Enteral feeding is a very useful method of ensuring adequate intake of fluid and nutrients in patients who, for a variety of reasons, are unable to use the oral route, or are unable to take sufficient nutrients to maintain growth and development.
Successful use of the enteral route to supply nutrients is dependent on the child having a functioning gastrointestinal tract.
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:
- Gastrostomy management guideline
- Jejunal tube management (including naso-jejunal and jejunostomy tubes) guideline
- Management of gastric and jejunal feeding tubes policy (available to GOSH staff internally on GOSHweb intranet site)
Nasogastric tubes (NGT)
- 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).
- 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).
Passing a nasogastric tube
- 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.
- Older patients and young people and/or parents/carers who have been trained in the skill and are deemed competent, in passing and testing nasogastric tubes.
Preparing the child and family
Types of tubes
- In general, the range of sizes for paediatric use is 6 Fr to 10 Fr (Rationale 13). All tubes are polyurethane.
Short term tubes should be changed every 30 days, with the exception of ventilated children and neonates that require a tube change every 7 days. This is advised by the manufacturer Medicina to reduce the risk of chest infection (Medicina)
Preparation of 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 14)
Inserting the nasogastric tube
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 (Rationale 16).
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.
- Date and time of nasogastric tube insertion
- Size of nasogastric tube
- Type of nasogastric tube.
- Length at which nasogastric tube fixed/inserted
- Confirmation of correct placement by pH reading or x-ray
- Record the length of visible tube from the nostril to the end of the tube (i.e. outside the child’s body) ( Rationale 21).
Confirming the position of a nasogastric tube
- 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).
- 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 (e.g. when visible tube length has increased) (NPSA, 2011).
- 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 oral / nasal gastric feeding tubes policy) and must be kept at the child’s bedside.
- Change the child’s position and try to aspirate again.
- Aspirate a small amount of stomach contents using a 20ml or 50ml syringe in infants and children
- Inject 1-2ml air into the tube using the same syringe as mentioned above to remove a blockage at the end of the line or move the end of the tube away 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 22).
Confirming feeding tube position by x-ray
- 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).
- 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, as confirmed by NG documentation.
- 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.
- 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.
Specific guidance for neonates
- 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 (2005a) flow sheet should be used to guide practitioners (Appendix E in the management of oral and gastric feeding tubes policy).
- 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 ‘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).
- 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
- 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.
Administering feeds/fluid via a feeding tube
- This is a clean procedure, requiring hand hygiene to be completed, apron and gloves.
- The position of the feeding tube should be confirmed immediately prior to administering an enteral feed.
- Do not heat enteral feeds prior to administration.
- Do not touch the key parts, such as the inner part of the spike set.
- Flush the feeding tube with 3-5ml water after confirming correct position and following administration of the feed.
- Document all fluids accurately in the child’s health care record.
- Never top-up enteral feeds into the reservoir of feeding systems.
- Never decant feeds from bottles into bed sets on the ward.
Administering medications via a feeding tube
- This is a clean procedure, requiring hand hygiene to be completed, 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 medicines efficacy if given via the jejunal route rather than the gastric route.
- Risk of aspiration if medicines are given via the gastric rather than jejunal route.
- Use oral syringes designed for administering medications via a feeding tube, never use intravenous syringes. ENFit products are designed specifically for enteral use to reduce any risk of misconnection.
- Low dose tip (LDT) syringes (1ml & 2.5ml), introduced with ENFit syringes and tubes, recommend using a drawing up device (for example, medicine straw or bottle adaptor) to ensure dose accuracy.
- http://stayconnected.org/wp-content/uploads/2016/09/ESPEN-Presentation.pdf p20
- 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 (e.g. enteric coated medications) are not suitable for crushing.
- Flush the feeding tube with 3-5ml water after confirming correct position and after administering the medicine. If more than one medicine is being administered, the tube should be flushed between each medicine. Document the amount of fluid on the fluid chart.
- Flush tube with 1-2mls of air to expel water from the tube ( Rationale 20).
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
- 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, length of tube remaining external, 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 E), found in the Management of oral/nasal feeding tubes policy.
- 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
- Liaison with the dietetics department regarding discharge should occur in good time
- This must be fully documented in the patient’s healthcare record, including parents / carers competency (as per ward policy).
- Ensure family are appropriately prepared for caring for their child at home, including, training the family to administer feeds and medicines via the tube, where appropriate
- Ensuring appropriate supplies are provided to the family (as confirmed / in line with local guidelines).
- 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 parental training and competence 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 23).
- Ensure child and family are appropriately prepared for this.
- Collect equipment
- non-sterile gloves
- foil bowl for dirty NG tube and tape
- Adhesive removal product (if needed to help remove tape)
- Perform hand hygiene.
- Put on gloves.
- Remove tube smoothly and swiftly, reassuring the patient throughout.
- 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 24).
How to insert an orogastric tube
Securing an orogastric tube
Care of the orogastric tube
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.
Auckland District Health Board (2014) Nasogastric/Orogastric Tube Placement. Newborn Services Clinical Guideline, ADHB New Zealand. [Accessed 22 January 2018].
Cirgin-Ellett ML, Cohen MD, Perkins SM, Smith CE, Lane KA and Austin JK. (2011) Predicting the Insertion Length for Gastric Tube Placement in Neonates. Journal of Obstetric, Gynecologic & Neonatal Nursing, 40 (4): 412-421.
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.
Medicina nasogastric feeding tubes. Available at: http://medicina.co.uk/downloads/ENFITNGMKT001.pdf [Last accessed 29/01/2018]
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. [Last accessed 22 January 2018].
National Patient Safety Agency (NPSA) (2005a) 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. [last accessed 22 January 2018].
National Patient Safety Agency (NPSA) (2005) Patient Safety Alert 2005-02-21. Reducing harm caused by the misplacement of nasogastric feeding tubes. London. Available at: http://www.nrls.npsa.nhs.uk/resources/?entryid45=59794%20 [Last accessed 22 January 2018]
Royal College of Nursing (2010) Restrictive physical intervention and therapeutic holding for children and young people. London. Available at: https://www.rcn.org.uk/professional-development/publications/pub-003573 [Last accessed 22 January 2018]