Introduction

A wide range of infants and children may require a nasogastric (NGT) or orogastric (OGT) tube.  It is imperative that nursing staff caring for patients who have enteral tubes understand why it is in-situ. These tubes may be used to:

• Administer bolus, intermittent and/or continuous enteral nutrition
• Administer Medication
• Facilitate free drainage and/or aspiration of the stomach contents
• Facilitate venting/decompression of the stomach
• Stent the oesophagus*
  

*This guideline does not refer to the care of trans-anastomotic tube (TAT), these remain in-situ post-operatively and should only be removed or replaced following medical clearance. If the TAT is dislodged inadvertently, immediately notify the neonatal and/or surgical teams. Feeds and medications should only be administered via a TAT tube at the direction of the treating medical team. 

This guideline aims to support nurses in inserting and managing nasogastric (NGT) or orogastric tubes (OGT) and is intended to be used in conjunction with clinical judgement and the needs of individual patients.

Note the scope of this guideline does not include jejunal tubes or gastrostomy tubes. For information regarding care of these tubes see the RCH Nursing Guideline: Jejunal Feeding, RCH Nursing Guideline: Enteral feeding and medication administration and the RCH Nursing Guideline: Gastrostomy.

Definition of Terms

• Continuous Positive Airway Pressure (CPAP): a type of positive airway pressure to deliver a set positive end expiratory pressure to the airway, maintained throughout the respiratory cycle.
  
• Nasal Retention Device (NRT): AMT Bridle™ see appendix
  
• Nasogastric tube (NGT): Thin, soft tube passed through a child’s nose, down the back of the throat, through the oesophagus and into the stomach.
  
• NEMU method: NGT tube placement measurement taken from nose to ear lobe to the point midway between the xiphisternum and the umbilicus 
  
• Neonate: an infant that is up to 28 days of age corrected post term (e.g. an infant born at 34 weeks gestation and is 8 weeks old is 14 days corrected post term) 
  
• Orogastric tube (OGT): Thin, soft tube passed through a child’s mouth, through the oropharynx, through the oesophagus and into the stomach
  
• pH value: describes how acidic or basic an aqueous solution is.  pH below 7 is acidic and a pH greater than 7 is basic. Gastric pH values are usually between 1-5.0
  

Assessment

Prior to commencing enteral feeding, the treating team must determine the safest route and site for enteral feeding.

Indications for NGT/OGT

An enteral feeding tube should be considered where a patient has unsafe or inadequate oral intake to meet nutritional requirements.

Indications may include:

• Congenital anomalies
• Eating disorders
• Facial, oropharyngeal and/or oesophageal structural abnormalities
• Increased nutritional requirements e.g. in Cystic Fibrosis, burns, oncology diagnosis
• Impaired oral feeding and swallowing e.g. prematurity, trauma

Enteral feeding tubes can also be used to:

• Prevent / reverse malnutrition related to chronic illness or recovery from trauma
• Optimise recovery post-surgery
• Facilitate venting and decompression of the stomach
• Prevent deterioration in quality of life

Additional enteral tubes can also be used for:

• Administering medications
• Gastro-intestinal de-compression and/or drainage

Contraindications for NGT/OGT

Absolute contraindications

• Gut failure (for feeding)
• Inability to gain safe enteral access ie significant mid face trauma, basal skull fracture (for NGT)

Relative contraindications

• Coagulation abnormalities
• Oesophageal trauma i.e. recent alkaline ingestion (due to risk of oesophageal rupture)
• Oesophageal varices (untreated or recently banded/cauterised)
• Oesophageal strictures including history of recent oesophageal surgery
• Oesophageal obstruction due to neoplasm or foreign body
• History of recent gastric perforation or gastric surgery
• Recent nasal surgery

In the presence of relative contraindications, the advantages and disadvantages of tube placement will need to be considered and discussed with the treating team and senior nursing staff in clinical area This responsibility remains with the treating team.

Special Considerations

Various aspects may hamper the ability to accurately and safely insert a NGT/OGT.  In the following clinical situations, only a skilled senior clinician should attempt insertion:

• Mucositis
• Low platelet count (remove stylet prior to insertion)
• Repeated insertions of NGTs more than 2 unsuccessful attempts
• Inability to swallow on command
• Impaired cough/gag reflex
• Intubation (current or recent)
• Tracheostomy
• Anatomical abnormalities
• Critical illness
• Liver disease and or portal hypertension
• Known or suspected oesophageal varices
• Previous gastric bypass surgery, hernia repair, or abnormal GI anatomy - tubes should be placed under endoscopy.
• If the child has procedural anxiety and child is unlikely to tolerate procedure, consider an EMR referral to Child Life Therapy or Comfort Kids or Comfort First for procedural support.

Selecting the correct NGT/OGT

• The smallest size possible should be used to accommodate feed consistency, gastric drainage and patient comfort. Tube size will vary with the size of the child and the rationale for insertion.
  
• If the purpose of the tube is decompression or drainage a larger size short term tube with radio opaque marker is appropriate. When enteral feeding commences, the tube should be changed to one with a smaller lumen size as soon as practical.

Tube considerations for neonates

• Neonates are obligatory nose breathers and the presence of a NGT may increase airway resistance.
• OGTs may be considered in:
  • very low birth weight neonates less than 1500g  
  • neonates that have respiratory distress needing midline CPAP or nasal cannula for oxygen delivery. 
  • structural or anatomical abnormality (e.g. choanal atresia, cleft lip/palate)  
  • nasal trauma.
    

Tube considerations for infants and older children

• In general, a tube size of 6fr-10fr should be used. 
• Larger sizes (over 10fr) may be used on children over 12 years based on clinical judgement. 

Table 1: Tube details

Preparing for NGT/OGT insertion

• The treating team places an EMR order for initial insertion of the NGT/OGT
• Prepare the patient and family for the insertion of the tube by providing an age-appropriate explanation of the procedure and explaining the reasons for necessity. The patients and family have received information relating to the intended procedure and given appropriate consent. 
• Inserting a NGT/OGT tube can be an uncomfortable and/or painful procedure therefore consideration should be given to the use of procedural pain management and/or sedation.
• Consider and plan for age-appropriate procedural holding and non-pharmacological distraction techniques
• Consider using sucrose for infants up to 12 months if appropriate
• Consider using topical anaesthetic nasal spray (co-phenylcaine) in older children (over 2years) if appropriate. 
• For further information please see the Procedure Management Guideline.
  

Equipment required

• Suction and oxygen should be available in hospital setting
• Appropriate type and size of tube
• Lubrication - Water or water-based lubricant OR use patient’s own saliva (neonates)
• pH test indicators
• 5-10ml enteral syringe for aspiration 
• Marker or Tape for securement of NGT/OGT
• Appropriate Personal Protective Equipment (PPE) for standard precautions such as gloves.
  

Procedure

1. Assessment of nasal passage 
   a) It is recommended that the nostrils and/or oral cavity be assessed to identify any possible abnormalities or obstructions prior to insertion of the tube. If reinserting a tube, consider alternating nostrils if possible.
2. Determining the length of the tube to placed
   a) Ensure distal end measurement (i.e. the part of the tube that will sit in the stomach) is to the exit port of the tube. The exit port may not be at the tip of the tube; it may be approximately 5-20mm from the actual tip of the tube.
   b) NEMU (Nose, Ear, Mid Umbilicus) method:  With head in the midline, measure the length of the tube to be inserted by placing the exit port of the tube at the tip of the nose (NGT) or corner of the mouth (OGT), and by measuring the length to the ear lobe, then to the point midway between the xiphisternum and the umbilicus.  
   c)Mark this point on the tube with marker or small piece of tape.
3. Positioning the Patient
   a) Neonate: Place neonate in supine position with the head in the midline. Swaddle limbs to contain activity.  Administer sucrose or initiate non-nutritive sucking with a dummy, which often helps to facilitate the advancement of the tube.
   b) Infant and Child: The child needs to be positioned/supported in a manner that prevents hyperextension of the neck.    Where possible allow child to sit up, without any head tilt (chin up). Maintaining the child's head tilted slightly forward will assist in closing the epiglottis and open the oesophagus. This is of relevance to children, as they are often positioned lying down for the procedure, and when distressed children will arch their back resulting in throwing their head back. Therefore, the person assisting may need to have a hand under the child's head to maintain it in the forward position.
   c) Procedural positioning for both infant and child can be found on the Comfort Kids website. Please see the Procedural Management guideline for further information
4. Lubricating the tube
   a) The purpose of lubrication is to aid the passing of the tube and reduce patient discomfort. Water or a water-based lubricant is recommended, or in neonates use their own saliva. Never use oil-based lubricant as this can result in aspiration pneumonia if the patient inhales during insertion. 
   b) The Nasogastric Tube may require lubricating internally by flushing 2-3mls of water prior to insertion. 
   
5. Insertion of tube
   a) NGT: Insert the tube into patent nostril, gently aiming posterior and parallel to the nasal septum then aim downward. Ask the child to swallow or waiting for a swallow to occur can assist in passing the tube. With a neonate or infant (who would normally use a dummy) the use of a dummy can assist the passing of the tube by causing a suck/swallow reflex. Insert tube to the pre-measured length.
   b) OGT: Insert the tube into the oral cavity over the tongue. Aim the tube posterior and downward through the oropharynx to the pre-measured length. 
   c) If resistance is met during insertion with either tube, stop advancement and adjust direction slightly before reattempting. 
   d) During insertion of the tube, monitor for respiratory distress, excessive coughing or choking.
          i) If this occurs, stop advancing the tube and observe inside the oral cavity as the tube may be coiled at the back of the throat. 
         ii) If it is, withdraw the tube slightly and reattempt.
        iii) It may be necessary to let the child rest, then continue to advance the tube slowly until the desired length has been passed. For neonates, remove tube completely, resettle the patient, and start again.
        iv) Note the patient may not have signs of respiratory distress when the tube is accidentally placed in the airway, especially if the patient has an impaired level of consciousness.
   *Please note for patients with known or suspected Oesophageal Varies the stylet should be removed prior to inserting NGT
6. Securing tube for use 
   a) Securement of the tube is recommended after position of tube has been confirmed however may be necessary prior to confirmation of position, particularly if the child is distressed.
   b) Current securement method recommended is Comfeel® taped to the cheek, followed by Hypafix®, Mefix ® or Tegaderm™, positioned over the tube to secure it in place. Ensure the tube is positioned so as not to place pressure on the nares and to reduce the risk of a pressure injury
   c) Document the centimetre marking on the tube, where it exits the nose or mouth
   d) Remove stylet prior to accessing tube.
7. Confirm placement prior to accessing tube
   a) Observe for a change in the marked reading of the tube at the lip/nares or change in length of external portion of the tube 
   b) Obtain gastric aspirate pH 1-5.0 (refer below)

Post Procedure

• Observe for signs of respiratory distress e.g. persistent coughing and gagging, and cyanosis, desaturations (if monitored).
• Document tube insertion into EMR under LDAs.
  

Obtaining gastric aspirate

Equipment

• pH test indicators
• 5-10ml enteral syringe for aspiration
• Appropriate PPE; Nonsterile gloves

Procedure

• The 5 moments of hand hygiene must be practiced before, during, and after this procedure
• Attach enteral syringe. Slowly and gently aspirate about 2.5 ml of fluid, (this makes sure the fluid is coming from the stomach, and not just from inside the tube).
• Apply gastric content to pH test strip and assess pH level  

Table 2 Trouble shooting

Special considerations

Patients with known/suspected oesophageal varices see the Acute management of an oesophageal variceal bleed guideline for further information.

Patients with liver disease, portal hypertension, known or suspected presence of portal gastropathy.

Please discuss with the gastro, treating team and senior nursing staff regarding the risk/benefits associated with tube changes, and troubleshooting gastric aspirates in these patient groups.

• NGT and OGTs can cause direct trauma to the stomach lining (for all types of patients)
• Aspiration should always be slow and gentle 
• Avoid frequent NG replacement due to the risk of local trauma and subsequent bleeding.  

Please discuss with the gastro, treating team and senior nursing staff regarding the risk/benefits associated with tube changes, and troubleshooting gastric aspirates in these patient groups.

Verification of tube placement

There is potential risk for NGT misplacement with each insertion. A misplaced NGT compromises patient safety, increasing the risk for serious and even fatal complications. There is no standardised method for verification of the initial NGT placement or reverification assessment of NGT location prior to use.

• X-ray is considered the gold standard to verify NGT location. Cumulative radiation exposure related to radiographs in paediatric patients is a concern and is not a practical method to verify tube placement or position for every patient prior to every feed or administration of medication.
• Measurement of the acidity or pH of the gastric aspirate is the most frequently used evidence-based method to verify NGT placement.
• Auscultation is not a reliable method for checking tube placement and should be avoided.
• Assessment of external tube position and a gastric aspirate should be sufficient to confirm tube placement for most patients. 
• An x-ray may be used to confirm placement if concerns remain or position can’t be confirmed via other methods.

The position of the tube must be confirmed in the following situations:

• When a new tube is inserted
• Before each use of the tube for feeds, water and/or medications.
• When there is concern that the tube may have been pulled out of changed position (ie markings have changed, taping has come loose etc)
• Changes in clinical condition that may indicate tube displacement – examples may include, but not limited to:
• For continuous feeds, verify external markings and confirm pH every 4 hours, at change of feed bottle or medication administration (whichever is shorter).

Special considerations

Consider an x-ray for any patient in whom there is any concern for correct NGT placement, such as:

• Difficulty placing the NGT
• NGT placement in any patient at high risk of misplacement.  Example: known history of facial fractures, neurologic injury/insult/baseline abnormality, respiratory concerns, decreased or absent gag reflex, and those who are critically ill.
• In any patient whose condition deteriorates shortly after NGT placement
  

Changing, reinserting or removal of an NGT/OGT

• Frequency of tube change may vary depending on material of the tube. Refer to manufacturer’s guideline on packaging for recommended length of time between tube changes.  
• In absence of manufacturer’s advice all PVC tubes should be routinely changed every 4 weeks and polyurethane tubes, changed every 8 weeks. 
• The medical team who has ordered the NGT/OGT to be placed is responsible for informing the family when a tube should be changed if inserted for long term use, the plan should be documented in the EMR.
• Tubes may be changed more frequently if evidence of skin compromise, frequent tube occlusion or clinical judgement.
• Care should be taken to prevent skin injury when removing adhesive tapes securing tube - consider use of protective barrier wipes such as Convacare™.

Equipment

• Appropriate PPE; Nonsterile gloves
• Adhesive remover if required.

Tube Removal Procedure

1. The 5 moments of hand hygiene must be practiced before, during, and after this procedure
   
2. Turn off suction or continuous feeding, if applicable.
   
3. Position the child in the supine position. Elevate the head of the bed as tolerated by the child. Encourage parental presence for support. Prepare the child as per the procedure management guideline.
   
4. Gently remove tape from the face. Consider the use of adhesive remover or saline wipe to assist in the removal of tape.
   
5. Occlude the tube by pinching it closed, bending it, and holding it with the thumb and index finger. Pull the tube out of the mouth or nose using a swift, consistent motion.

Please remember to read the disclaimer.


The development of this nursing guideline was coordinated by Keryn Coster, Dietitian, Nutrition, Shae Lane, CNS, Specialist Clinics, and Kate Hession, RN, Specialist Clinics, approved by the Nursing Clinical Effectiveness Committee. First published August 2024.