Nasogastric tube feeding is a way to deliver nutrition, hydration and medication into the Gastrointestinal (GI) tract through an artificial flexible tube that is inserted into the stomach through the nasal passage.  It is the most suitable route for patients requiring short term enteral feeding support or for patients awaiting procedures to provide longer term access such as a gastrostomy tube.  This method of feeding is only necessary or desirable when a patient’s nutritional needs cannot be met orally for various reasons.

  This may include, but not limited to;

• Unable to feed by mouth (orally)
• The need for supplemental nutrition or hydration
• Distress during feeding or oral aversion
• Recurrent aspiration
• Decompression and drainage of stomach contents
• Chronic illness
• Acute illness
• Unconscious patient

Nasogastric feeding can provide effective support in both the short and long terms for patients who cannot meet their nutritional requirement orally and where their gut is still functional.  The associated risks and benefits must be assessed and discussed with the patient, their parents/ carers before commencing nasogastric feeding.

• Confirmation and documented by medical staff that this is an appropriate treatment plan
• Is it appropriate to pass a nasogastric tube and commence feeding at this time and is the required equipment available?
• Is there sufficient knowledge or expertise available to test for safe placement of the nasogastric tube?
• Consider referral to Dietetics via Trakcare for assessment, continuing recommendations and monitoring

All healthcare support workers involved in the insertion, testing and administration of nasogastric feeding should be appropriately trained and supervised until considered competent.  A practitioner can be described as competent if they have had the necessary training, clinical experience, skills and knowledge to undertake the task safely and without supervision.

The table below outlines the specific roles and responsibilities for healthcare practitioners

Consent is required before healthcare practitioners undertake any care for a patient.  Informed consent must be obtained before any procedure taking place, this involves a clear explanation of the risks and benefits.  This may be informal (verbal) or formal (written) for more complex procedures. Children and young people under 16 years old have the legal capacity to consent, or refuse treatment on their own behalf, if they are deemed capable of understanding the nature and possible consequences of treatment.  A parent or legal guardian may consent to medical treatment if the child lacks decision-making capacity.

In emergency situation, common law and duty of care reasoning allows healthcare practitioners to use clinical judgment as to whether the risks of delaying a procedure outweighs the need for formal consent. The healthcare practitioner must ensure that it is necessary, reasonable and proportionate.

Short Term

These tubes are typically made from Polyvinylchloride (PVC) and are fully radio-opaque. They can remain in place for between 7-10 days, depending on manufacturer’s recommendations.  They should be replaced if required for a longer duration as can become brittle over time.

Long Term

These tubes are made from Polyurethane (PUR), fully radio-opaque and typically have a guidewire to aid the passing of the tube.  They can remain in place for 90 days or as long as required, depending on manufacturer’s recommendations provided the tube remains intact with no complications.  These tubes remain soft and flexible throughout use.

All nasogastric tubes (short and long term) are single use.  These should be discarded and replaced with a new tube should it become dislodged.

The size of the nasogastric tube will vary with the size of the child and the purpose of insertion. If the purpose is for feeding, a smaller size tube is appropriate.  This table provides recommended nasogastric tube sizing, however clinical judgement must be used for each individual patient.

If the purpose of the tube is decompression or drainage, a larger size tube should be used.

There are several contraindications to be considered prior to insertion of a nasogastric tube. Seek advice from senior medical staff if a nasogastric tube is to be inserted or the patient is considered at risk.

These may include but not limited to:

• A competent patient refuses treatment
• Basal skull fracture
• Maxilla facial disorders
• Unstable c-spine injuries
• Nasal/ pharyngeal oesophageal obstruction
• Oesophageal Atresia before repair
• Having undergone oesophageal surgery
• Actively bleeding oesophageal or gastric varices
• Clotting disorders

Potential complications which may arise during and after the insertion procedure can include:

All staff must be aware of strangulation risk with enteral feeding lines, the highest risk being overnight (NPSA 2011). Minimise the risk by observing the following steps:

• Reduce the length of tubing in the cot/ bed
• Remove any unnecessary tubing
• Position feeding pump at head of the cot/ bed with feeding set through the bars and not over the top
• Secure tubing through clothing if possible
• Equipment and tubing should be assessed at regular intervals overnight
• Feeding regimes should be reviewed regularly, especially at the stage where movement overnight is likely to change

If continuous overnight feeding is required, this must be clearly documented in the medical notes.

Statement

Nasogastric tubes should only be inserted where a patient’s nutritional needs cannot be met orally due to various reasons, and in conjunction with an agreed care plan. The continuing need for a nasogastric tube should be reviewed on a daily basis and should be removed as soon as it is no longer required.

Requirements

• Appropriate PPE (minimal consideration disposable apron and gloves)
• Clean tray
• Nasogastric tube in an appropriate size
• Sterile water
• Enteral syringe (20/60ml)
• Appropriate securing device/ hypoallergenic tape
• CE marked pH indicator strip (to test human gastric aspirate)
• Disposable sick bowl
• Nasogastric Feeding Tube Care plan Acute Paediatrics

Timing

Short term nasogastric tubes (PVC) should be replaced every 7-10 days.

Long term tubes (PUR) should be replaced every 90 days, or may remain in-situ longer depending on manufacturer’s recommendations provided the tube remains intact with no complications.

Procedure 

• Explain procedure to patient/ carer and obtain consent to proceed
• Perform hand hygiene
• Apply PPE
• Where possible position patient sitting upright with head tilted forward, alternatively babies can be wrapped in a blanket to help keep them secure
• Ensure no contraindications to carrying out procedure. If possible, ask patient to blow nose and ensure nostrils are clean prior to commencement of procedure
• Clean surface of tray as per decontamination of equipment procedure
• Perform hand hygiene
• Check expiry dates of all equipment and open onto clean surface

Note: when removing pH indicator strip from the packet, hold the white plastic end. Do not let the three coloured squares touch anything as this may alter the result

• Apply disposable gloves
• Ensure all ports of nasogastric tube are closed, if guidewire in-situ ensure securely attached to the end of the tube
• Measure the length of tube to be inserted to ensure that tip enters the gastric region, this is referred to the NEX measurement (Nose-Ear-Xiphisternum)
  • Place tip of tube at the tip of nose
  • Extend tube to the child’s earlobe
  • Then extend to the base of the breastbone (xiphisternum)
  • Use centimetre (cm) marks on the tube for reference, note length of tube to be passed

Note: anatomical landmarks remain the same across all age groups

• Lubricate the tip of the tube with sterile water
• Pass the tube using the following steps:
  • Insert the tip of the tube into the chosen nostril and advance along the floor of the nose to the nasopharynx
  • As the tube passes down into the nasopharynx then the oropharynx, ask child to take sips of water if permitted via a straw to facilitate passage. If the patient is a baby you can offer a dummy to trigger a swallow
  • Advance until the pre-noted length (NEX measurement) is at the entrance of the nostril

• Pause procedure if patient is coughing, choking or if there is colour change. Using clinical judgement assess whether procedure should continue or tube should be removed. Escalate to senior health professional if concerned
• Check to ensure tube is not coiled in the patient’s mouth, if it is withdraw until coil not visible. Re-advance tube until the pre-noted length is at the nostril
• Secure the tube at the nostril with hypoallergenic tape
  • Apply Hypafix or Hydrocolloid dressing onto cheek under nasogastric tube, then secure with Hypafix or clear film dressing on top, such as Tegaderm

• Confirm position of nasogastric tube by following steps in Procedure for confirmation of position of Nasogastric Tube
• If unable to obtain aspirate, remove guidewire if applicable (following manufacturer’s guidance) and re-attempt to obtain aspirate. Follow steps on Decision tree for nasogastric tube placement checks in children and Infants
• Once position of tube confirmed to be within the stomach and if guidewire still in-situ, remove guidewire following manufacturer’s guidance. Flush the tube with at least 10mls sterile water using enteral syringe. Close connections on tube

NOTE: Remove guidewire when secure and in place, it is not required for x-ray confirmation

• Discard all disposable equipment
• Remove PPE and discard as healthcare waste
• Perform hand hygiene

Do not administer anything down tube until correct position is confirmed

Do not reinsert guide wire when the nasogastric tube is in the patient

Aftercare

Record result in Nasogastric Feeding Tube Care Plan Acute Paediatrics (in PICU use care plan and ‘fluids out’ page within Electronic Clinical Information System)

Statement

PH testing is used as the first line to test for position and patency of a nasogastric tube.

X-ray should be used as a second line test when no aspirate can be obtained, pH indicator strip has failed to confirm the position of the nasogastric feeding tube (NPSA, 2011) or there are clinical concerns following the placement of a nasogastric tube.

Requirements

• Appropriate PPE (minimal consideration disposable apron and gloves)
• Clean tray
• Enteral syringe (20/60ml)
• CE marked pH indicator strip (to test human gastric aspirate)
• Nasogastric tube position confirmation record

Timing

• Following initial insertion
• Before administering each feed or medications
• Any new or unexplained respiratory symptoms, if oxygen saturations decrease, or any other clinical concern
• At least 12 hourly during continuous feeds
• Following episodes of vomiting, retching or coughing spasms
• When there is a suggestion of tube displacement

Procedure 

• Explain procedure to patient/ carer and obtain consent to proceed
• Perform hand hygiene
• Apply PPE
• Position child/ young person with head and shoulders elevated or if possible in a sitting position
• Clean surface of tray as per decontamination of equipment procedure
• Perform hand hygiene
• Check expiry dates of all equipment and open onto clean surface

Note: when removing pH indicator strip from the packet, hold the white plastic end
Do not let the three coloured squares touch anything as this may alter the result             

• Apply disposable gloves
• Check external cm marking at the nostril is the same as documented on care plan
• Attach Enteral syringe to connector on nasogastric tube, pull back gently on plunger to aspirate fluid. Use a 20 ml syringe for infants and small children, and a 60 ml syringe for the older child

Note: only a small amount, 2-3 drops, aspirate is required

• Remove syringe and apply aspirate onto CE marked pH indicator strip covering all three coloured squares
• Follow manufacturer’s guidance, for the colour change process to complete and compare pH indicator strip to colour chart on packaging
• If pH ≤ 5 remove guidewire if still in-situ and flush tube with at least 10mls sterile water using Enteral syringe and proceed to feed, where pH readings fall between 5 and 5.5 it is recommended that a second competent person checks the reading or retests, refer to Decision tree for nasogastric tube placement checks in children and Infants

Note:

If pH >5.5 or no aspirate obtained– Do not use - Refer to Decision tree for nasogastric tube placement checks in children and Infants

• Discard all disposable equipment
• Remove PPE and discard as healthcare waste
• Perform hand hygiene

Aftercare

Record result in Nasogastric Feeding Tube Care Plan Acute Paediatrics

Within PICU record result in the ‘Fluids Out’ page and Care Plan on the Electronic Clinical Information System

Statement

Bolus feeding via nasogastric tube delivers a pre-determined volume of feed over a short period of time.

Requirements

• Appropriate PPE (minimal consideration disposable apron and gloves)
• Clean tray
• Enteral syringe (20/60ml)
• CE marked pH indicator strip (to test human gastric aspirate)
• Sterile water
• Breastmilk/ infant formula/ prescribed milk feed
• Nasogastric tube position confirmation record

Note: when removing pH indicator strip from the packet, hold the white plastic end. Do not let the three coloured squares touch anything as this may alter the result

• Check the feed including feed type and expiry date. Opened containers should be kept in the fridge and discarded after 24 hours
• Apply disposable gloves
• Test the position of the tube following the Procedure for confirmation of position of Nasogastric Tube
• If pH ≤ 5 proceed to feed, where pH readings fall between 5 and 5.5 it is recommended that a second competent person checks the reading or retests, refer to Decision tree for nasogastric tube placement checks in children and Infants
• To flush the tube remove the nasogastric tube cap
• Remove the plunger from the 60ml enteral syringe and attach the syringe to the end of the nasogastric tube  
• Pour the recommended amount of sterile water into syringe barrel as per individual child’s care plan
• Elevate the syringe slightly above patient’s nose level and let the water run in by gravity
• After the water has been administered, pour the feed into the syringe, continue refilling syringe barrel with feed at a rate tolerated by the child/ young person until feed volume is complete

Note: If the feed is going too fast lower the height of the syringe, if the feed is going too slow raise the height of the syringe. The average time it should take for the feed to run through is 15-30 minutes

• Gravity feeding is the preferred method however there may be times when you need to gently push the feed using the plunger for example thickened feeds
• Once the feed is complete flush the tube with the prescribed volume of sterile water as per individual child’s care plan
• Remove syringe and replace nasogastric tube cap
• Discard all disposable equipment
• Remove PPE and discard as healthcare waste
• Perform hand hygiene

Note: If the child or young person starts coughing or vomiting during the feed, then stop the feed. Once they have settled, retest the position of the tube again following the Procedure for confirmation of position of Nasogastric Tube before recommencing the feed.

Timing

As often as necessary to administer feeds as per individual child’s care plan.

Procedure 

• Explain procedure to patient/ carer and obtain consent to proceed
• Perform hand hygiene
• Apply PPE
• Position child/ young person with head and shoulders elevated or if possible in a sitting position
• Clean surface of tray as per decontamination of equipment procedure
• Perform hand hygiene.
• Check expiry dates of all equipment and open onto clean surface

Aftercare

Record result of pH aspirate in Nasogastric tube position confirmation record and document feed in the Fluid Balance Chart.

Within PICU record result in the ‘Fluids Out’ page and Care Plan on the Electronic Clinical Information System

Statement

A feeding pump can be used for bolus, continuous feeds and high risk abdomen feeding (PICU only), delivering a pre-determined volume of feed at a controlled rate. Be aware of strangulation risk with enteral feeding lines.

Requirements

• Appropriate PPE (minimal consideration disposable apron and gloves)
• Clean tray
• Enteral syringe (20/60ml)
• CE marked pH indicator strip (to test human gastric aspirate)
• Sterile water
• Breastmilk/ infant formula/ prescribed milk feed
• Enteral feeding pump (for continuous/ intermittent feed/ high risk abdomen in PICU)
• Feeding administration set
• Nasogastric tube position confirmation record

Timing

• As often as necessary to administer feeds as per individual child’s care plan.
• Feed administration sets should be replaced at least every 24 hours. 
• Refer to dietitian for hang times of milk feeds.

Procedure

• Explain procedure to patient/ carer and obtain consent to proceed
• Perform hand hygiene
• Apply PPE
• Position child/ young person with head and shoulders elevated or if possible in a sitting position
• Clean surface of tray as per decontamination of equipment procedure
• Perform hand hygiene
• Check expiry dates of all equipment and open onto a clean surface

Note: when removing pH indicator strip from the packet, hold the white plastic end. Do not let the three coloured squares touch anything

• Apply disposable gloves
• Check the feed including feed type and expiry date. Opened containers should be kept in the fridge and discarded after 24 hours
• Fill the feeding bag if applicable or pierce bottle/ pack with giving set and insert into the pump. Prime the feeding set as instructed by the manufacturer. Nutricia Flocare Infinity II Video and Training Simulator
• For High Risk Abdomen feeding within PICU use Alaris Enteral Feeding Pump Syringe Driver. See PICU guideline for the nutritional management of ‘high risk abdomen
• Set the rate and volume as prescribed by the dietitian/ clinician
• Test the position of the tube following the Procedure for confirmation of position of Nasogastric Tube
• If pH ≤ 5 proceed to feed, where pH readings fall between 5 and 5.5 it is recommended that a second competent person checks the reading or retests, refer to Decision tree for nasogastric tube placement checks in children and Infants
• To flush the tube remove the nasogastric tube cap
• Remove the plunger from the 60ml enteral syringe and attach the syringe to the end of the nasogastric tube 
• Pour the recommended amount of sterile water into syringe barrel as per individual child’s care plan
• Elevate the syringe slightly above patient’s nose level and let the water run in by gravity
• After the water has been administered, remove the syringe and attach primed feeding set, open any clamps on feeding set and commence feed
• Once the feed is complete close all clamps and detach the feeding set
• To flush the tube remove the nasogastric tube cap
• Remove the plunger from the 60ml enteral syringe and attach the syringe to the end of the nasogastric tube
• Flush with the prescribed volume of sterile water, as per individual child’s care plan
• Remove syringe and replace nasogastric tube cap
• Discard all disposable equipment
• Remove PPE and discard as healthcare waste
• Perform hand hygiene

Note: If the child or young person starts coughing or vomiting during the feed, then stop the feed. Once they have settled, retest the position of the tube again following the Procedure for confirmation of position of Nasogastric Tube before recommencing the feed.

Aftercare

Record result of pH aspirate in NHSGGC Nasogastric tube position confirmation record and document feed in the Fluid Balance Chart.

Within PICU record result in the ‘Fluids Out’ page and Care Plan on the Electronic Clinical Information System

Statement

A nasogastric tube should be removed at the earliest convenience if it is no longer required, following discussion with clinician.

Requirements

• Appropriate PPE (minimal consideration disposable apron and gloves)
• Medical adhesive remover
• Disposable orange bag

Timing

When there is no further clinical need or tube displacement / misplacement occurs.

Procedure 

• Explain procedure to patient/ carer and obtain consent to proceed.
• Perform hand hygiene
• Apply PPE
• Position child/ young person with head and shoulders elevated or if possible in a sitting position.
• Remove any tape using medical adhesive remover to prevent Medical Adhesive Related Skin Injury
• Ensure cap is insitu to prevent flow of tube contents into the oesophagus on removal.
• Withdraw the tube in a single swift motion until completely removed
• Inspect tube to ensure it is all intact
• Offer tissues/clean patients nose
• Discard all disposable equipment
• Remove PPE and discard as healthcare waste
• Perform hand hygiene
• Document removal of tube

Aftercare

Ensure patient comfortable post removal.

Nasogastric Feeding Tube Care Plan Acute Paediatrics (pdf)

Nasogastric tube position confirmation record (pdf)