Enteral Tube Placement Confirmation and Risks of Misplacement: What Does the Evidence Say?

Enteral Tube Placement Approach May Differ

From NICU to NICU, clinical protocols drive practice. As we continue to learn more from ongoing research, modifications to these protocols allow for up-to-date practice recommendations. When it comes to placement and management of enteral feeding tubes, practice continues to vary. I took a deeper look into current research-based recommendations on placement practices in the neonatal population and associated risks of tubes being mis-or displaced. 

In your own practice, you may have used various methods of determining the appropriate insertion depth for a feeding tube. Some are weight-based and utilize a formula for estimating tube depth in infants, while others involve physical measurements based on the infant anatomy.

• The NEX method measures the enteral tube length from the nares to the ear and then to the xiphoid process. Although this method was used for many years, it has not been validated in the literature and, unfortunately, has been demonstrated in multiple studies that tubes are often mal-positioned (most frequently in the esophagus) when this method is used.
• The NEMU method, another way of measurement, is currently the recommended best practice method. Measurement from the nares to the ear and to the mid-umbilicus area (the distance halfway between the xiphoid process and the umbilicus) provides a consistent location of placement for enteral tubes in the neonatal population. National guidelines, including those set by the American Academy of Pediatrics Neonatal Resuscitation Program and the National Association of Neonatal Nurses, currently recommend the NEMU placement method.

My research exploration perpetually took me to the ASPEN Consensus Recommendations for Safe Practices for Enteral Nutrition Therapy. This document organizes the great work of so many and arranges it into an easy to navigate experience. One of the things that caught my attention while reading through this document was neonatal-specific confirmation of placement, once the measurement method is completed and the tube is ready to be placed. Clinically, this practice also varies.

Other Enteral Tube Placement Considerations

Approaches such as ultrasound or fluoroscopy-guided placement offer direct visualization of accurate placement; however, this practice is unfortunately not widely available for day-to-day feeding tube management.

For the typical bedside placement of a feeding tube, what is the best option for confirmation? From my review of the research, gastric pH is a common technique for non-radiologic assessment of tube placement. Based on the gastric aspirate, evidence of placement can be determined. If an appropriate pH is not obtained, additional intervention to verify positioning is necessary.  Although still utilized in some practice today, ASPEN recommends eliminating the reliance of auscultation alone for placement verification. However, in this high-risk population, erring on the side of caution is often the approach taken. Per ASPEN, the clinician should confirm that the initial enteral feeding tube position is correct via proper radiographic imaging that visualizes the entire enteral feeding tube. They mention that neonatal and pediatric-age patients may be the exception to this because they often require multiple tube placements, which increases radiation exposure.

I think about the frequency that neonates are exposed to radiation for recurrent imaging during a NICU stay and if adding routine feeding tube placements would be reasonable. Of course there are times where obtaining a film is unavoidable, but a risk versus benefit approach may need to determine the best option in implementing clinical protocols for this unique population.

Once the tube is correctly and safely placed, ongoing monitoring must occur continuously throughout its dwell. In my clinical experience, newborns are quite “helpful” when it comes to grabbing at tubes/lines/drains. They seem to know they don’t want them there and are quick to take action! Feeding tubes can not only become dislodged with the help of little fingers, but also with increased gastric pressure from emesis, gagging, or even just routine patient movement. Securement at the nare or lip is a simple way to visualize correct placement prior to the next feeding and some protocols even call for gastric aspiration confirmation before each feeding. I would love to hear what your NICU does!   

While placing and managing a feeding tube may seem less complex or critical than other interventions managed on a daily basis in the NICU, the possibility for serious complications exists. Because of this, care should be taken throughout the entire process. Shout out to all the wonderful NICU nurses providing the highest level of care within even the most routine responsibilities for this vulnerable population!

References

1. Following the Evidence: Enteral Tube Placement and Verification in Neonates and Young Children - Authors

Clifford, Patricia MSN, RNC-NIC

Heimall, Lauren MSN, PCNS-BC

Brittingham, Lori MSN, CNS-ACCNS-N

Finn Davis, Katherine PhD, RN

Following the Evidence: Enteral Tube Placement and Verification in Neonates and Young Children | CE Article | NursingCenter

2. Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., . . . Guenter, P., ASPEN Safe Practices for Enteral Nutrition Therapy Task Force, American Society for Parenteral and Enteral Nutrition (2017). ASPEN Safe Practices for Enteral Nutrition Therapy. JPEN. Journal of parenteral and enteral nutrition, 41(1), 15–103. https://doi.org/10.1177/0148607116673053 ASPEN Safe Practices for Enteral Nutrition Therapy - Boullata - 2017 - Journal of Parenteral and Enteral Nutrition - Wiley Online Library