1. Lyman, Beth MSN, RN, CNSC, FAAN, FASPEN
  2. Linford, Lorraine RN, CNSC

Article Content

We read the article "Enteral Tubing Connection Changes: A Failure Modes and Effects Analysis" (November 2019) by Heidi L. McNeely, MSN, RN, PCNS-BC, and Sasha Jacobs-Lowry, BSN, RN, CPN, with interest. It's a thorough discussion of the transition from legacy feeding tube-related connections to a worldwide International Organization for Standardization (ISO) connector. The authors identified several concerns that prompted their institution to put a hold on their transition plans.


Our institutions transitioned to the new enteral tubing connectors in 2017. Although many of the concerns raised by the authors of this article were addressed by our transition teams, many were never seen. There are no reports in the literature of patient care events associated with the new connectors compared with a report of 116 inadvertent misconnections with other enteral systems.1 In 2018, the US Food and Drug Administration issued a letter to healthcare professionals recommending that they "use enteral devices that meet the ISO standards and are intended to reduce the risk of misconnections."2


The authors mentioned increased costs from additional supplies and the new connectors. The Intermountain Healthcare system conversion expenses were less than originally anticipated. The cost was neutral for new feeding tubes and most syringes. There was an additional cost for adapters to convert legacy devices that weren't needed before. Toothbrushes are used for cleaning the devices, with no significant volume increases. Overall, the conversion expenses were minimal for the system (<5%). At Children's Mercy Kansas City, commercial cleaning brushes are used, along with medication straws and oral adapters.


The authors also mentioned potential choking hazards, which are always a concern in direct patient care, especially in pediatric settings. We haven't seen this in our settings, and it hasn't been reported in the literature. As always, nursing vigilance is required to protect our patients from this risk, which hasn't changed with the transition to ISO standard connectors.


Difficulty administering blended diets was identified by the authors due to the change in the connector's diameter. Two studies using various blended diets didn't find problems with administration other than it may take longer via gravity feeding.2,3 The rising popularity of both commercial and home blended diets to improve patient tolerance hasn't been hindered by the new connectors in our institutions.


The use of both oral legacy and new syringes was mentioned by the authors for good reason. They indicated that the best solution is to use just one system to address workflow and safety issues. We agree completely with the authors and encourage every healthcare system to look closely at their suggestions because planning for the transition is complicated and involves several departments. Their strategies are well thought out and will save time for nurses and families. Our institutions have successfully employed the new syringes. At Children's Mercy Kansas City, the outpatient pharmacy does dispense legacy syringes for oral administration of liquid medications to children who don't have a feeding tube. When a liquid medication is ordered in an ambulatory setting or at discharge, the healthcare provider must select the oral or feeding tube route.


Medication administration accuracy using the new syringes was alluded to in the article. Compared with legacy systems, we find it easier to get the dose comfortably back into the cheek of the infant or child using the oral dosing accessories created for the new syringes. A literature search revealed no actual reports of medication under- or overdosing using these syringes. An analysis of the dose accuracy was performed to determine if any statistically significant differences were observed between the new low-dose tip syringes and currently marketed enteral/oral syringes. Testing indicated that the low-dose tip syringe performs equal to or better than existing enteral/oral syringes.4 This is a worldwide practice change, with most of the European Union, including the UK, already transitioned to the new syringes, with no known reports of such issues.5


Finally, the concern about over-the-counter availability of enteral syringes was discussed because a prescription is required to obtain medication syringes. This is a serious issue that's now been addressed; the new style multiple-use syringes are now cleared by the FDA for over-the-counter purchase.


This article can serve as a template for organizations as they plan their transition to ISO standard connectors. It's our understanding that the authors' pediatric hospital plans to transition in the summer of 2020. As your facility makes the transition, consider utilizing the resources provided by the nonprofit Global Enteral Device Suppliers Association, which has volunteer clinicians to help answer questions and share transition experiences.




1. Simmons D, Symes L, Guenter P, Graves K. Tubing misconnections: normalization of deviance. Nutr Clin Pract. 2011;26(3):286-293. [Context Link]


2. US Food and Drug Administration. The FDA encourages use of enteral device connectors that reduce misconnection and patient injury. 2018. [Context Link]


3. Mundi MS, Duellman W, Epp L, Davidson J, Hurt RT. Comparison of gravity flow rates between ENFit and legacy feeding tubes. JPEN J Parenter Enteral Nutr. 2018;42(3):522-528. [Context Link]


4. Global Enteral Device Suppliers Association. Frequently asked questions ENFit low dose tip (LDT) syringes. [Context Link]


5. Personal communication with Mike Cusak, executive director, Global Enteral Device Suppliers Association, January 6, 2020. [Context Link]