45. Principles of infant nutrition
nasogastric feeding
CHAPTER CONTENTS
Considerations311
Role and responsibilities of the midwife315
Summary315
Self-assessment exercises315
References315
LEARNING OUTCOMES
Having read this chapter the reader should be able to:
• highlight the potential risks of naso- and orogastric feeding tubes
• detail the steps that are taken to ensure that the tube is correctly placed
• describe how one is inserted and removed safely
• describe how a baby is fed using a nasogastric tube
• summarise the role and responsibilities of the midwife.
Nasogastric tubes (NGTs) may be used in both adults and babies. An NGT is, as the name suggests, a tube that passes through the nose (or mouth (orogastric)), into the oesophagus and through into the stomach. They have two main uses:
1. placing food or medication into the stomach
2. removing substances from the stomach.
This chapter considers, for a baby, nasogastric tube insertion, correct tube positioning, feeding technique and tube removal.
Considerations
Feeding via a nasogastric tube is the most unnatural method of feeding. An important part of digestion begins in the mouth, this is missed when using a tube. Jones & Spencer (1999) also note that significant fat globules can adhere to the inside of the tube and so render lesser nutrition than is expected. In 2005, the National Patient Safety Agency (NPSA) also issued an alert to the fact that deaths had occurred because of the misplacement of nasogastric tubes. Inadvertently placing a tube into the lungs can cause death, either in the short term or from aspiration pneumonia in the longer term. Babies with nasogastric tubes also have an increased risk of vomiting and gastric reflux, issues that also make feeding less pleasurable. Consequently, nasogastric tubes are used for feeding only when necessary. The midwife is most likely to see their use in special care baby units or babies under transitional care; the midwife also has a role in educating and supporting parents who need to undertake nasogastric feeds in the home.
The use of nasogastric tubes in adults in maternity settings tends to relate to the need to empty the stomach. Occasionally if a general anaesthetic is needed in an emergency a nasogastric tube may be used to empty the stomach to reduce the risk of silent inhalation on intubation. Women who are ‘nil by mouth’ with a complication (e.g. paralytic ileus) may need continuous drainage of the stomach using a nasogastric tube. Inserting a tube into an adult is very similar except that the woman (if permitted) assists by taking sips of water so that as she swallows the tube is advanced into her stomach.
Safety
The NPSA (2005) revised the guidelines for all age groups with regard to ensuring the tube is in the correct place. Tubes may migrate to the oesophagus, duodenum or lungs, or become coiled or kinked within the oral cavity. Several previously advocated methods are no longer valid. The following methods should not be used to assess an NG tube position:
• Auscultation (listening over the stomach with a stethoscope as air is inserted down the tube): sounds may be heard even if the tube is in the lungs.
• Placing the end of the tube in water and watching for bubbles: air may come from both the stomach and lungs.
• Blue litmus paper: its sensitivity to detect between pH variations of gastric and bronchial secretions is insufficient.
• The baby’s condition: respiratory distress is not necessarily seen if the tube is in the lungs.
• The presence of aspirate in the tube: this may be still there from the last feed; it is also difficult to assess visually the differences between gastric and bronchial aspirate.
• Presence of securing tape in the same place: a tube can migrate without causing changes to the tape; the tube may also not have been placed correctly on insertion.
The NPSA (2005) has issued specific guidance for the use of naso- and orogastric tubes in neonates:
• The position of the tube should be checked on insertion, before administering any feed or medication, following any episodes of vomiting, retching or coughing or if there is any visible indication that the tube may have moved, e.g. loose tape, change in length of visible tube. All tubes should have markings and be marked on insertion. If continuous feeds are happening, tube checking should be undertaken 15–30 minutes after the end of the feed, before the next one is commenced.
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