Enteral Nutrition Q&A

Commercially prepared enteral nutrition (EN) formulations that do not meet the regulatory requirements for federal food regulation are not appropriate for use and should not be recommended in Canada. To do so would be considered unsafe dietetic practice. If a client chooses to use an EN formulation that has not been approved by Health Canada, which includes the Canada Food Inspection Agency (CFIA) and the Health Products and Food Branch (HPFB), you should advise the client that the product is inappropriate and recommend a suitable EN formulation. If you have questions about a food or natural health product, you can contact Health Canada.

An exception exists when you have recommended a formula that meets the required regulations, but the client has chosen to use an unregulated product. If it is within your individual scope of practice, you may work with the client to determine the amount and rate of feed of the unregulated EN product. This complies with Principle 5 of the CDBC Code of Ethics where “A Registered Dietitian demonstrates respect, dignity and privacy at all times when interacting with clients at by… including the client or substitute decision maker in discussions of service provision and by… inviting the client to make choices .”

You must be aware of the legal implications in the event of an adverse event occurring related to the use of an unregulated commercial product while under your care. You must document all encounters thoroughly and continue to recommend appropriate EN formulations. Additionally, you should consult with your employer and your insurance provider for liability coverage to make sure these interventions are supported.

CDBC outlines requirements for Restricted Activities, but doesn’t specify which products are approved and may be instilled through a feeding tube. You are encouraged to look for federal guidance.

This answer has been developed with thanks to a registrant working as a pharmaceutical nutrition formula representative.

You may consider looking at the following Government of Canada websites:

• Foods for Special Dietary Use
• Lists of foods that have received temporary marketing authorization letters (you will find products such as Liquid Hope here, including when specific item authorization expires).
• Authorized food products, including information about the transition of food/Natural Health Products to the new regulatory framework

 This is not meant to be an exhaustive list. The message here is that you are looking for federal regulatory guidance for determination of what products are approved. CDBC’s role is to provide guidance such that dietitians in BC are practicing while being aware of which laws govern their areas of practice. Health Canada has specific documentation requirements for companies whose products are Health Canada approved. Please contact Health Canada for more information on industry documentation requirements.

 While some products are intended solely for enteral use, some products have a dual purpose in that they can be infused through a feeding tube or taken orally. In Canada, for a food to be called a “meal replacement” it must meet the prescribed nutritional and labelling requirements in the food and drug regulations. You can find these here: https://laws.justice.gc.ca/eng/regulations/C.R.C.%2C_c._870/page-83.html#h-574120 (see section B.24.200 and the associated table for composition, and section B.24.202 for labelling).

If the food does NOT meet any of the prescribed compositional or labelling requirements, it should go through Health Canada approval under what’s called the “temporary marketing authorization (TMA)” process: https://www.canada.ca/en/health-canada/services/food-nutrition/legislation-guidelines/acts-regulations/lists-foods-that-have-received-temporary-marketing-authorization-letters.html#meal.  A food cannot state that it is an meal replacement without either a) meeting meal replacement regulatory requirements or b) having Health Canada TMA approval.

Changing the fluid volume/replacing fluid in a balloon retention tube and using a Stoma Length measuring device are not within scope for a dietitian as they involve procedures “below the dermis”. The Dietitians Regulation does not state that a dietitian is permitted to perform a procedure “below the dermis” through a gastrostomy. Therefore, procedures below the dermis are not permitted.

 You may teach how to check the balloon volume to patients/clients/caregivers on a demonstration tube (see Q5 for details) and teach the use of a Stoma Length measuring device as long as it is not directly applied to a patient’s stoma.  

 Although there is room in the regulation around the word “administer” to interpret changing fluid volume/replacing fluid in a balloon gastrostomy as being within scope, the legislation does not support this at present. Additionally, the CDBC has also developed standards and guidelines for feeding tubes insertions, which are limited to naso/oro gastric or post-pyloric tubes. The practice guidelines (scroll to the bottom of the page) for tube feeding insertions are clear in excluding enterostomy tubes.

You may teach family and patients how to check and/or replace balloon volume by description/demonstration (on a tube that is not connected to the patient). Please consider whether these activities are within your personal scope before performing such tasks. You may choose to consult the Decision Tool for New Aspects of Dietetic Practice, specifically regarding your personal competencies.

It is important to consider the risks involved should the procedure go unexpectedly. To assess risks, you may want to ask yourself the following questions:

• Is it within your scope professionally and personally to safely resolve any issues related to a pierced balloon?
  • a balloon that is difficult or from which it is impossible to remove the fluid?
  • a tube that may need replacement after an attempt to refill the balloon?
  • complications arising from using a stoma length measuring device?
• Could this procedure be best handled by another health professional whose scope includes intervention and removal/re-insertion of the balloon gastrostomy if needed?

It is important to consider a working partnership in your practice in order to align yourself with someone (i.e. likely RNs) whose scope includes working with enterostomy tubes when procedures below the dermis are required. This partnership will be particularly useful when certain aspects of tube troubleshooting need to be addressed.

Per the Restricted Activities Interpretive Guide, dietitians registered with Restricted Activity C are allowed to “physically manipulate or adjust the enteral device or system”, as well as teaching enteral nutrition administration and tube maintenance (i.e. unblocking, maintaining patency). However, dietitians are not permitted to perform tasks (instillation/infusion) below the dermis, unless it involves enteral nutrition as defined by the Interpretive Guide.

You may not pull the tube out of, nor may you push it into the stoma. The CDBC has consulted with the College of Physicians and Surgeons of BC to clarify that the rotation of an enterostomy tube (of a ¼ turn or more) does not constitute a restricted activity limited to physician practice. It is therefore considered to be within a dietitian’s scope of practice, when competent and safe to practicing Restricted Activity C. As a dietitian, you must ensure that this specific activity is within your personal scope and that you are registered with Restricted Activity C to you perform it.

The CDBC is confirming that both the teaching of enterostomy tube changes and the physical act of changing an enterostomy tube change are outside of scope for dietitians in BC.

 Dietitians who are performing home tube feed teaching must be registered with Restricted Activities A and C:

• Restricted Activity A allows a dietitian in BC to “design, compound or dispense therapeutic diets where nutrition is administered through enteral means.”
• Restricted Activity C allows a dietitian in BC to “administer a substance to a person by instillation through enteral means.” This includes all aspects of teaching a patient or caregiver how to administer a tube feed safely.

 At any time, you are encouraged to review the competencies associated with each of these Restricted Activities, by viewing the Restricted Activity Interpretive Guide.

 Of specific interest pertaining to this question, please note the following competencies associated with Restricted Activity C, two of which have had minor wording changes to optimize clarity:

• Understands +/- ability to impart knowledge/demonstrate care and use of tube feeding pumps, nasoenteric and enterostomy tubes.
• Understands +/- ability to impart knowledge care, use, and replacement of tube feeding bags and other tube feeding supplies.
• Understands +/- ability to impart knowledge and advocate for circumstances when nasoenteric and enterostomy tubes may need replacement.

 The Dietitians Regulation outlines scope for dietitians in BC. Herein, specifically in section 6, limits on scope are listed as “No registrant may insert a feeding tube” and goes on to describe when this limitation doesn’t apply. In this case, a registrant of the CDBC may insert a feeding tube under delegated authority from a medical practitioner and as approved by the College of Physicians and Surgeons of BC (CPSBC). For the purposes of defining scope, the CDBC has worked with the CPSBC to develop Standards for Insertion of Nasal/Oral Feeding Tubes. Please note that these standards pertain only to Naso-enteric and Oral-enteric feeding tubes and NOT to enterostomy tubes. You may view the Certification documentation required for gastric or post-pyloric Naso/Oral-enteric tubes here: Restricted Activities – College of Dietitians of British Columbia (collegeofdietitiansofbc.org).

 It is also important to note that performing a procedure “below the dermis” (such as insertion or removal of an enterostomy tube) is considered to be a restricted activity, and one that is outside of scope for dietitians in BC. Please refer to the Enteral Nutrition Q&A, specifically Q4, Q5, and Q7, whereby more specific questions pertaining to scope in this context are discussed. You’ll note that in Q7, the CDBC and CPSBC have denoted the difference between rotation of a G-tube in the stoma vs manipulating a G-tube into or out of the stoma, the latter being considered a procedure “below the dermis”.

 Dietitians in BC may not teach replacement, nor may they undertake the task of replacement of an enterostomy tube.

As with any other activity, providing clear, plain language instruction is important (Standard of Practice 9), along with clear documentation of the intervention in the medical record (Standard of Practice 15 and  CDBC Standards for Record Keeping).

Once education and emergency contact information has been provided, it is the responsibility of the capable patient or caregiver, who consented to undertake an activity independently, to complete the task correctly. As in all other areas of dietetics, you are not responsible for a patient’s non-compliance to recommendations, guidelines and education provided.

Yes, a dietitian registered with Restricted Activity C can perform these activities, per the wording of Restricted Activity C as defined in the Restricted Activity Interpretive Guide:

“If a substance is being administered by instillation through enteral means, the RD: … physically manipulates or adjusts the enteral delivery device or system.”

The external bumper may be adjusted by the dietitian to support the maintenance of the correct position of the enterostomy tube within the stoma. The purpose of measuring the external length of the tube is to ensure that the tube has not migrated into or out of the stoma. If the position is not optimized (i.e. the tube appears to have moved), dietitians are not permitted to adjust the tube by moving it into or out of the stoma, since that would be deemed a procedure “below the dermis”. If the tube has migrated or there is another indication that it is not appropriate to use for feeding, a dietitian must recognize that any action taken will be outside of a dietitian’s scope and refer to another health professional (Standard of Practice 2.3).

Yes. This activity is directly related to the provision of nutrition by enterostomy tube, and so it falls within a dietitian’s scope of practice. Generally, nursing professionals are responsible for stoma care, but in some practice situations, you may be asked to provide instruction or care. You must be registered with Restricted Activity C, otherwise refer to another health professional who is competent to provide this type of care.

Stoma care may include instructing patients/caregivers how to

• clean the stoma with warm soapy water and how to air dry the stoma,
• apply over-the-counter agents (such as barrier creams) that were recommended by the healthcare team,
• replace the dressings and any adhesive required for the dressings.

Administration of scheduled medications is not part of a dietitian’s legal scope.  Any troubleshooting required (leaking, irritated, swollen, infected stoma) must be referred to an appropriate healthcare team member and documented in the patient’s medical record.

A: Yes. It is within a dietitian’s scope of practice to design and/or administer home blenderized tube feeding (HBTF), as any other product available for enteral nutrition. If you do so, you must be mindful of your own personal skill and competence to practice HBTF and take the necessary steps to ensure safe, ethical, and competent practice. You must also have the appropriate Restricted Activities (RAs) in order to practice HBTF:

• RA “A” – design, compound or dispense therapeutic diets if nutrition is administered through enteral means, and
• RA “C” administer a substance to a person by instillation through enteral means.

When providing care in HBTF, you should also consider the CDBC Code of Ethics and Standards of Practice in terms of:

• Providing a client-centered care approach and informed consent,
• Conducting evidence informed practice,
• Adhering to legislation or organizational requirements, and
• Communicating and collaborating with clients, their families, and the health care team.

Refer to Decision Tool for New Aspects of Dietetic Practice to navigate any unfamiliar new dietetic situations, including HBTF.

For more information on HBTF, you may want to consult information provided by the College of Dietitians of Ontario or check out Dietitians of Canada’s learning resource on Home Blenderized tube feeds  available at a cost .

No. When an RD provides instruction of enteral feeding to non-regulated staff (i.e. a care aide), this is not deemed as “delegation” and the RD’s responsibility ends with the completion of teaching. “Delegation” implies ongoing monitoring of the care provider’s ability to perform the task and accepting accountability for the care giver’s actions.

Further, an RD cannot delegate a Restricted Activity to another registered professional (i.e. RN, LPN) when the activity lies within the other professional’s scope of practice. RNs and LPNs are governed by the BC College of Nursing Professionals. As registered health professionals, RNs and LPNs are legally responsible for their practice, including the administration of enteral feeds on a doctor’s order.

This task lends itself to the assessment and plan with respect to tube feeding tolerance and is thereby a consideration a dietitian would make in the provision and monitoring of nutrition support. It is one that includes opening the G-port cap to allow for air or gastric secretions to be expelled.

 Because it involves manipulation of the tube outside of the body, it is within dietetic scope for dietitians who are registered with Restricted Activity C. Specifically, “Demonstrate ability +/- impart knowledge of troubleshooting complications (e.g., pump issues, unclogging tube, etc.)”. You can refer to the Restricted Activities Interpretive Guide for details on Restricted Activity C competencies.

 Having said that, there are a few additional considerations:

 Is it within your personal scope? Are you comfortable performing this task? You are encouraged to review the Decision Support Tool for New Aspects of Dietetic Practice for guidance, if this task is new for you. While you may not physically be performing the task, because it is within scope for a dietitian with Restricted Activity C to perform, it is also within that same dietitian’s scope to discuss with physicians and subsequently write an order or a recommendation for nursing to perform this task. Refer to Standard of Practice 3: “A Dietitian maintains competence in their practice area.”

 Is it within your workplace scope? Are there organizational polices/procedures in place that would limit your ability to order/recommend or perform a decompression of the G-port? Please refer to Standard of Practice 1: “A Dietitian practices dietetics in compliance with legislation and organizational requirements.”