Comfort Measures for Infants During Insertion of Nasal/Oral Gastric Tube

 

Neonatal and pediatric NG/OG tubes are placed by skilled nurses at patients’ bedsides across the country every day. This procedure happens regularly, and at times can be repeated more than once for the same patient in a day.

Premature infants in the NICU almost always require enteral feeding tubes for abdominal venting and for feeding. Oftentimes, feeding tubes are required for feeding over an extended period of time.

When infants are very active, they can unintentionally pull out their own feeding tube. These little ones can be quick, and their little fingers reach up and grab the tube… and in the blink of an eye, the tube is out!

For these reasons, infants in the NICU require feeding tubes to frequently be placed and re-placed.

This procedure can be uncomfortable at best, and painful at worst. Inserting a feeding tube in a manner that is as safe (always the priority) and comfortable as possible for the infant is significantly important.

Experts in neonatal pain have measured and documented that feeding tube insertion is a painful procedure. When clinicians were asked to rate the severity of pain associated with various interventions provided in the NICU, they rated the insertion of the feeding tube as moderate pain.1

What are the best procedures, techniques, and practices for inserting a feeding tube to minimize pain and discomfort for infants?

This question led me on a search to review the most up-to-date and current literature. Although I conducted a robust search, I was not able to find as much information as I originally hoped.

There are not a lot of recently published articles to provide up-to-date recommendations or best practices around comfort measures for infants/neonates for feeding tube insertion. Despite this, there are a few essential practice recommendations that can be incorporated into care practices, and they will provide comfort for infants during the insertion process.

Positioning the infant: Swaddling the infant may help with tolerance of gavage tube insertion.2  Core measures of developmental care recommend a few tips when positioning infant for comfort. First, when repositioning the infant, handle infant in flexion, containment, and alignment during all caregiving activities.   Place infant supine, head of bed may be elevated; and then swaddle infant by wrapping arms in a blanket.2

Offer non-nutritional sucking:  Offering the infant a pacifier (contingent on infant’s stability) before, during, and after a noninvasive procedure supports physiologic stability. DiPietro et al. published data on the benefits of offering preterm infants non-nutritive sucking, recognizing that infants exhibit less behavioral distress.3

Moisten the tip: Lubricate the tip of the feeding tube with sterile water or sterile lubricating jelly (water soluble jelly).2  This requires only a very small amount of lubricating jelly applied to the tip of the distal end of the feeding tube. In my experience, I used to insert the distal tip of the syringe in a small 3g packet, coating the tube with a small amount of lubricant immediately prior to inserting gavage tube. A small amount of lubricant can make a vast difference when gently advancing the tube to the desired position. A physician order most likely is not required.

Securing the feeding tube: When long-term intermittent feeding tubes are placed, secure the feeding tube to the face with tape. Frequently transparent tape is used for visibility of the tube makings. Premature infants have very fragile skin and a best practice is to apply a thin layer of hydrocolloid dressing as a barrier to protect the skin. There is a variety of tape and feeding tube securement devices available on the market. Type and kind of products varies and depends on the infant’s size and maturity of skin. Most importantly, protect the infant’s skin as much as possible. It is critically important to take great care when securing the feeding tube to the chin or the face to minimize adverse oral stimulation.2   

Involve parents/family support: There is an increasing amount of research that reports the benefits of involving parents in the care giving process. Premature infants are exposed to many stressful events during routine care, and parent involvement can help with reducing pain and discomfort. The soothing sound of a mother’s voice and pleasing touch of her hand while the infant is swaddled for the procedure will aid in supporting the infant’s physiologic stability.4

These are easy and effective support measures that can be incorporated into practice to reduce pain, increase physiologic stability, and discomfort for infants when placing a feeding tube. Adopting these recommendations should not be overwhelming as they can be easily adopted in routine practice.

I would be very interested to learn if there are any other best practices your hospital uses. I would like to share your feedback about how to provide comfort for infants during the insertion of feeding tubes. Share your thoughts below in the comments section!

Learn more about Medela neonatal enteral feeding tubes

References

1. Wallace T, Steward D. Gastric tube use and care in the NICU. NAINR 2014;14(3):103-108
2. Gardner SL, Carter BS, Enzman-Hines MI, Hernandez JA. Merenstein and Gardner’s Handbook of Neonatal Intensive Care. (8th). 2016
3. Dipietro, Cusson RM, Caughy, MO, Fox NA. Behavioral and physiologic effects of nonnutritive sucking during gavage feeding in preterm infants. Pediatr Res. 1994;36(2).
4. Ludington-Hoe, SM. Skin-to-skin contact: A comforting place with comfort food. MCN. 2015;40(6):359-364.