One of my first memories of the NICU took place during nursing school.
Our class took a tour of the Neonatal Intensive and Intermediate Care Nurseries, two separate units in the hospital where I trained (yes, I was in one of the last diploma training programs in the country!).
On our tour through the intermediate nursery, the charge nurse – who had many years of experience by this time and had placed any number of feeding tubes – demonstrated feeding tube placement. The infant was a week or two old and certainly not one of the smallest ones in the nursery. The patient was not on respiratory support, and was just being fed by gavage until adequate growth and development allowed oral feeding.
The nurse demonstrated the passing of the tube, checked for placement by auscultation, and started the feeding on a pump. She then turned away and began telling us about other things in the nursery.
Right about then the infant’s alarm went off.
As it turned out, the tube had gone into the infant’s trachea instead of esophagus, and the infant demonstrated increasing respiratory distress when only a small portion of the feeding had been infused into his lungs.
This incident happened sometime in the late 70’s, and I still have respect for the nurse who misplaced the feeding tube. She was a conscientious, caring, and experienced nurse. As we often say when these sorts of things happen (or we think when we hear about them): “It could happen to any of us!”
The important thing is that we learn from it and never, never think, “That could not happen to me.” Thankfully, that infant was okay in the end.
Feeding tube misplacement
Misplacement of feeding tubes has always been a very real concern in the neonatal population. There are several things that can help ensure proper placement:
- Proper measurement for insertion length
- Securing the tube adequately
- Checking placement prior to starting a feeding
All of these have more research and information around them today than was available in the late 70’s… and yet misplacements can still happen.
The Child Health Patient Safety Organization issued a safety alert in 2012 for just this sort of event.1 This was not specific to neonates, but feeding tubes are used far more often in this population and “blind” passage of the tube is common.
Feeding tube placement accuracy
Let’s start at the beginning with measuring the tube for accurate placement.
Traditionally, this has been done by measuring from the tip of the nose (for nasogastric) or corner of the mouth (for orogastric) to the ear lobe and then to the xiphoid process, umbilicus or mid-umbilicus (halfway between the xiphoid process and umbilicus).
The measurement to the point midway between the xiphoid and umbilicus was established as a more accurate measurement in a small study published in 20042, showing that with measurement to the xiphoid, the tip was frequently noted in the lower esophagus, possibly resulting in aspiration of the feeding that does not go directly into the stomach. With measurement to the umbilicus, the tip of the tube was frequently found too low, i.e. through the pylorus, resulting in less than optimal digestion due to the feeding not being delivered into the stomach. With measurement midway to the umbilicus, the majority of the tubes (41 of 43) were found to be in the proper location.
Several studies have reported the incidence of tube malposition ranging from 21 to 50%, even when using these measurement techniques. However, inaccurate placement is less frequent when utilizing the measurement to midway between the xiphoid and umbilicus.2, 3, 4, 5, 6, 7 Strong evidence exists to support that the measurement to the xiphoid should no longer be used. The preferred measurement is nose to ear to mid-umbilicus.
Feeding tube securement
Next, the tube must be secured. While there is controversy about whether a tube should be placed via the nasal or oral route, it is well established that nasal placement is more secure.8 Securing the tube on the upper lip with a small loop and taping again to the “moustache” tape will be an effective method to secure the tube. If the loop is too big, it is easy for tiny fingers and hands to get into the loop and pull!
These are the initial steps to ensure the tube is placed correctly, and is not inadvertently misplaced. In next month’s blog, I will discuss position confirmation of the tube prior to use and with each feeding.
- National Association of Childrens Hospitals (NACH), ECRI Institute. Blind Pediatric NG Tube Placements Continue to Cause Harm. Overland Park, KS: Child Health Patient Safety Organization, Inc; 2012.
- Tedeschi L, Altimier L, Warner B. Improving the accuracy of indwelling gastric feeding tube placement in the neonatal population. Neonatal Intensive Care. 2004; 16:16-18.
- Cirgin Ellett ML, Cohen MD, Perkins SM, Smith CE, Lane KA, Austin JK. Predicting the insertion length for gastric tube placement in neonates. J Obstet Gynecol Neonatal Nurs. 40:412-421.
- Scalzo AJ, Tominack RL, Thompson MW. Malposition of pediatric gastric lavage tubes demonstrated radiographically. J Emerg Med. 1992; 10:581-586.
- Ellett ML, Maahs J, Forsee S. Prevalence of feeding tube placement errors & associated risk factors in children. MCN Am J Matern Child Nurs. 1998; 23:234-239.
- De Boer J, Smit BJ, Mainous RO. Nasogastric tube position and intragastric air collection in a neonatal intensive care population. Adv Neonatal Care. 2009; 9:293-298.
- Ellett MLC, Cohen MD, Perkins SM, Croffie JMB, Lane KA, Austin JK. Comparing methods of determining insertion length for placing gastric tubes in children 1 month to 17 years of age. J Specialists Pediatr Nurs. 2012;17(1):19-32.
- Irving, S. Y., Lyman, B., Northington, L., Bartlett, J. A., & Kemper, C. (2014). Nasogastric tube placement and verification in children: review of the current literature. Nutrition in Clinical Practice, 29(3), 267-276.