fluid restricted patients with renal failure where dialysis is delayed or may not be available. However in persistent cases of ongoing gastrointestinal intolerance (GI) complications, nasojejunal (NJ) feeding is more recommended. If this is not available, hydrolysed feeds could be an alternative if this does not work it is possible parenteral nutrition (PN) will be implemented.

For more information see also the following websites:

Publication: A novel protein mixture containing vegetable proteins renders enteral nutrition products non-coagulating after in vitro gastric digestion

BDA (The Association of UK Dieticians) Critical Care Group COVID-19 Guidance

What are in general the recommendations regarding (early) enteral nutrition in COVID-19 patients?

Medical societies such as [ESPEN, BDA] recommend giving enteral nutrition (EN) within 24–48 hours of admission. Early EN should comprise a standard high-protein formula. The provision of nutrition must be weighed against the risk of generating a positive fluid balance, which has been shown to have an important detrimental impact on clinical outcome in acute respiratory distress syndrome (ARDS).

For more information see also the following websites:

Publication WHO: Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected

Publication: ESPEN guideline on clinical nutrition in the intensive care unit

Publication: ESPEN Guidelines on Enteral Nutrition: Intensive care

Which feeding method should be prioritized for critically ill COVID-19 patients total parenteral nutrition (TPN) or enteral nutrition (EN)?

General guidance for severely ill COVID-19 patients is to receive enteral feeding as early as possible. If there are limitations for the enteral route it could be considered to prescribe peripheral parenteral nutrition. In ICU patients who do not tolerate full dose enteral nutrition (EN) during the first week in the ICU, initiating parenteral nutrition (PN) should be weighed on a case-by-case basis. PN should not be started until all strategies to maximize EN tolerance have been attempted.

Critical care specialist group (CCSG): ‘Patients with COVID-19 may require significant levels of sedation and neuromuscular blockade which may increase the incidence of GI intolerance. There is guidance for monitoring GI tolerance and suggestions for feed use. Only once these are explore including placement of NJ tubes, then use of PN is indicated. It may therefore increase in sites where post-pyloric feeding is not available.’

For more information see also the following websites:

BDA (The Association of UK Dieticians) - Critical Care Specialist Group (CCSG) of the BDA Guidance on management of nutrition and dietetic services during the COVID-19 pandemic

Publication: ESPEN guideline on clinical nutrition in the intensive care unit

Publication: ESPEN guideline on clinical nutrition in the intensive care unit

Publication: ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection

What type of enteral nutrition is recommended for critically ill COVID-19 patients?

What type of enteral nutrition is recommended for critically ill COVID-19 patients? Standard high protein enteral feeds with 1.2 -1.5kcal/ml are suggested. In the case of GI tolerance issues avoidance of 2kcal/ml may be indicated. There are 2.0kcal/ml products containing a P4 protein blend (consisting of whey, casein, soy and pea protein) available] where evidence shows good gastric emptying in critically ill patients.
For COVID-19 patients with renal failure either the feeds as above can be used or in case of disturbances feeds with low electrolyte concentrated feeds prescribed.
In the event there are not enough dialysis machines a 2.0kcal enteral feed with low electrolytes may be indicated. Many COVID-19 patients with pre-esisting diabetes could benefit from feeds supporting glycaemic control.

For more information see also the following websites:

ESPEN

BDA (The Association of UK Dieticians) - Critical Care Specialist Group (CCSG) of the BDA Guidance on management of nutrition and dietetic services during the COVID-19 pandemic

How should we/I clean and disinfect Flocare Infinity™ pump?

The Flocare Infinity™ pump should be cleaned according to its product manual. On a regular basis thoroughly clean all surfaces of the pump (including the sensors and rotor) with warm soapy water, a 5% bleach solution in water, a multipurpose disinfectant cleaner or a soft cloth. Many alcohol- and bleach-based products have been contra-indicated for cleaning use with Infinity II due to the long-term corrosive and/or housing cracking effects. However, a 5% bleach solution and 70% IPA for short term contact are approved for cleaning and disinfecting the Infinity pumps.

For more information see also the following website:

Flocare

How can we (re-)use older models of Flocare Infinity™ enteral feeding pumps available at the hospitals?

If the pump has been stored for any period of time, it should be plugged into the mains to recharge the battery before commencing enteral feeding. The battery will be completely charged after approximately 6 hours.

It is in general safe to use older pumps when they have undergone a service-check. All pumps must be serviced either by one of Nutricia’s external service partners or by the hospital using the Flocare Service Suitcase every 2 years as recommended and indicated on the pump. Only authorized personnel is allowed to perform the service check on Flocare pumps.

It is not necessary to service the pump in-between 2 patients if the pump is still within next service check date. However, normal pump cleaning and disinfection should be done in-between patients to avoid cross- via the pump and to ensure the patients receive a pump in pristine condition.

For more information see also the following website: 

Flocare

What is the list of approved cleaning and disinfecting agents to clean, disinfect Flocare Infinity™ pumps?

Acceptable cleaning agents are:

- Warm soapy water (standard dish soap)
- Bleach/ chlorine solution (5% chlorine or equivalent and 95% water) - Metrex CavaCide® (ammonium chloride)
- MetriCide®28 Glutaraldehyde - 70% Isopropyl Alcohol*
- Antisept N® or equivalent (povidone iodine)
- Approximately 1:1000 anti-bacterial detergent to water mixture
- Mikrobac (Bode) Forte and Tissues
- Dismozon Plus (Bode)
* CAUTION Only use 70% Isopropyl Alcohol or alcohol based disinfectants on the purple colored over-mold surface for short term contact only. Avoid any contact with other, transparent, parts of the pump. Refer to the service manual for approved cleaners for other surfaces.

Document reference: MTF2020027 v02.1

What is the maximum usage period of the Flocare® administration sets for tube-feeding?

The administration sets (giving sets for the pump feeding, gravity feeding sets) should be changed at least every 24 hours (as indicated on the label). It can be sooner if deemed appropriate (e.g. reduction in risk of microbiological contamination).

Using the administration sets for more than 24 hours is generally not recommended because as it might result in:

  • (Retrograde) bacterial growth in the feeding line
  • More hand touch contamination points (increased risk of bacterial growth in feeding lines and reservoir) 
  • Wear of the giving set, potentially leading to, amongst others, a lesser delivery accuracy 

For more information see also the following website:

Flocare

Please refer to all Instructions for use.

What is the maximum hanging time to feed tube nutrition?

Always follow the instruction on the product label. In general, respect the maximum 24 hours hanging time of the ready to feed tube nutrition.

For more information see also the following website:

Flocare

Please refer to all Instructions for use.

How frequently do I need to flush nasal tubes?

Flush the nasal tubes regularly, at least every 8 hours and before and after every delivery of feed and medication.

For more information see also the following website:

Flocare

Please refer to all Instructions for use.

Is enteral Nutrition (EN) still feasible for patients on continuous positive airway pressure (CPAP)? What about oral nutritional supplements (ONS)?

In many circumstances, patients requiring Non Invasive Ventilation (NIV) do not meet their energy and protein targets via oral intake alone. Healthcare professionals weigh the decision for nasogastric (NG) feeding in patients requiring Non Invasive Ventilation with the likelihood of the patient requiring intubation.

Critical Care Dietitians Specialist Group (CCSG recommends) the following:

  • Consider placement of an NGT on admission to facilitate feeding and hydration.
  • If this practice is not adopted, monitor oral intake and utilize oral nutrition support (ONS) if appropriate with the progression to NG feeding if oral intake remains poor (<65% of energy and protein targets).
  • Patients that have been extubated to NIV are likely to have poor oral intake and NG feeding should be continued until they have been assessed and are managing sufficient oral intake. 

For more information see also the following website:

BDA (The Association of UK Dieticians) - Critical Care Specialist Group (CCSG) of the BDA Guidance on management of nutrition and dietetic services during the COVID-19 pandemic

Can I gravity feed with the Flocare Infinity™ feeding sets?

It is not possible to use Flocare InfinityTM feeding sets for gravity feed. Flocare InfinityTM pump feeding sets are fitted with an anti-free flow concept for optimal safety.

For more information see also the following website:

Flocare

Please refer to all Instructions for use.

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Coronavirus (COVID-19)

Nutricia shares the World Health Organization’s (WHO) recommendations on how to protect your baby, but also yourself, especially if you are a carer and in contact with older people or patients.

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Free COVID-19 webinar series and FAQ

Watch our free COVID-19 related webinar series and find answers to FAQs on product accessibility & supply, safety & instructions on product use and health through nutrition & lifestyle. This section is for healthcare professionals only.

Please note that information contained in this FAQ Q&A is provided for general purposes and is not intended as medical advice, please always follow public health authorities guidelines and instructions.