This guideline forms part of a series under 'Nutrition' regarding the management of enteral tubes, including placement, access and management. Please also see guidelines and policies for:
July 2014 - temporary practice change until further notice
A recent field safety notice from Merck Serono has advised that a new coating they have added to all their PH indicator strips (non- bleeding) has been found to give a similar PH reading with water as with stomach contents.
Therefore until further notice current practice will need to change to insure all NG tubes are flushed with a small amount of air after the water (once correct placement has been determined) to ensure no water is left in the NG tube to contaminate the next aspirate for testing.
Nasogastric is the most common route for enteral feeding. Benefits include:
- It is quick and easy to establish ( Rationale 1).
- Minimally invasive.
- Parents, carers and mature patients can be taught to pass the tube at home ( Rationale 1).
Risks/drawbacks associated with nasogastric tube feeding include:
- The procedure for inserting the tube is traumatic for the majority of children.
- The tube is very noticeable ( Rationale 2).
- Babies and young children are likely to pull out the tube making regular re-insertion necessary ( Rationale 3).
- Aspiration, if the tube is incorrectly placed ( Rationale 4).
- Increased risk of gastroesophageal reflux with prolonged use.
- Damage to the skin on the face ( Rationale 5).
Nasogastric tube feeding is particularly useful in the short term, and when it is necessary to avoid a surgical procedure to insert a gastrostomy device. However, in the long term gastrostomy feeding may be more suitable ( Rationale 6
Passing a nasogastric tube
Establish the reason for inserting the nasogastric tube and document this in the healthcare record. Check that there are no contra-indications to passing a nasogastric tube, such as anatomical deformity, trauma, recent oral, nasal or oesophageal surgery, or severe gastro-oesophageal reflux disease (GORD).
Nasogastric tubes may be inserted by:
- A registered health care practitioner (HCP) who has undergone appropriate training and is deemed competent in the skill.
- A HCP in training who is fully supervised by a competent professional.
- A health care assistant who has undergone appropriate training and is deemed competent in the skill, under supervision by a registered, competent HCP.
- Mature patients and/or parents/carers who have been trained in the skill and are deemed competent.
Preparing the child and family
Provide the child and family with adequate information on the reasons and need for enteral feeding and the procedure to be performed ( Rationale 7
). The play specialist or nurse should be asked to assist in preparing the child and family by using picture books, toys and video aids ( Rationale 8
If the child’s condition allows, use a procedure room to pass the tube ( Rationale 9
). If possible or practicable, the child should be fasted for approximately two hours prior to the procedure ( Rationale 10
). Consider the use of distraction techniques during the procedure ( Rationale 11
Types of tubes
All tubes must be radio opaque throughout their length and have externally visible markings ( NPSA, 2011).
Tubes obtained through Great Ormond Street Hospital (GOSH) supplies will conform to these standards, but those which are in-situ before a child is transferred may not. If in doubt remove the tube and re-insert with a new tube obtained through GOSH ( Rationale 12).
An assessment of the child’s requirements must be made to determine if there is a requirement for long or short term feeding, or need for a tube for reasons other than nutritional support, for example the administration of medicines ( Rationale 13).
Wide bore tubes (usually PVC):
- These tubes are for short term use only.
- They should be changed every seven days.
- In general, the range of sizes for paediatric use is 6 Fr to 10 Fr ( Rationale 14).
Fine bore tubes (polyurethane):
- These tubes are intended for long term use ( Rationale 15).
- They should be changed every 30 days.
Check the manufacturer’s instructions for intended duration of use, as different tubes come with different recommendations.
In general, a tube size of 6 Fr is used for standard feeds, and 7 Fr is used for higher density and fibre feeds. The tubes come in a range of lengths, usually 55cm, 75cm or 85cm.
Preparation of equipment
Prepare the following equipment:
- the appropriate size and type of tube
- sterile water to lubricate the tube
- foil bowl and tissues
- pH indicator paper
- 20ml syringe to withdraw aspirate from the stomach
- sterile water to flush the tube clear of aspirate, once correct placement has been confirmed
- non-sterile gloves
- tape to secure the tube to the child’s skin
- a drink with a straw or a dummy for the child to suck on ( Rationale 16)
Wash and dry hands thoroughly, gathering together all the equipment needed and place on a clean tray.
Find the most appropriate position for the child, depending on age and ability to co-operate. For example, an older child may be able to sit upright with support to their back and head. Younger children may sit on a parent/carer(s) lap, or an infant may be wrapped in a sheet or blanket ( Royal College of Nursing 2003).
Ensure the chosen nostril is clear of debris. Ask the child, if age appropriate, which side they would prefer to have the tube positioned ( Rationale 17).
Wash and dry hands thoroughly, put on non-sterile gloves and apron.
Check that the tube is intact. The tube should be stretched to remove any shape retained from being packaged. If the tube has a guide wire, make sure it is correctly inserted in the tube and is not bent.
If the tube has a guidewire - it is helpful to flush the tube with 10ml of sterile water before insertion ( Rationale 18).
For infants and children: measure the length of tube to be inserted. Measure from the bridge of the nose to the ear lobe, then from the ear lobe to xiphisternum. The length of tube can be marked with indelible pen or a note taken of the measurement marks on the tube.
For neonates: measure from the nose to ear and then to the halfway point between xiphisternum and umbilicus ( Marsha, 2011).
The length of tube can be marked with indelible pen or a note taken of the measurement marks on the tube.
Lubricate the end of the tube in sterile water; do not use K-Y Jelly® ( Rationale 19).
Bend the child’s head slightly forward and gently pass the tube into the child’s nostril, advancing it along the floor of the nasopharynx to the oropharynx. At this point, ask the child to swallow a little water or offer a younger child their soother, to assist passage of the tube down the oesophagus until the required length of tube has been inserted.
Never advance the tube against resistance ( Rationale 20).
If the child shows signs of breathlessness or severe coughing, remove the tube immediately ( Rationale 21).
Lightly secure the tube with tape, or have an assistant hold the tube in place until the position has been checked.
The position must be checked using the NPSA decision tree for NGT placement checks ( NPSA, 2011).
Once correct placement has been confirmed, remove the guide wire if present, secure the tube to the skin with a suitable tape or dressing and flush the tube with water. The amount of water used to flush the tube is determined by the length of the tube and the age of the baby/child.
Flush tube with 1-2mls of air to remove water from tube ( Rationale 22).
The guide wire should be cleaned, dried and placed in a sealed container, and labelled with the child’s name for reuse ( Rationale 23). Wash hands.
Record on the child’s Nasogastric Tube Testing Chart (or on ICCA Carevue) the date and time, as well as the size and type of tube that has been used. Also record the length of tube inserted, and record that correct placement has been confirmed. Record the length of visible tube from the nostril to the end (ie outside the child’s body) ( Rationale 24).
Confirming the position of a nasogastric tube
The position of all feeding tubes must be checked:
- After insertion.
- Before any liquid, feed or medications is introduced via the tube.
- At the change of feed if the child is receiving continuous tube feeding (this will be four-hourly for expressed breast milk and six-hourly for all other feeds).
In the event of the child having an episode of:
- Excessive coughing.
- Respiratory distress following a successful attempt to resolve a blocked tube.
- in the event that the tube appears to have been partially dislodged (eg when visible tube length has increased).
The feed may need to be stopped to allow time for the stomach to empty and the pH to become acidic. However, this may not be possible in some metabolic/endocrine patients who quickly become hypoglycaemic. If the feed needs to be stopped in these patients then this needs to be discussed with their medical team as to whether this is possible, an action plan decided and then documented in the patient's notes.
pH testing using pH indicator paper must be the first line method of checking the tube position:
- Aspirate a small amount of stomach contents using a 20ml or 50ml syringe in infants and children. For neonates use a 2-5 ml syringe ( Auckland District health Board, 2014, Knox and Davie, 2009). Test the aspirate on CE marked pH indicator paper intended by the manufacturer to test human gastric aspirates
- For gastric tubes (NGT/OGT) the safe pH range is between 1 and 5.5.
- Each test and test results must be documented on the NGT testing chart as appropriate (Appendix C in the management of gastric and jejunal feeding tubes policy) and must be kept at the child’s bedside.
If no aspirate can be obtained OR if the aspirate is NOT between 1-5.5 for gastric tubes:
- Change the child’s position and try to aspirate again.
- Inject 1-5ml air into the tube to remove a blockage at the end of the line or move the end of the tube from the lining of the stomach.
- Wait for 15-30 minutes and aspirate again.
- Advance or withdraw the tube by 1-2cm.
- Give mouth care to patients who are nil by mouth (this stimulates gastric secretions of acid).
- NEVER use water to flush the tube before confirming the position ( Rationale 25).
If no aspirate is then obtained or the aspirate is still outside of the safe range (gastric tubes 1-5.5), the tube position must be checked by x-ray (second line testing).`
Confirming feeding tube position by x-ray
The confirmation of feeding tube position by x-ray is a second line intervention and should only be used when pH testing of feeding aspirates has failed.
The x-ray request form must clearly state that the purpose of the x-ray is to establish the position of a gastric or jejunal tube for the purposes of feeding or medication administration. The radiographer must take responsibility for ensuring that the feeding tube can be clearly seen on this x-ray.
The x-ray must be interpreted by clinicians who have been deemed competent in assessing the position of feeding tubes by x-ray. This includes:
- All radiologists, as this is a core part of their training and role.
- Medical staff who have been assessed as competent by completing the trust e-learning module (available internally to GOSH staff via GOSHGold) or, if this is not possible, by a consultant radiologist.
- Nurses and Allied Health Care Professionals who have undertaken an advanced practice programme at masters level AND have completed the trust e-learning module (available internally to GOSH staff via GOSHGold).
The assessment of feeding tube placement must be documented in the patients’ healthcare record. Documentation must include:
- Confirmation that the x-ray viewed was the most recent for that patient.
- How the placement was interpreted.
- Clear instructions as to any required actions.
- The length of the feeding tube at the nostrils or mouth at the time of x-ray.
- If the x-ray been formally reported upon, a clinician must write in the healthcare record that they have viewed the radiologists report and that the feeding tube position is confirmed as satisfactory.
HCP who rely on x-ray confirmation of the feeding tube’s position should confirm before feeding:
- That the entry in the patients’ healthcare record is the most recent one.
- That the tube has not become significantly dislodged by cross-checking the length of the tube at the nostril or mouth with the entry confirming correct tube placement.
Any tubes identified to be in the lung are to be removed immediately, whether in the x-ray department or the clinical area.
Specific guidance for neonates
Neonates differ physiologically to children and the NPSA (2005) has recommended the following:
- None of the existing methods for checking feeding tube position are totally reliable. Their advice is based on the premise that it is better to base clinical decisions on one reliable test (pH indicator paper or radiography) than a combination of tests with varying reliability.
- Small bore feeding tubes are particularly difficult to gain aspirate from.
- Tube markings should be used for all babies to enable accurate measurement of depth and length and the position of the tube documented.
- Although radiography is the most reliable indicator of feeding tube position, x-rays should not be ‘routinely’ used. However if the baby is going to have an x-ray as part of their clinical care, the feeding tube should be placed beforehand and checked for positioning.
- The NPSA (2005) flow sheet should be used to guide practitioners (Appendix D in the management of gastric and jejunal feeding tubes policy)).
If the pH is outside the safe range AND an x-ray is not planned as part of routine care, a risk assessment should be performed and the following factors which may contribute to high pH considered:
- The presence of amniotic fluid in a baby under 48 hours old.
- Milk in the baby’s stomach, particularly if they are on one to two-hourly feeds.
- Use of medication to reduce stomach acid.
Feeding tube placement – techniques that must NEVER be used
The following are considered by the NPSA (2011) to be ‘never events’ and should not be used, no matter what the circumstances:
The ‘whoosh test’ – injecting air into the tube and auscultating the stomach.
- Acid/alkaline tests of gastric aspirates using litmus paper.
- Interpretation based on the appearance of the aspirates alone.
- Inject water into a feeding tube to confirm its position.
- Internal guide wires/stylets should NOT be lubricated before feeding tube position has been confirmed.
- Confirmation of feeding tube position based on x-ray alone by staff who have not been deemed competent to perform this assessment by this trust (either by successful completion of the e-learning or are deemed as competent by a consultant radiologist).
Additional advice for neonates (NPSA 2005):
- DO NOT interpret the absence of respiratory distress as an indicator of safe positioning.
- DO NOT test correct tube positioning by monitoring for bubbling at the end of the tube.
- Radiography should NOT be used ‘routinely’ but can be used if the baby is being x-rayed for another reason. Tube markings should be used for all babies to enable accurate measurement of depth and length and the position of the tube documented
Managing blocked feeding tubes
The same safety principles apply to managing blocked tubes:
- If aspirate cannot be obtained because the tube is blocked, fluid SHOULD NEVER be injected into the tube to unblock it.
- If a tube is blocked, remove it immediately and re-insert a new tube.
Follow the principle of confirming tube placement outlined above
Administering feeds/fluid via a feeding tube
Administering medications via a feeding tube
- This is a clean procedure, requiring a hygienic hand wash, apron and gloves.
- The position of the feeding tube should be confirmed immediately prior to administering the medication.
- Follow the principles outlined in the medicines administration policy (available to GOSH staff internally via GOSHweb intranet.
- The majority of medicines prescribed enterally can be administered via the gastric or the jejunal route. The risks and benefits of this should be discussed within the multi-professional team, but considerations include:
- Evidence of interference with the drugs efficacy if given via the jejunal route rather than the gastric route.
- Risk of aspiration if drugs are given via the gastric rather than jejunal route.
- Use syringes designed for administering medications via an feeding tube, never use intravenous syringes.
- Use liquid preparations where possible. If the preparation is very thick and may block the tube, consult the pharmacist for advice.
- Soluble, dispersible and crushed tablets may need to be administered, but ensure that the pharmacist is aware that administration is via a feeding tube. Certain preparations (eg enteric coated medications) are not suitable for crushing.
- Flush the feeding tube with 3-5ml water after confirming correct position and after administering the drug. If more than one drug is being administered, the tube should be flushed between each drug. Document the amount of fluid on the fluid chart.
- Flush tube with 1-2mls of air to expel water from the tube ( Rationale 22).
Care of the skin and nasal cavity
- Check the integrity of the nose and the surrounding skin and document daily – paying particular attention to the position of the tube as it exits the nose and the tape. Reposition as required to prevent tissue damage.
Documentation of feeding tube care
Documentation must happen at key points in the patient’s care. This includes:
- The decision-making and rationale behind the initial assessment that placement of a feeding tube is required for feeding or medications.
- Insertion of feeding tube – date, time, type and size of tube inserted, length of tube at nostrils or mouth, method of confirming tube position.
- Each pH test and the result on the NGT testing chart, even if the pH is outside the safe level.
- Each attempt to confirm tube position which has failed because no aspirate was obtained.
- Any interventions performed to gain aspirate as outlined on the decision tree for children (Appendix B) or neonates (Appendix D).
- Confirmation of feeding tube position using x-ray as outline above.
- Whether parents and/or patients are involved in the insertion and/or checking of feeding tube position and administration of feeds and medications.
- Date and time of feeding tube removal and the reason why this was undertaken.
Discharging a patient with a feeding tube
A full multi-professional supported risk assessment must be made before a child with a feeding tube is discharged into the community. The child’s community team must be consulted/informed about the decision before the child is discharged.
- This must be fully documented in the patient’s healthcare record.
- Ensure family are appropriately prepared for caring for their child at home, including:
- Training them to administer feeds and medicines via the tube- where appropriate
- Ensuring appropriate supplies are provided to the family (usually one to two weeks worth until community can arrange supplies to be delivered).
- That any pumps needed are arranged through the community/dietician and in place prior to discharge.
- Information on what to do if the tube falls out and where to go (this information should be clinician led for each child as the urgency of the need for the feeds and medicines varies from child to child)
- Ensure that this training is documented in the child’s health record.
Removal of the tube
- Stop feed pump if a continuous feed is running two hours prior to removal if possible ( Rationale 26).
- Ensure child and family are appropriately prepared for this.
- Collect equipment
- non-sterile gloves
- foil bowl for dirty NG tube and tape
- appeel (if needed to help remove tape)
- Wash hands.
- Remove tube smoothly and swiftly,reassuring the patient throughout.
Reasons for orogastric feeding include:
- A baby who has choanal atresia.
- A baby requiring nasal prong continuous positive airway pressure (CPAP).
- A baby whose airway would be compromised if a nasogastric tube was inserted, for example a baby with a craniofacial anomaly.
- Orogastric tubes must be inserted in children with a suspected or confirmed basal skull fracture ( Rationale 27).
How to insert an orogastric tube
The technique and precautions taken are the same as those for the passage of a nasogastric tube, except that the tube is passed directly through the mouth. Refer to section on insertion of a nasogastric tube.
The length of the tube must be adjusted appropriately, the measurement being taken from the xiphisternum to the lips.
Securing an orogastric tube
The tube should, if possible, be secured to the chin using a suitable hypoallergenic tape. Care should be taken not to damage the lips or gums ( Rationale 28).
It may prove very difficult to secure an orogastric tube, particularly when the baby becomes more active.
Care of the orogastric tube
Testing and documentation of the tube are the same as with the nasogastric tube.
If the baby is awake/alert they must be closely observed as the risk of tube displacement due to normal tongue suckling motion is high.
Rationale 1: Any suitably trained health care practitioner or carer can pass the tube without the need for specialist equipment or planning.
Rationale 2: The appearance of the tube may lead to unwanted attention from strangers and may be unacceptable to parents and children, particularly teenagers, whose self-esteem and body image are vulnerable.
Rationale 3: Regular re-insertion is traumatic for the child and family.
Rationale 4: Aspiration may occur when a tube is not correctly placed in the stomach, allowing feed to enter the lungs. This may lead to serious respiratory tract infection.
Rationale 5: It is necessary to secure the tube with a suitable tape.
Rationale 6: A gastrostomy is hidden under clothing and the tube is less likely to migrate from its gastric position, reducing the risk of aspiration and associated infection.
Rationale 7: To ensure that informed consent is obtained as the procedure is distressing for the child and family.
Rationale 8: To ascertain that the child understands the procedure and to explore fears, past experiences and preconceptions.
Rationale 9: To preserve the child's bedroom/space as a safe environment, free of painful or unpleasant procedures.
Rationale 10: To ensure the child's stomach is empty, reducing the risk of vomiting during the procedure.
Rationale 11: To ensure adherence to the NPSA (2011) standards of all tube being radio opaque.
Rationale 12: To avoid the child's whole attention being focused on the traumatic episode.
Rationale 13: This will enable an informed choice being made as to which tube is the most appropriate to use.
Rationale 14: The hard plastic material can cause irritation or discomfort to the skin and lining of the nose and oesophagus. The gastric juices cause the tube to become hard, resulting in a risk of perforation.
Rationale 15: They are softer and are therefore more comfortable for the patient, and cause less irritation and difficulty when swallowing.
Rationale 16: Drinking or sucking may assist passage of the tube.
Rationale 17: To involve the child and to let them have some control over the procedure.
Rationale 18: To ease removal of the guide wire following insertion.
Rationale 19: This may affect the pH reading.
Rationale 20: To avoid risk of perforation.
Rationale 21: The tube may have passed into trachea.
Rationale 22: To ensure no water is left in the tube to affect the next aspirate to be tested.
Rationale 23: Polyurethane tubes can be reused when they fall out, provided they are reinserted immediately and are still serviceable.
Rationale 24: To provide an accurate record of the procedure and because the measurement can be used in the future to ascertain whether the tube has migrated.
Rationale 25: The tube can be in the lungs by mistake.
Rationale 26: To ensure the stomach has had time to empty some of the contents to reduce the risk of vomiting.
Rationale 27: The tube could enter the cranial cavity.
Rationale 28: This can occur if the tube is pulled too tightly when securing it.
Marsha, L. et al (2011) Predicting the Insertion Length for Gastric Tube Placement in Neonates. Journal of Obstetric, Gynecologic & Neonatal Nursing, 40 (4): 412-421.
National Patient Safety Agency (NPSA) (2011) Patient Safety Alert NPSA/2011/PSA002 Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. London. [Accessed 22 July 2014].
National Patient Safety Agency (NPSA) (2005) Patient Safety Alert NPSA/2005/9 Reducing the harm caused by misplaced naso and orogastric feeding tubes in babies under the care of neonatal units . London. [Accessed 22 July 2014].
Royal College of Nursing (2010) Restrictive physical intervention and therapeutic holding for children and young people. London. [Accessed 22 July 2014].
Auckland District Health Board (2014) Newborn Services Clinical Guideline, ADHB New Zealand . [Accessed 9 July 2014].
Knox, T. and Davie, J. (2009). Nasogastric tube feeding--which syringe size produces lower pressure and is safest to use? Nursing Times, 105 (27): 24-26.
Aliakbari Sharabiani, B. et al (2011) Nasogastric tube placement errors and complications in pediatric intensive care unit: a case report. Journal of Cardiovascular & Thoracic Research, 3 (4): 133-134.
Clarke, S. and Richardson, O. (2007) A review of nasogastric tube management in children 1: Enteral Feeding. Childrens and young people’s Nursing, 1 (2): 72-80.
Durai, R. and Venkatraman, R. (2009) Nasogastric tubes 1: Insertion technique and confirming the correct position. Nursing Times, 105 (16): 12-13.
Durai, R. and Venkatraman, R. (2009) Nasogastric tubes 2: Risks and guidance on avoiding and dealing with complications. Nursing times, 105 (17): 14-16.
Johnson, T. (2007) Enteral Nutrition. In: Shaw, V. and Lawson, M. Clinical Paediatrics Dietetics. (3rd edition). Oxford: Blackwell.
National Patient Safety Agency (NPSA) (2005) Patient Safety Alert 2005-02-21. Reducing harm caused by the misplacement of nasogastric feeding tubes. London.
Document control information
Rachel Scott, Practice Educator, MDTS
Vanessa Shaw, Head of department, Dietetics
Joanne Brind, Clinical Nurse Specialist, Nutrition, Gastroenterology
Rachel Scott, Practice Educator, MDTS
Guideline Approval Group
First introduced: 29 September 2004
Date approved: 12 May 2014
Review schedule: Three years
Next review: 12 May 2017
Document version: 4.0
Replaces version: 3.0