Next generation microfluidics: fulfilling the promise of lab-on-a-chip technologies.

Microfluidic lab-on-a-chip technologies enable the analysis and manipulation of small fluid volumes and particles at small scales and the control of fluid flow and transport processes at the microscale, leading to the development of new methods to address a broad range of scientific and medical challenges. Microfluidic and lab-on-a-chip technologies have made a noteworthy impact in basic, preclinical, and clinical research, especially in hematology and vascular biology due to the inherent ability of microfluidics to mimic physiologic flow conditions in blood vessels and capillaries. With the potential to significantly impact translational research and clinical diagnostics, technical issues and incentive mismatches have stymied microfluidics from fulfilling this promise. We describe how accessibility, usability, and manufacturability of microfluidic technologies should be improved and how a shift in mindset and incentives within the field is also needed to address these issues. In this report, we discuss the state of the microfluidic field regarding current limitations and propose future directions and new approaches for the field to advance microfluidic technologies closer to translation and clinical use. While our report focuses on using blood as the prototypical biofluid sample, the proposed ideas and research directions can be extrapolated to other areas of hematology, oncology, biology, and medicine.

A Systematic Analysis of Recent Technology Trends of Microfluidic Medical Devices in the United States.

In recent years, the U.S. Food and Drug Administration (FDA) has seen an increase in microfluidic medical device submissions, likely stemming from recent advancements in microfluidic technologies. This recent trend has only been enhanced during the COVID-19 pandemic, as microfluidic-based test kits have been used for diagnosis. To better understand the implications of this emerging technology, device submissions to the FDA from 2015 to 2021 containing microfluidic technologies have been systematically reviewed to identify trends in microfluidic medical applications, performance tests, standards used, fabrication techniques, materials, and flow systems. More than 80% of devices with microfluidic platforms were found to be diagnostic in nature, with lateral flow systems accounting for about 35% of all identified microfluidic devices. A targeted analysis of over 40,000 adverse event reports linked to microfluidic technologies revealed that flow, operation, and data output related failures are the most common failure modes for these device types. Lastly, this paper highlights key considerations for developing new protocols for various microfluidic applications that use certain analytes (e.g., blood, urine, nasal-pharyngeal swab), materials, flow, and detection mechanisms. We anticipate that these considerations would help facilitate innovation in microfluidic-based medical devices.

Evaluation of Glove Performance after Decontamination.

Studies of healthcare providers doffing personal protective equipment, especially gloves, indicate that self-contamination does occur. Although generally this is not hazardous, working with particularly pathogenic organisms, such as Ebola virus and Clostridium difficile, can present a serious health risk. Decontaminating medical gloves before removal can reduce self-contamination and mitigate the spread of these types of pathogens. Also, in cases of extreme shortage, the Centers for Disease Control and Prevention (CDC) has specific recommendations for decontaminating gloves for extended use. Reuse of medical gloves is strongly discouraged by both the CDC and Food and Drug Administration. This work seeks to lay a foundation of testing to evaluate whether a decontamination method is compatible for a given glove type and material. Four potential methods of decontamination (commercial hand soap, alcohol-based hand sanitizer, commercial bleach, and quaternary ammonium solution) were tested on a variety of surgical and patient examination gloves. The method of barrier performance evaluation was ASTM D5151-19, Standard Test Method for Detection of Holes in Medical Gloves. Our results indicated that the performance of the gloves after treatment was highly dependent on the composition of the medical gloves. In general, the surgical gloves in this study performed better than the patient examination gloves, regardless of the material from which they were made. Specifically, vinyl examination gloves tended to have poorer performance. In this study, the number of gloves available to test were limited and therefore statistical significance is beyond the scope of this project.

Benchtop assessment of sealing efficacy and breathability of additively manufactured (AM) face masks.

The onset of the 2019 novel coronavirus disease (COVID-19) led to a shortage of personal protective equipment (PPE), medical devices, and other medical supplies causing many stakeholders and the general public alike to turn to additive manufacturing (AM) as a stopgap when normally accessible devices were not available. However, without a method to test these AM constructs, there continued to be a disconnect between AM suppliers and the community's needs. The objective of this study was to characterize the pressure drop and leakage of four different publicly available AM face mask models with two filter material combinations, as well as to investigate the impact of frame modification techniques including the use of foam strips and hot-water face forming to improve fit when the masks are donned on manikin head forms. AM face mask frame designs were downloaded from public repositories during the early stages of the COVID-19 pandemic. AM face masks were fabricated and tested on manikin head forms within a custom chamber containing dry aerosolized NaCl. Pressure drops, particle penetration, and leakage were evaluated for various flow rates and NaCl concentrations. Results indicated that filter material combination and frame modification played a major role in the overall performance of the AM face masks studied. Filter material combinations showed improved performance when high filtration fabric was used, and the cross-sectional area of the fabric was increased. AM frame modifications appeared to improve AM face mask leakage performance by as much as 69.6%.

Characterization of aerosols generated by high-power electronic nicotine delivery systems (ENDS): Influence of atomizer, temperature and PG:VG ratios.

The aerosol characteristics of electronic nicotine delivery systems (ENDS) are important parameters in predicting health outcomes since parameters such as aerosol particle size correlate strongly to aerosol delivery and deposition efficiency. However, many studies to date do not account for aerosol aging, which may affect the measurement of ultra-fine particles that typically coagulate or agglomerate during puff development. To reduce aerosol aging, we herein present a unique instrumentation method that combines a) positive pressure ENDS activation and sample collection, b) minimization of both sample tubing length and dilution factors, and c) a high-resolution, electrical low-pressure impactor. This novel approach was applied to systematically investigate the effects of coil design, coil temperature, and propylene glycol to vegetable glycerol ratios on aerosol characteristics including aerosol mass generation, aerosol count generation, and the mass and count size distributions for a high-powered ENDS. Aerosol count measurements revealed high concentrations of ultra-fine particles compared to fine and coarse particles at 200°C, while aerosol mass measurements showed an increase in the overall aerosol mass of fine and coarse particles with increases in temperature and decreases in propylene glycol content. These results provide a better understanding on how various ENDS design parameters affect aerosol characteristics and highlight the need for further research to identify the design parameters that most impact ultra-fine particle generation.

Overcoming technological barriers in microfluidics: Leakage testing.

The miniaturization of laboratory procedures for Lab-on-Chip (LoC) devices and translation to various platforms such as single cell analysis or Organ-on-Chip (OoC) systems are revolutionizing the life sciences and biomedical fields. As a result, microfluidics is becoming a viable technology for improving the quality and sensitivity of critical processes. Yet, standard test methods have not yet been established to validate basic manufacturing steps, performance, and safety of microfluidic devices. The successful development and widespread use of microfluidic technologies are greatly dependent on the community's success in establishing widely supported test protocols. A key area that requires consensus guidelines is leakage testing. There are unique challenges in preventing and detecting leaks in microfluidic systems because of their small dimensions, high surface-area to volume ratios, low flow rates, limited volumes, and relatively high-pressure differentials over short distances. Also, microfluidic devices often employ heterogenous components, including unique connectors and fluid-contacting materials, which potentially make them more susceptible to mechanical integrity failures. The differences between microfluidic systems and traditional macroscale technologies can exacerbate the impact of a leak on the performance and safety on the microscale. To support the microfluidics community efforts in product development and commercialization, it is critical to identify common aspects of leakage in microfluidic devices and standardize the corresponding safety and performance metrics. There is a need for quantitative metrics to provide quality assurance during or after the manufacturing process. It is also necessary to implement application-specific test methods to effectively characterize leakage in microfluidic systems. In this review, different methods for assessing microfluidics leaks, the benefits of using different test media and materials, and the utility of leakage testing throughout the product life cycle are discussed. Current leakage testing protocols and standard test methods that can be leveraged for characterizing leaks in microfluidic devices and potential classification strategies are also discussed. We hope that this review article will stimulate more discussions around the development of gas and liquid leakage test standards in academia and industry to facilitate device commercialization in the emerging field of microfluidics.

Synthesis of research on ENFit gastrostomy tubes with potential implications for US patients using these devices.

Misconnections between enteral devices and other medical devices have been associated with patient death and serious injuries. To minimize such misconnections, the design of connectors on enteral devices has been standardized. The most common adaptation of the standardized enteral connector is called ENFit. Gastrostomy tubes (G-tubes), which may or may not possess the ENFit connector, are increasingly used to deliver commercial and blenderized diets in home settings to enteral device users. To investigate and compare the performance of G-tubes with and without ENFit connectors, research investigations have recently been performed. However, synthesis of such investigations and quantitative discussion of the consequences of transitioning to ENFit-based G-tube devices has not yet occurred. Here we review the research findings from these studies, with data on patient practices from a Mayo Clinic survey, to estimate the impact on tube feeders in home settings of transitioning to ENFit-based G-tube devices. Extrapolating the findings from these studies to US enteral G-tube patients, 1.5%-8.6% of adult patients and 0.2%-1.9% of pediatric patients may experience perceptible slowing in their gravity feeds if using ENFit-based G-tube devices. About 2.5%-8.6% of adult patients and 0.5%-5.5% of pediatric patients (or their caregivers) may need to push with perceptibly more force for syringe push-based feeding using ENFit-based G-tube devices. Lastly, the article offers suggestions for patients and device manufacturers. [Correction added on 2 May 2022, after first online publication: In the preceding sentence, the percentage of adult patients was revised from 2.5%-8.6% to 1.5%-8.6%.].

Assessing dosing errors in legacy and low dose tip ENFit® syringes.

WHAT IS KNOWN AND OBJECTIVE: To avoid misconnections between different medical devices, a unique standardized design of connectors (ENFit® ) for enteral medical devices has been developed. It was expected that the syringes with these connectors will replace the pre-existing syringes, henceforth referred to as legacy syringes. However, the changes in the connector's design led to concerns regarding dosing errors for low volume syringes (≤2 ml). Therefore, novel low dose tip (LDT) syringes were designed to address these concerns. These LDT syringes can connect with the standardized ENFit® male connectors. Only a few studies have investigated dosing errors, and findings have largely been mixed. The objective of this report was to calculate the contributions of unavoidable dosing errors for LDT syringes, compare with legacy syringes and to suggest strategies to optimize dose accuracy for enteral applications. METHODS: Studies performed with a limited number of syringes to date may not reflect the actual diversity of dosing error that can occur across syringe orientations, batches, manufacturers, medications, etc. A computer-aided design software SolidWorks® was used to calculate the dosing errors in 0.5 and 1.0 ml legacy syringe connectors and were compared with dosing errors in LDT syringe connectors with the same nominal volume. Influence of orientation during delivery, spillage and flushing on dosing error was also investigated. RESULTS AND DISCUSSION: For 0.5 and 1.0 ml LDT syringes, in absence of medication in the moat area, the maximum dosing error will be ±5% when delivering 100% of nominal volume, which is also equal to the dosing error in 0.5 and 1.0 ml slip tip legacy syringes. However, with medication present in moat area, and with syringe reused during flushing, the LDT dosing error can range from 1% to 18% and 28% to 35% for 1.0 and 0.5 ml syringes, respectively. The corresponding dosing error for legacy syringes would be when the same syringe is used for flushing or when syringe disengages pointing vertically up. The corresponding dosing errors for legacy syringes could range from -7 to 12% and -9% to 19% for 1.0 and 0.5 ml syringes, respectively. Dosing errors for legacy and LDT syringes increase as the nominal capacity of syringe reduces, or when the dose delivered is lower than the nominal capacity of the syringe. WHAT IS NEW AND CONCLUSION: For LDT syringes, dosing errors can be reduced by clearing the moat area of the syringe and by using a new syringe for flushing post-delivery of medication. For legacy syringes, dosing errors can be minimized by ensuring the female connector points up during disengagement from the syringe post-medication administration, and by using a new syringe for flushing.

A computational model for predicting changes in infection dynamics due to leakage through N95 respirators.

In the absence of fit-testing, leakage of aerosolized pathogens through the gaps between the face and N95 respirators could compromise the effectiveness of the device and increase the risk of infection for the exposed population. To address this issue, we have developed a model to estimate the increase in risk of infection resulting from aerosols leaking through gaps between the face and N95 respirators. The gaps between anthropometric face-geometry and N95 respirators were scanned using computed tomography. The gap profiles were subsequently input into CFD models. The amount of aerosol leakage was predicted by the CFD simulations. Leakage levels were validated using experimental data obtained using manikins. The computed amounts of aerosol transmitted to the respiratory system, with and without leaks, were then linked to a risk-assessment model to predict the infection risk for a sample population. An influenza outbreak in which 50% of the population deployed respirators was considered for risk assessment. Our results showed that the leakage predicted by the CFD model matched the experimental data within about 13%. Depending upon the fit between the headform and the respirator, the inward leakage for the aerosols ranged between 30 and 95%. In addition, the non-fit-tested respirator lowered the infection rate from 97% (for no protection) to between 42 and 80%, but not to the same level as the fit-tested respirators (12%). The CFD-based leakage model, combined with the risk-assessment model, can be useful in optimizing protection strategies for a given population exposed to a pathogenic aerosol.

Comprehensive characterization of protective face coverings made from household fabrics.

BACKGROUND: Face coverings constitute an important strategy for containing pandemics, such as COVID-19. Infection from airborne respiratory viruses including Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) can occur in at least three modes; tiny and/or dried aerosols (typically < 1.0 µm) generated through multiple mechanisms including talking, breathing, singing, large droplets (> 0.5 µm) generated during coughing and sneezing, and macro drops transmitted via fomites. While there is a growing number of studies looking at the performance of household materials against some of these situations, to date, there has not been any systematic characterization of household materials against all three modes. METHODS: A three-step methodology was developed and used to characterize the performance of 21 different household materials with various material compositions (e.g. cotton, polyester, polypropylene, cellulose and blends) using submicron sodium chloride aerosols, water droplets, and mucous mimicking macro droplets over an aerosol-droplet size range of ~ 20 nm to 0.6 cm. RESULTS: Except for one thousand-thread-count cotton, most single-layered materials had filtration efficiencies < 20% for sub-micron solid aerosols. However, several of these materials stopped > 80% of larger droplets, even at sneeze-velocities of up to 1700 cm/s. Three or four layers of the same material, or combination materials, would be required to stop macro droplets from permeating out or into the face covering. Such materials can also be boiled for reuse. CONCLUSION: Four layers of loosely knit or woven fabrics independent of the composition (e.g. cotton, polyester, nylon or blends) are likely to be effective source controls. One layer of tightly woven fabrics combined with multiple layers of loosely knit or woven fabrics in addition to being source controls can have sub-micron filtration efficiencies > 40% and may offer some protection to the wearer. However, the pressure drop across such fabrics can be high (> 100 Pa).

A Modified Method for Measuring Pressure Drop in Non-medical Face Masks with Automated Data Acquisition and Analysis.

Background: Non-medical face masks, such as face coverings donned by the general population play an important role in reducing transmission of respiratory pathogens. Pressure drop or breathability of such masks is an important attribute especially with the advent of new standards such as ASTM F3502-21 that have specified pressure drop limits for general use of face coverings. Although several standards are available that discuss pressure drop measurement techniques, the methodologies reported are typically complex or are part of more sophisticated and expensive instruments. Thus, the applicability of such methods is often limited to medical device manufacturers. Objective and Methods: This manuscript adapts from the pressure drop measurements proposed in British Standard EN 14683:2019 and describes a methodology to create a simple 3D printed model of a pressure rig for measuring the breathing resistance across non-medical face masks. The method also enables real time pressure drop data acquisition and analysis of multiple samples or batches using Python and MATLAB scripts. Results: We performed a validation study by comparing the pressure drop obtained for one brand of respirators with our set up and compared it with data obtained by traditional means by CDC. An unpaired two-tailed student t-test (n=3) between the two means implied no statistically significant difference. Conclusion: The method we have developed can be easily implemented at community levels for characterizing the breathability of non-medical grade face masks.

Accelerating innovation and commercialization through standardization of microfluidic-based medical devices.

Worldwide, the microfluidics industry has grown steadily over the last 5 years, with the market for microfluidic medical devices experiencing a compound growth rate of 22%. The number of submissions of microfluidic-based devices to regulatory agencies such as the U.S. Food & Drug Administration (FDA) has also steadily increased, creating a strong demand for the development of consistent and accessible tools for evaluating microfluidics-based devices. The microfluidics community has been slow, or even reluctant, to adopt standards and guidelines, which are needed for harmonization and for assisting academia, researchers, designers, and industry across all stages of product development. Appropriate assessments of device performance also remain a bottleneck for microfluidic devices. Standards reside at the core of mature supply chains generating economies of scale and forging a consistent pathway to match stakeholder expectations, thus creating a foundation for successful commercialization. This article provides a unique perspective on the need for the development of standards specific to the emerging biomedical field of microfluidics. Our aim is to facilitate innovation by encouraging the microfluidics community to work together to help bridge knowledge gaps and improve efficiency in getting high-quality microfluidic medical devices to market faster. We start by acknowledging the progress that has been made in various areas over the past decade. We then describe the existing gaps in the standardization of flow control, interconnections, component integration, manufacturing, assembly, packaging, reliability, performance of microfluidic elements and safety testing of microfluidic devices throughout the entire product life cycle.

Assessment of Flow through Microchannels for Inertia-Based Sorting: Steps toward Microfluidic Medical Devices.

The development of new standardized test methods would allow for the consistent evaluation of microfluidic medical devices and enable high-quality products to reach the market faster. A comprehensive flow characterization study was conducted to identify regulatory knowledge gaps using a generic inertia-based spiral channel model for particle sorting and facilitate standards development in the microfluidics community. Testing was performed using 2-20 µm rigid particles to represent blood elements and flow rates of 200-5000 µL/min to assess the effects of flow-related factors on overall system performance. Two channel designs were studied to determine the variability associated with using the same microchannel multiple times (coefficient of variation (CV) of 27% for Design 1 and 18% for Design 2, respectively). The impact of commonly occurring failure modes on device performance was also investigated by simulating progressive and complete channel outlet blockages. The pressure increased by 10-250% of the normal channel pressure depending on the extent of the blockage. Lastly, two common data analysis approaches were compared-imaging and particle counting. Both approaches were similar in terms of their sensitivity and consistency. Continued research is needed to develop standardized test methods for microfluidic systems, which will improve medical device performance testing and drive innovation in the biomedical field.

Technical considerations for medical device manufacturers when designing gastrostomy tubes (G-tubes) using the new ISO 80369-3 connector.

BACKGROUND: Gastrostomy tubes (G-tubes) are typically used when people cannot eat food by mouth. The connector section that allows G-tubes to connect to other devices, such as feeding sets or syringes, has been modified on some of the devices to reduce misconnections in hospital settings. The narrow internal diameter of the new connector, standardized under ISO 80369-3, has caused some users to express concern about a reduced flow rate. Previous studies performed on commercial devices determined that it was not conclusive how much the ISO 80369-3 connector contributed towards the reduced flow rate, because when manufacturers designed these new connector-based devices, they often changed other geometric variables (such as distal tube diameter, or length) at the same time. Thus, it became difficult isolating the effect of the connector from other geometric variables. METHOD: The key objective of this study was to investigate how different design variables impacted the flow rate through the G-tubes. 3D-printed devices were used to assess the geometric parameters in a systematic manner. Commercial diets and Newtonian analog fluids with matched viscosities were used for testing. RESULTS: The flow path length of the "transition section" encompassing the standardized ISO 80369-3 connector in the new devices was found to cause reduced flow. Additionally, results showed that a shortened (≤ 10 mm) transition section, along with a 10% increase in the distal inner diameter of large bore devices (e.g., 24 Fr), can restore flow rates to levels consistent with the previous devices prior to the connector standardization. CONCLUSIONS: The strategy for restoring flow rates to previous levels may help alleviate concerns raised by multiple stakeholders such as health care professionals, patients, caregivers and device manufacturers. In addition, the approach proposed here can be used as a tool for designing future G-tube devices.

Impact of Design Changes in Gastrostomy Tube (G-tube) Devices for Patients Who Rely on Home-Based Blenderized Diets for Enteral Nutrition.

OBJECTIVE: Blenderized diets are gaining increasing popularity among enteral tube users. Connectors in gastrostomy tubes (G-tubes) are undergoing standardization to reduce misconnections. These standardized G-tubes are referred to as ENFit G-tubes. This study was performed to quantify the in vitro performance of existing (legacy) G-tubes and compare them with ENFit G-tubes for blenderized diets. METHOD: Patient blenderized diet recipes and practices were obtained through patient advocacy groups. Different blenders and blending times were studied. Five legacy G-tube brands and three corresponding ENFit brands, sized between 14 Fr and 24 Fr, were studied under gravity and push modes of feeding. RESULTS: Considering both thin and thick blenderized gravity mode diets, an average increase in feeding time from 20 minutes to 32 ± 18 minutes in transitioning from legacy to ENFit was observed with standard G-tubes, compared to 22 ± 3.5 minutes for low profiles. For push-mode diets, a 60-second push with standard ENFit G-tubes was easier compared to standard legacy G-tubes (61% ± 21% as much force), but faster 5-second pushes required considerably more effort for ENFit standard G-tubes (167% ± 96%). Low-profile ENFit G-tubes required slightly less effort compared to low-profile legacies for both 60-second and 5-second pushes (72% ± 22% and 90% ± 19%, respectively). Clogging was common in both legacy and ENFit devices, particularly under gravity mode. CONCLUSIONS: For a push mode of feeding, patients will largely be unimpacted after the transition to ENFit. For a gravity mode of feeding, some ENFit users may need higher-powered blenders and should expect increased feeding times.

Modeling the Effectiveness of Respiratory Protective Devices in Reducing Influenza Outbreak.

Outbreaks of influenza represent an important health concern worldwide. In many cases, vaccines are only partially successful in reducing the infection rate, and respiratory protective devices (RPDs) are used as a complementary countermeasure. In devising a protection strategy against influenza for a given population, estimates of the level of protection afforded by different RPDs is valuable. In this article, a risk assessment model previously developed in general form was used to estimate the effectiveness of different types of protective equipment in reducing the rate of infection in an influenza outbreak. It was found that a 50% compliance in donning the device resulted in a significant (at least 50% prevalence and 20% cumulative incidence) reduction in risk for fitted and unfitted N95 respirators, high-filtration surgical masks, and both low-filtration and high-filtration pediatric masks. An 80% compliance rate essentially eliminated the influenza outbreak. The results of the present study, as well as the application of the model to related influenza scenarios, are potentially useful to public health officials in decisions involving resource allocation or education strategies.

Accuracy of commercial electronic nicotine delivery systems (ENDS) temperature control technology.

OBJECTIVES: For electronic nicotine delivery systems (ENDS), also commonly called e-cigarettes, coil temperature is a factor in the potential production of toxic chemical constituents. However, data are lacking regarding the temperatures that are achieved in the latest generation of these devices. Fourth-generation ENDS are capable of producing heating coil temperatures well above e-liquid boiling points, and allow the user to monitor and set the heating coil temperature during a puff. In this study, we evaluate the accuracy and consistency of the temperature measurement and control settings for different brands of fourth-generation ENDS. METHODS: A study was performed using three commercially available, fourth-generation ENDS. The atomizer coil temperatures were obtained from the device (using the EScribe software) reading and from thermocouples attached to the coils during simulated puffing conditions. In addition, aerosol temperatures were measured inside the atomizer and at the mouthpiece. RESULTS: Measured temperatures varied widely across samples taken from the same brand. For example, thermocouple measurements for one unit were 40 Celsius (°C) below the 300 °C set point, while another unit of the same brand exceeded the set point by more than 100 °C. We observed a significant variation in temperature (approximately 100 °C) along the length of the coil in some cases. CONCLUSIONS: The possibility of wide temperature variation across ENDS samples, as well as variations between maximum coil temperatures and internal temperature readings, may have implications for studies that seek to determine correlations between coil temperature and toxin generation.

In Vitro Performance Testing of Legacy and ENFit Gastrostomy Tube Devices Under Gravity Flow Conditions.

BACKGROUND: Changes in connector design for the gastrostomy tube were implemented to reduce the risk of misconnections. This study aimed to determine whether there are differences in gravity flow rates between legacy devices and the ENFit devices intended to replace them. MATERIALS AND METHODS: We compared 5 legacy gastrostomy tube brands with 3 corresponding ENFit brands, sized between 14 French (Fr) and 24 Fr. Seven commercial diets were used. One comparison involved low-profile devices. RESULTS: Whether an ENFit device manifested a lower flow rate than a legacy device was not a strong function of diet. One 14-Fr ENFit device, because of its reduced distal inner tube diameter, produced an average feeding time of 56 (±13) minutes from a 20-minute baseline. For other 14-Fr ENFit devices, the increase was much less pronounced (25 ± 4 minutes). At larger sizes, both decreases and increases in feeding time were observed, depending on device type; on average, the 20-minute feeding time increased to 25 (±7) minutes. For low-profile devices, across all sizes, an increase in 20-minute feeding time occurred, but the difference was small (23 ± 2). CONCLUSION: Statistically lower flow rates were observed for 70% of ENFit devices relative to their legacy counterparts. We estimate that 30% of the differences may be noticeable. In the scenarios studied, lower flow rates (relative to other devices at the same Fr number) arise from energy losses in straight tubing. This difference can be reduced by increasing the tube inner diameters in distal end of ENFit tubes.