Neonatal Gastrointestinal Tube Use and Management

 

Initial feedings in the NICU are often via an oral or nasal gastric tube. This method of feeding can go on for weeks for most infants.

The scientific evidence supporting practices around this common procedure is minimal. Most practices are supported by evidence from the adult and pediatric populations.

Neonatal gastrointestinal tubes

Gastrointestinal tubes are often indicated in the neonate for feedings or gastric decompression. The benefit of gastric decompression may be to decrease distension that could potentially lead to bacterial translocation, although this evidence is minimal.1 Certainly, when infants have ileus or medical necrotizing enterocolitis, placing a gastric tube to either gravity drainage or suction is common practice as distension can be extreme.

The size of the gastric tube varies by the purpose of the tube, size of the infant, and individual and institutional practice. There are practical recommendations for size based on the purpose of the tube since a smaller tube may not serve to decompress the stomach.2 Smaller tubes are usually used for feedings to decrease discomfort and airway obstruction.

Nutrient loss

Nutrient loss in the feeding tube is a concern for the neonatal population since reaching optimal growth is often difficult in the premature infant. Various things effect nutrient loss, including syringe position, tubing diameter and length (surface area), and the amount of time the feed is exposed to the tubing.3-7

Most clinicians are aware of fat loss in tube feedings, but researchers have found loss of other nutrients including calcium and carotenoids, which are important in prevention of chronic lung disease in neonates.8,9 The clinical significance of these studies are:

• Shorter tubing may be preferred
• The shortest feeding time should be used when medically possible
• It is recommended to angle the syringe for best possible fat delivery, yet fat can still be lost in the tubing.

Route of insertion

The question of nasal versus oral gastric tube placement has been going on for many years. Clinicians have firm beliefs about one or the other, but evidence is still weak.

Many believe there is increased airway resistance with nasal placement, but two papers show no difference in apnea or bradycardia between the two methods.10,11 Ultimately, the most recent Cochrane review concludes that there are insufficient studies to inform practice.12 Arguments of one method of placement versus another include:

Nasogastric	Orogastric
More comfortable	More gagging/potential for bradycardia when placed
Possible increased airway resistance	Easy to displace via tongue thrusting
Periodic breathing/apnea	May lead to gagging during oral feeds
Less risk for displacement	Larger tube can be placed
Potential for nasal erosion

 

Measuring for insertion

Many clinicians may have been taught that gastric tubes should be measured from nose to ear to xiphoid (NEX). Some were taught to measure nose to ear to umbilicus (NEU).

However, current evidence demonstrates that the most accurate method is to measure nose to ear to mid-umbilicus to ensure placement in the stomach.13 The NEX method more often results in placement in the esophagus which could result in aspiration. The NEU method results in placement that is too low, resulting in feeding into the duodenum which results in less nutrient absorption and more likely green residuals that result in holding feedings. Other researchers are evaluating the use of length or weight based measures for more accurate tubing placement.14-16

Confirmation of placement

Methods of tubing confirmation have been a common topic of conversation in the neonatal unit since the Joint Commission Patient Safety Goal of decreasing this incidence. While tubes are not often misplaced, it can result in poor outcomes and complications when it does happen. Furthermore, more gastric tubes are placed in the NICU than in any other patient care area, thus increasing the risk. Various methods used for placement confirmation include:

• Marking of the tube at point of entry
• Auscultation
• Aspiration of fluid
• pH testing
  • pH of 4 or less thought to be predictive of placement in the stomach
• Radiologic verification17

Complications of gastric tubes

Many complications of gastric tubes can be avoided by following the appropriate recommendations for proper measuring and placement of the gastric tube. However, two complications that warrant more discussion are risk of infection from the gastric tube and tubing misconnections. These will be the topic of a future blog. Meanwhile, find more information and discussion about these complications in the recorded webinar, Use and Care of Gastrointestinal Tubes in the Neonate, that also discussed the points presented above. This program offers 1.0 Nursing contact hours or 1.0 CPE Dietician credits.

BONUS: Use promo code DM4CSE to access the recorded webinar at no charge. This code will be offered through March 31, 2018. Go to  www.MedelaEducation.com and redeem the code at the bottom of the page.

 

References:

1. Lefrak, L. (2016). Infection Risk Reduction in the Intensive Care Nursery: A Review of Patient Care Practices That Impact the Infection Risk in Global Care of the Hospitalized Neonates. The Journal of perinatal & neonatal nursing, 30(2), 139-147.
2. de Boer, J. C., Smit, B. J., & Mainous, R. O. (2009). Nasogastric tube position and intragastric air collection in a neonatal intensive care population. Advances in Neonatal Care, 9(6), 293-298.
3. Brooke, O. G., & Barley, J. (1978). Loss of energy during continuous infusions of breast milk. Archives of disease in childhood, 53(4), 344-345.
4. Narayanan, I., Singh, B., & Harvey, D. (1984). Fat loss during feeding of human milk. Archives of disease in childhood, 59(5), 475-477.
5. Brennan-Behm, M., Carlson, G. E., Meier, P., & Engstrom, J. (1994). Caloric loss from expressed mother’s milk during continuous gavage infusion. Neonatal network: NN, 13(2), 27-32.
6. Brooks, C., Vickers, A. M., & Aryal, S. (2013). Comparison of lipid and calorie loss from donor human milk among 3 methods of simulated gavage feeding: one-hour, 2-hour, and intermittent gravity feedings. Advances in Neonatal Care, 13(2), 131-138.
7. Rogers, S. P., Hicks, P. D., Hamzo, M., Veit, L. E., & Abrams, S. A. (2010). Continuous feedings of fortified human milk lead to nutrient losses of fat, calcium and phosphorous. Nutrients, 2(3), 230-240.
8. Tacken, K. J., Vogelsang, A., van Lingen, R. A., Slootstra, J., Dikkeschei, B. D., & van Zoeren-Grobben, D. (2009). Loss of triglycerides and carotenoids in human milk after processing. Archives of Disease in Childhood-Fetal and Neonatal Edition, 94(6), F447-F450.
9. Rogers, S. P., Hicks, P. D., Hamzo, M., Veit, L. E., & Abrams, S. A. (2010). Continuous feedings of fortified human milk lead to nutrient losses of fat, calcium and phosphorous. Nutrients, 2(3), 230-240.
10. Symington, A., Ballantyne, M., Pinelli, J., & Stevens, B. (1995). Indwelling versus intermittent feeding tubes in premature neonates. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 24(4), 321-326.
11. Bohnhorst, B., Cech, K., Peter, C., & Doerdelmann, M. (2010). Oral versus nasal route for placing feeding tubes: no effect on hypoxemia and bradycardia in infants with apnea of prematurity. Neonatology, 98(2), 143-149.
12. Watson J, McGuire W. Nasal versus oral route for placing feeding tubes in preterm or low birth weight infants. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD003952. DOI: 10.1002/14651858.CD003952.pub3.
13. Wallace, T., & Steward, D. (2014). Gastric tube use and care in the NICU. Newborn and Infant Nursing Reviews, 14(3), 103-108.
14. Cirgin Ellett, M. L., Cohen, M. D., Perkins, S. M., Smith, C. E., Lane, K. A., & Austin, J. K. (2011). Predicting the insertion length for gastric tube placement in neonates. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40(4), 412-421.
15. Freeman, D., Saxton, V., & Holberton, J. (2012). A weight-based formula for the estimation of gastric tube insertion length in newborns. Advances in Neonatal Care, 12(3), 179-182.
16. Nguyen, S., Fang, A., Saxton, V., & Holberton, J. (2016). Accuracy of a Weight-Based Formula for Neonatal Gastric Tube Insertion Length. Advances in Neonatal Care, 16(2), 158-161.
17. Society of Pediatric Nurses (SPN) Clinical Practice Committee, Longo, M.A. (2011). Best Evidence: Nasogastric Tube Placement Verification. Journal of Pediatric Nursing, 26, 373-376.