This guideline forms part of a series regarding the management of enteral tubes, including placement, access and management. Please also see guidelines for:
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Nasogastric is the most common route for enteral feeding. Benefits include:
- It is easy to establish and minimally invasive (Rationale 1).
- Parents 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 (Rationale 4).
- 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 under supervision by a registered, competent HCP.
- 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.
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 12
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 13).
Fine bore tubes (polyurethane):
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 15)
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 16).
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. Flush the tube with 10ml of water (Rationale 17).
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.
Lubricate the end of the tube in sterile water; do not use K-Y Jelly® (Rationale 18).
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 19).
If the child shows signs of breathlessness or severe coughing, remove the tube immediately (Rationale 20).
Lightly secure the tube with tape, or have an assistant hold the tube in place until the position has been checked.
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. It is now safe to use the tube for administration of feed and medication.
The guide wire should be cleaned, dried and placed in a sealed container, and labelled with the child’s name for reuse (Rationale 21). Wash hands.
Record in the child’s notes 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 22).
Confirming the position of a nasogastric tube
Correct nasogastric tube position must be confirmed:
- at the time of insertion
- before each use
- 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 tube position should be checked every six hours where possible, or at least once per shift during continuous feeds (NNNG 2004).
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 patients who quickly become hypoglycaemic if the feed is stopped.
Following the issue of a medical devices alert by the Medicines and Healthcare products Regulatory Agency 2004, and reinforced by an alert issued by the National Patient Safety Agency 2005, only pH indicator paper should be used to confirm the position of a nasogastric tube.
- gastric position - pH ≤5.5
- bronchial position - pH 6-8
- small bowel position - pH 6-8
It is important to be aware that some medications, such as proton pump inhibitors and H2 receptor blocking agents, can elevate gastric pH readings. Radiography is recommended to check initial placement in patients who are unconscious, intubated or have absence of swallow reflex.
To check position of the tube, aspirate a small amount of stomach content using a 20ml or 50ml syringe (except in neonates).
Use pH paper to confirm correct placement of the tube. Use the colour indicator chart with pH numbers, as supplied with strips. Document details of test on nasogastric tube testing chart.
If no aspirate can be obtained, insert the tube a further few centimetres or change the child’s position and try again (Rationale 23
). If still unable to aspirate and it is safe to do so, offer the child a drink of water and try again (Rationale 24
Consider any drug therapy the child is receiving:
- Omeprazole or ranitidine may affect the pH, although in the majority of cases a pH of less than five has been found.
- Domperidone will speed up the process of gastric emptying.
If still unable to confirm position by aspirate, an X-ray may be necessary to confirm placement. Consult the next level of senior staff and conduct a risk assessment. Document actions and decision on nasogastric tube testing chart.
Options: replace/re-position tube, X-ray, continue based on assessment of risk.
Air insufflation with abdominal auscultation is unreliable and should not be used (Rationale 25).
If the tube has been advanced through the stomach into the intestine, the pH will increase to 6-8 and the aspirate will be bile-stained.
Reasons for oro-gastric 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 26).
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 27
It may prove very difficult to secure an orogastric tube, particularly when the baby becomes more active.
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 avoid the child's whole attention being focused on the traumatic episode.
Rationale 12: This will enable an informed choice being made as to which tube is the most appropriate to use.
Rationale 13: 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 14: They are softer and are therefore more comfortable for the patient, and cause less irritation and difficulty when swallowing.
Rationale 15: Drinking or sucking may assist passage of the tube.
Rationale 16: To involve the child and to let them have some contol over the procedure.
Rationale 17: To ease removal of the guide wire following insertion.
Rationale 18: This may affect the pH reading.
Rationale 19: To avoid risk of perforation.
Rationale 20: The tube may have passed into trachea.
Rationale 21: Polyurethane tubes can be reused when they fall out, provided they are reinserted immediately and are still serviceable.
Rationale 22: 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 23: To change the fluid level in the stomach.
Rationale 24: The stomach may be empty.
Rationale 25: The tube can be in the oesophagus and be mistaken for being in the stomach.
Rationale 26: The tube could enter the cranial cavity.
Rationale 27: This can occur if the tube is pulled too tightly when securing it.
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Document control information
Maggie Stewart, formerly Clinical Nurse Specialist, Nutrition, Gastroenterology
Crispin Walkling-Lea (editor), Clinical Guidelines and Care Pathway Co-ordinator, Strategic Development
Vanessa Shaw, Head of department, Dietetics
Susan Macqueen, CNS, Infection control, Microbiology
Nettie Fabian, formerly Senior Staff nurse, Transitional Care Unit
Susan Chapman, Nurse Consultant, Acute Care
Joanne Brind, Clinical Nurse Specialist, Nutrition, Gastroenterology
Clinical Practice Committee
First introduced: 29 September 2004
Date approved: 3 June 2011
Review schedule: Two years
Next review: 3 June 2013
Document version: 3.0
Replaces version: 2.0