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NICU guideline identifier

Enteral Feeding of the Neonate

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Nasogastric/Orogastric Tube Placement

Indications:

Nasogastric tubes should be used preferentially except under conditions below where orogastric tubes may need to be placed:

  • Nasal prong CPAP
  • Choanal atresia
  • Respiratory distress
    • respirations >60bpm
    • grunting
    • recession
  • Babies with an oxygen requirement
  • Nasal trauma 

Follow the steps to ensure correct tube placement.

  1. Measure the distance from either the nostril or the mouth (depending on insertion site) to the tragus (lobe of the ear) to the half way point between the xiphisternum and theNGMeasurement umbilicus.
  2. Swaddle infant to provide comfort
  3. Gently check nostrils for patency.
  4. Select the appropriate size gastric tube; size 6 French for the majority of infants, alternatively size 8 French for large infants or those requiring gut drainage
  5. The tube is gently inserted to point obtained at measurement by nursing staff.
  6. Check position by aspirating and checking with pH strips using a 2 - 5 ml enteral syringe.The pH strip needs to show a reading of 5 or less to indicate tube is in the stomach and therefore safe to use.
  7. Place a duoderm base on the infant's cheek and secure tubing with hypafix tape.

Safety of infant is maintained

Follow the steps below to ensure the safety of the baby is maintained.

  1. Ensure tube remains in correct position. Check before first feed on each shift with pH strips.
  2. Visually check position of tube before each feed. If in doubt aspirate to check position.
  3. Check that the duoderm and hypafix tape is firmly attached to the tube.
  4. Aspirate routinely 6 hourly or PRN as ordered or if uncertain of placement.
  5. Observe for abdominal distension.
  6. Ensure NBM infants have their tubes on free drainage with the free end of the tube draining into a specimen pot.
  7. Replace tubes every 2 weeks. (note if the gastric tube is not to be removed e.g. post TOF repair - see surgical guideline)
  8. Document date, time and depth of insertion on observation chart and care map.
  9. Note: If N/G tube is unable to be inserted in either nares after two attempts, a senior nurse colleague may have one further attempt. If still unsuccessful, discontinue procedure, notify medical staff and document same in clinical record

Trans-pyloric feeding

All infants with a trans-pyloric feeding tube require a gastric tube in place for aspiration, potentially drainage and possible medication administration (consult the Pharmacist or Neonatologist involved).

Trans-pyloric tubes may be on free drainage but are not used for regular aspiration.

Indications

  • Infants who are not tolerating gastric feeds.
  • Duodenal atresia - post-operatively
  • Infants who are at great risk for aspiration, e.g. gastro-oesophageal reflux receiving CPAP. Risk is minimised because the end of the tube is beyond the pyloric sphincter.

Complications

  • Aspiration
  • Difficulty with tube placement
  • Perforation of the gut
  • Malabsorption

Considerations

  • Trans-pyloric feeding may induce symptoms of malabsorption because the stomach is not able to aid in digestion e.g. frequent bowel motion, slow weight gain, necrotising enterocolitis.
  • Consider where medication is absorbed prior to administration (i.e. stomach or small intestines)

Trans-pyloric tube placement

Follow the steps below for placement of trans-pyloric tube.

  1. A weighted tube is required for trans-pyloric placement (white Vygon paediatric duodenal tube with weighted tip, 6 Fr or Corpak Jejunal weighted tube). These do not harden over time and may be left in situ for several weeks.
  2. Length for tube insertion is measured from as per gastric placement with a further length from the xiphoid to the left or right costal margin.
  3. The tube is allowed to cool in the refrigerator for an hour; this reduces the chance of it coiling durinTP Tube placementg insertion.
  4. Swaddle infant to provide comfort
  5. With the infant lying supine at a 15o-40o angle, insert the tube to the stomach as normal.
  6. Check stomach positioning by aspirating and testing on a pH strip (reading of 5 or less)
  7. Place the infant into a right lateral position
  8. Advance the tube 1 cm at a time while instilling up to 2-3 ml of air and auscultate the abdomen
  9. Transpyloric placement is characterised by high pitch crackles and the inability to withdraw air ('snap test')
  10. Insert further length (as measured) to ensure distal duodenal or proximal jejunal placement.
  11. Give a 3 ml feed and remove stylet (if present with brand).
  12. The infant should then be placed right side down for 1-1.5 hours
  13. Confirmation of placement will then be made by a radiograph.
  14. Secure tubing to infant's cheek in same manner as gastric tubes
  15. Insertion should be documented in the infant's caremap (equipment section) and in the clinical notes

Commencing continuous Gastric or Trans-pyloric feeding

Continuous feeding should only be instituted once the infant has reached volumes of at least 7 ml/hr, or on discussion with Neonatologist. This restriction is to avoid the need to purge the tubing every 4 hr with the change of bottle that would be required for lower rates (due to safe hang times).

Follow the steps below for commencing continuous Gastric or Jejunal feeding:

  1. Draw up prescribed volume of milk.
  2. Label with type of milk, date and time.
  3. Ensure the correct procedure for setting up the continuous feed pump is observed.
  4. Check that the tube is in the correct position and the tape is secure (observe hourly).
  5. Commence continuous feed
  6. Aspirate gastric tube at least once per shift to confirm placement and determine residual volume

Nutritional needs of the infant

Follow the steps below to ensure the nutritional needs of the baby are met.

  1. Check that the correct ml/kg are calculated daily
  2. Infant's weight is updated as ordered and documented.
  3. Observe for spills and abdominal distension.
  4. Accurate intake is recorded hourly.
  5. Ensure correct type of milk is given and documented.
  6. Ensure the amount of EBM/milk mixture in the bottle is recorded

The safety of the infant is maintained

Follow the steps below to ensure the safety of the infant is maintained.

  • That the correct hourly rate on the continuous feed pump is maintained
  • The total volume infused is accurate.
  • Two nurses check and sign on the balance sheet each time rate is changed and at the change of shift.
  • The tubing is changed every 24 hours and labelled clearly with date, time and EBM/NIF.
  • Ensures that the trans-pyloric tube is not aspirated unless on Doctor's/NS-ANP's orders.
  • Gastric tube is aspirated 6 hourly and documented.
  • Administer medication as prescribed by disconnecting at the junction of the trans-pyloric tube and the pump tubing or as per medical staff/NS-ANP instruction (be aware of where of where medication is absorbed)
  • Only use four hours worth of milk at a time (unless otherwise specified on the bottle label)

Long term Gastric Feeding Tube care and insertion

If an infant is expected to require long term gastric feeding the parents need to be taught care and insertion techniques prior to discharge.

  1. Prior to tube insertion the tube must be lubricated with water.
  2. Measure length of tube as for short term gastric tubes.
  3. Ensure that the cap is on the medication port of the Corpak long term feeding tube.
  4. Insert long term feeding tube as for short term tubes.
  5. Remove stylet once inserted.
  6. Establish gastric placement by aspirating stomach contents and testing on pH strips. A reading of 5 or less should be apparent when touched with stomach fluid.
  7. If unable to aspirate fluid then push 1-2 ml of air with a 50 ml syringe. Listen with a stethoscope on the baby's stomach. You should hear a 'whoosh' of air.
  8. Secure tube to face with duoderm base and hypafix on top.
  9. Flush tube with 3 ml of water using 50 ml syringe.
  10. Rinse stylet with warm soapy water and save for future use.

Commencing feeding

Follow the steps below for commencing feeds via a long term tube.

  1. Warm milk in a bottle and bowl of warm water as usual.
  2. If the infant is in a cot pick them up for feeds and utilise a pacifier for non-nutritive sucking if appropriate
  3. Connect a 50 ml syringe to the long term feeding tube and pour feed into syringe.
  4. Adjust the flow of the feed by raising or lowering the height of the syringe.
  5. When finished flush the tube with 3 ml of sterile water via 50 ml syringe.
  6. Close tube.

Note: USE ONLY A 50 ML SYRINGE TO ADMINISTER ANY MILK OR MEDICATION.  The higher pressure of the smaller syringes has potential to perforate the tube.

See Also  Starship nasogastric/nasojejunal protocol

Short term enteral feeding in NICU

  • The optimal care is for all babies to receive breast milk only. This addresses those infants who do not need IV fluids and whose mothers have not established a breast milk supply. 
  • In general, IV infusions should not be started if there are no medical indications for IV fluids (such as respiratory distress, hypoglycaemia etc.) 
  • Babies who need feeding should be given what mother's breast milk is available and always receive mother's breast milk in preference to formula. Be sure to check that no breast milk is available before considering infant formula. 
  • If they require additional feeds, infants should then be started on term infant formula, after discussion with their mother/father. In such discussions, parents should be informed that there are few - if any - adverse effects of formula used short term in this way in a neonatal unit. 
  • For a baby who is already on an IV infusion, it is reasonable to continue the infusion for a short time if mother's milk supply is being established and there is a reasonable expectation that she will be producing enough breast milk with in a day or so. This time period needs to be judged against the ease of IV access and the condition of the baby. Babies should not have IVs re-inserted solely because no breast milk is available. 
  • Smaller preterm infants will often have a medical indication for ongoing IV fluids and in them it is desirable to increase the oral fluids slowly. The pace of increase of oral fluids can usually be matched to the increase in the availability of expressed breast milk. 
  • Mothers should be advised and helped with expressing. NICU staff should discuss expressing as soon as possible. It is accepted that the role of initially helping with expressing lies with postnatal ward staff. NICU staff should support mothers' expression of breast milk. 
  • Nasogastric feeding rather than bottle or cup feeding is advantageous for ex-premature babies. Term babies who do not have problems with hypoglycaemia can usually transition directly from IV fluids to breast feeds. Alternatively, bottle or tube feeds may be used for larger infants. 
  • NICU does not provide hydrolysed formula unless there is a clinical indication (other than a history of allergy). If there is a very strong family history of allergy, hydrolysed formula may be supplied on an individual basis. Parents may supply their own formula (hydrolysed or non-cow's milk preparations) if they wish. 

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Document Control

  • Date last published: 01 April 2010
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years