This first of two articles on nasogastric tube insertion explains the procedure for a child or young person, including ethical, practical and safety considerations
This article, the first of two on nasogastric tube insertion, outlines the procedure for children and young people. It considers reasons for insertion, ethical considerations, positioning and preparation of the patient, and the procedure of passing the nasogastric tube. There is a key focus on the correct selection and testing of the nasogastric tube and the importance of training before performing the procedure.
Citation: Lawson-Wood H, Hucker J (2022) Nasogastric tube insertion 1: children and young people. Nursing Times [online]; 118: 8.
Authors: Hayley Lawson-Wood is lecturer in children’s nursing; Jackie Hucker is senior lecturer and assistant academic lead; both at Oxford Brookes University.
- This article has been double-blind peer reviewed
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Nasogastric (NG) tube insertion is an essential skill for children’s nurses. In children and young people, NG tubes are used primarily to provide enteral nutrition but they may also be used because of:
- Problems with swallowing or sucking;
- The need for supplemental nutrition;
- A need to administer medication;
- The need to aspirate;
- A need for drainage of gastric contents.
Maintaining children or young people’s nutrition is paramount, as it helps their growth, development and activity (Public Health Agency, 2018). Poor nutrition can lead to malnourishment, delayed growth and increased risk of future health problems. Due to differences in the reasons for insertion and other clinical considerations, this article does not cover neonatal care.
NG tube insertion should only be performed after the health professional has had approved training, supervised practice and competency assessment, and in accordance with all relevant local policies and protocols.
There are risks associated with NG tube insertion. The National Patient Safety Agency (NPSA) introduced a safety alert – (NPSA, 2011b) – intended to reduce harm from misplaced NG feeding tubes; this was followed by NHS Improvement’s (2016a) resource about performing initial placement checks on NG tubes.
The misplacement of NG tubes was also included in NHS Improvement’s (2018) list of serious preventable events that should not occur; these are termed ‘never events’. Nonetheless, the most recent never event report highlights that between 1 April 2021 and 31 January 2022 there were 27 misplaced NG or orogastric tubes and feeds administered (NHS England and NHS Improvement, 2022). Although this figure includes patients of all ages, not just children and young people, it highlights the need for continued education and support around the use of NG tubes to eliminate the risk of patient harm.
Ethical considerations and contraindications
Passing an NG tube on a child or young person carries many ethical considerations. The choice must be discussed with patients as well as their parent or guardian. Questions to consider are:
- Is there a clinical need for an NG tube to be passed?
- Does the child or young person have the capacity/ability to consent/assent to the procedure?
- Has the child or young person been adequately prepared for the procedure?
- Is the health practitioner competent to carry out the procedure?
- What are the agreed parameters for the removal of the tube?
If an NG tube is to be passed on a child or young person without their consent/assent, this must be discussed with the nursing and medical team alongside the parent or guardian, and the decision and rationale recorded in the patient’s notes.
Contraindications to consider before passing an NG tube in children and young people, include:
- Severe facial trauma, due to an increased risk of tube misplacement and further trauma to the face;
- Altered anatomy, as there is the potential for misplacement caused by inaccurate measurements;
- Abnormal clotting capabilities, due to an increased risk of bleeding during placement;
- Skull fracture, as there is an increased risk of placement into the cranial cavity (Rosengarten and Davies, 2021).
If any of the above are present, NG tube placement should be used with caution and with further guidance from the multidisciplinary team.
During the procedure, patients need to be positioned correctly (Fig 1). They may need to be clinically held to help the process (Bray et al, 2019); this should be discussed with the patient and their parent or guardian. Fig 2 shows some therapeutic holding techniques.
NG tubes are pre-packaged and sterile. Local infection prevention and control policies should be adhered to throughout to minimise the risk of infection. Non-sterile gloves, aprons and a visor should be donned to minimise risk to the health practitioner and the patient.
Before inserting an NG tube, make sure the patient is aware the procedure is going to take place; explain the process and reconfirm consent/assent. Distraction techniques and working with a play specialist or play therapist can minimise patients’ anxiety (Koller and Goldman, 2012).
Patients should not have had anything to eat or drink for 15-30 minutes before the procedure to make sure there is no forcible gastric emptying. The health professional should also make sure there are no contraindications to using the nostril, such as narrowing, trauma or structural deformities. If any are present, the other nostril should be used. If children are old enough, they can clear their nostril before insertion. The patient should then be positioned correctly.
Equipment and measurements
The following are required:
- NG tube;
- Skin protection, such as a hydrocolloid dressing;
- pH testing strip;
- Securing material;
- 20ml enteral syringe;
- Water or pacifier;
- Personal protective equipment (PPE);
- Receptacle, in case the patient vomits;
- Sterile water;
Commonly, children and young people have size 6-10 French gauge tubes passed, with a length of 100-110cm, depending on the patient’s age and size. Short-term NG tubes are made of polyvinyl chloride and are changed regularly according to manufacturer’s guidelines (Reddy et al, 2021). Long-term NG tubes are made of polyurethane and can stay in place for 4-6 weeks; they are usually more rigid and contain a guide wire.
There are two commonly used methods of measuring for NG tube placement:
- Nose-earlobe-xiphoid (NEX);
- Nose-earlobe-midline of the umbilicus (NEMU).
Although NEX measurement (Fig 3) is commonly used in practice settings, NEMU measurement (Fig 4) has superior accuracy for stomach placement – namely 97%, compared with 59% for NEX (Irving et al, 2018).
- Explain the procedure and gain consent/assent from the child or young person.
- Ensure the required equipment is available and assembled.
- Wash your hands and don the appropriate PPE, following trust policies to minimise the risk of infection.
- Ensure the child or young person is held or supported effectively to aid the passing of the NG tube.
- Measure the length of the NG tube using the NEX or NEMU methods to ensure correct tube placement.
- Ensure the nostrils are clean; clean with sterile water and soft gauze if necessary.
- Lubricate the end of the NG tube with warm, sterile water. Do not use lubricating jelly as this can affect the pH of the aspirate.
- Gently pass the NG tube into the nostril and advance into the nasopharynx; encourage the patient to drink, suck or swallow to aid passing the pharynx. Do not force the tube down.
- Advance the tube until it reaches the premeasured length; this should ensure it is in the stomach.
- Temporarily secure the tube in place to allow it to be easily advanced or retracted if necessary.
- Using a 20ml or 50ml enteral syringe, withdraw some gastric contents to test; obtaining aspirate ensures the correct placement of the NG tube.
- Test the tube contents; aspirate with a pH of ≤5.5 confirms placement in the stomach.
- If no aspirate is obtained, follow the decision tree for NG tube placement checks in children and infants (Fig 5). Do not use the ‘whoosh’ test (rapidly injecting air down an NG tube while auscultating the epigastrium) as it is not current evidence-based practice.
- If an aspirate is still not obtained or the pH is >5.5, the tube may need to be removed and replaced. In certain circumstances, the position can be confirmed using an X-ray.
- When the correct aspirate has been obtained, secure the tube in place, ensuring it is adequately fastened close to the nostril to avoid accidental removal.
- Remove the guide wire if one has been used and dispose of it according to trust policy.
- Flush the tube with sterile water to avoid blockage.
- In the patient’s notes, document the size of the tube, measurement, date and time of passing, pH of the aspirate, and how many attempts at tube placement were made.
It is important to acknowledge practitioners’ limitations. If unable to pass the NG tube, they must seek guidance from a senior practitioner, who may need to take over. It is recommended giving patients some time to recover before attempting the procedure again.
Placement testing, complications and removal
An NG tube must be tested:
- Following initial insertion;
- Before administering feeds, medications or flushes;
- At least once a day if it is not being used;
- If the patient has vomited or has excessive coughing or breathing difficulties;
- If there are concerns about tube placement (Guidelines and Audit Implementation Network, 2015).
NG tubes should be tested by obtaining gastric aspirate using a 20ml or 50ml enteral syringe, to avoid damaging the internal tubing (Macqueen et al, 2012). The gastric contents should be tested using CE-marked pH testing strips (NHS Improvement, 2016b); correct NG tube position is confirmed by obtaining a gastric aspirate with a pH of 1-5.5 (Guidelines and Audit Implementation Network, 2015).
Table 1 highlights key complications that can occur during and after NG tube insertion, and solutions and potential preventative measures.
When the NG tube is no longer required, it should be removed. This should be decided by the child or young person (if competent), their parent or guardian, the practitioner and extended multidisciplinary team. The patient’s best interests must be considered.
Passing an NG tube on a child or young person comes with practical, ethical and procedural considerations. Before initiating the process, health professionals must consider the reasons for the procedure along with correct preparation techniques and tube sizes to ensure the patient is supported throughout the NG tube insertion. Practitioners must make use of clinical frameworks and local policies to support them with this clinical skill and facilitate patient- and family-centred care. They must also consider risks to the patient to minimise harm and potential mortality.
The second article in this series of two articles will describe nasogastric tube insertion in adults.
This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.
Bray L et al (2019) A qualitative study of health professionals’ views on the holding of children for clinical procedures: constructing a balanced approach. Journal of Child Health Care; 23: 1, 160-171.
Guidelines and Audit Implementation Network (2015) Guidelines for Caring for an Infant, Child or Young Person who Requires Enteral Feeding. GAIN.
Irving SY et al (2018) Pediatric nasogastric tube placement and verification: best practice recommendations from the NOVEL project. Nutrition in Clinical Practice; 33: 6, 921-927.
Koller D, Goldman RD (2012) Distraction techniques for children undergoing procedures: a critical review of pediatric research. Journal of Pediatric Nursing; 27: 6, 652-681.
Macqueen S et al (2012) The Great Ormond Street Hospital Manual of Children’s Nursing Practices. Wiley-Blackwell.
NHS England and NHS Improvement (2022) Provisional Publication of Never Events Reported as Occurring between 1 April 2021 and 31 January 2022. NHSE and NHSI.
NHS Improvement (2018) Never Events Policy and Framework. NHSI.
NHS Improvement (2016a) Resource Set: Initial Placement Checks for Nasogastric and Orogastric Tubes. NHSI.
NHS Improvement (2016b) Patient Safety Alert: Nasogastric Tube Misplacement: Continuing Risk of Death and Serious Harm. NHSI.
National Patient Safety Agency (2011a) Decision tree for nasogastric tube placement checks in children and infants (not neonates). cas.mhra.gov.uk (accessed 19 July 2022).
National Patient Safety Agency (2011b) Reducing the Harm Caused by Misplaced Nasogastric Feeding Tubes in Adults, Children and Infants. NPSA.
Public Health Agency (2018) Nutrition Matters for the Early Years: Guidance for Feeding Under Fives in the Childcare Setting. PHA.
Reddy H et al (2021) Inserting a Nasogastric Tube in Infants, Children and Young People. Clinical Skills Limited.
Rosengarten L, Davies B (2021) Nutritional support for children and young people: nasogastric tubes. British Journal of Nursing; 30: 13, S12-S18.
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