Gavage or gastric tubes are commonplace in the NICU. They are necessary to provide enteral nutrition until infants are able to take nutrition from their mothers or a bottle.
The importance of early enteral nutrition has been well-documented and recognized over the last 25 years. Once it was thought that by avoiding early enteral nutrition, necrotizing enterocolitis and perhaps other complications would be avoided.
It turns out that early enteral nutrition is an important component in avoiding necrotizing enterocolitis. However, this requires the use of gavage tubes to provide the nutrition since many infants in the NICU are not capable of feeding in a traditional manner within three to four days of delivery. Infants who remain intubated for some length of time are unable to feed orally either by breast, bottle, or cup.
While the use of the gavage tube provides life-sustaining nutrition to these infants, it is also important to recognize the potential complications associated with such a commonplace tool in the NICU.
The potential for misplacement of the feeding tube is vivid in my mind. While I have never personally had this experience, I remember being in the NICU as a student nurse when an experienced nurse demonstrated passage of a feeding tube and began the feeding. Within minutes, the infant’s heart rate dropped, saturation dropped and it was discovered that the feeding tube had most likely gone into the airway rather than stomach. Thankfully, the infant was okay, but returned to a higher level of care for a few days until he again stabilized.
In other blogs, I discussed measures to ensure appropriate placement of the feeding tube. Recommendations are changing to include such measures as pH testing and ultrasound guidance that will hopefully provide a higher level of accuracy without excessive exposure to radiation.1
Misplacement may also refer to the tip position of the feeding tube. The current recommendation for most accurate tip placement is to measure from the nose to ear to midway between the umbilicus and xiphoid.2 Other more traditional measurements can lead to tip placement in the esophagus (resulting in increased risk of aspiration) or tip placement in the duodenum (resulting in poor absorption of nutrients).3
There have also been reports of feeding tubes causing punctures of the esophagus or stomach.4,5 It is unknown exactly what this is related to since most reports don’t go into detail about the material the tube is made of or the tip design. However, it is reasonable to assume that stiffer tubes with a sharper point on the end would be more likely to result in this complication. That being said, the two cases that I have seen in my career were with softer tubes and at least one had a blunt point. The important precaution here is to avoid undue pressure and to pass the tube with lubrication and at an appropriate angle. In many cases, when the tube goes into the airway versus the esophagus and stomach, it is more difficult to pass. Resistance is met and more than one try is needed to successfully pass the tube to the pre-determined length. This may cause some trauma to the area as well.
The final complication I’ll mention is risk of infection. We have, for some ten years now, been acutely aware of and taken steps to avoid central line associated blood stream infections (CLABSI) and recognize the added risk of these devices. Any indwelling device, however, increases the risk of infection.
As programs have been ongoing to battle CLABSI, it has been recognized that the next most frequent source of infection is related to the gastrointestinal tract. There may be several explanations for this that have not yet been sorted out. But it is known that bacterial translocation or passage of pathogenic bacteria may be common in small amounts in the GI tract, and, when allowed to grow extensively, pass into the blood stream (translocate).
Colonization of the NICU infant gut is different than for those term infants who are quickly home with family.6 This colonization is related to the environment and perhaps feedings (formula versus breast milk) as well as the feeding tube itself – how it is handled, frequency of replacement, and others.7,8,9
One group of researchers found bacteria that sometimes appeared in the infant’s GI tract before appearing in the feeding tube, and other bacteria was found in the feeding tube before being found in the GI tract.10 This shows that contamination of the tube can be either from retrograde or from care practices or feeding contamination.
The overriding question is what care practices should be in place to protect the infant as much as possible from contamination of the feeding tube. Most of the published material evaluated the bacterial growth in the feeding tube at 48 hours or 7 days.7,8 One paper showed most colonization occurred at more than 48 hours and none at less than 12 hours.10 There is little evidence about practices that impact bacterial growth, and more importantly, the effect on the infant. However, some recommendations include:11,12,13
- Management of the feeding tube to maintain cleanliness of the system
- Use of gloves when inserting gastric tubes
- Secure the feeding tube to avoid contamination with movement
- Flush the tube after feedings to clear out milk that may harbor growth of bacteria
- Change feeding tubes at regular intervals (no recommendation can be given based on research so manufacturer’s recommendations should be followed)
In the end, our goal is to always provide the best care possible. Proper maintenance and best practices around gavage tubes for our NICU infants should always take priority.
Read more on this topic in Sandy’s recent blog post, Neonatal Gastric Feeding Tubes, Part 3: Bacterial Risks and Benefits.
- Irving SY, Lyman B, Northington L, Bartlett JA, Kemper C, Novel Project Work Group. Nasogastric tube placement and verification in children: review of the current literature. Nutrition in Clinical Practice. 2014 Jun;29(3):267-76.
- Wallace T, Steward D. Gastric tube use and care in the NICU. Newborn and Infant Nursing Reviews. 2014 Sep 1;14(3):103-8.
- de Boer JC, Smit BJ, Mainous RO. Nasogastric tube position and intragastric air collection in a neonatal intensive care population. Advances in Neonatal Care. 2009 Dec 1;9(6):293-8.
- Knight RB, Webb DE, Coppola CP. Pharyngeal perforation masquerading as esophageal atresia. Journal of pediatric surgery. 2009 Nov 1;44(11):2216-8.
- Jones KE, Wagener S, Willetts IE, Lakhoo K. Oesophageal perforation in extreme prematurity. BMJ case reports. 2012 May 23;2012:bcr1120115261.
- Moles L, Gómez M, Jiménez E, Bustos G, de Andrés J, Melgar A, Escuder D, Fernández L, del Campo R, Rodríguez JM. Bacterial Diversity of the gastric content of Preterm infants during their first month of life at the hospital. Frontiers in nutrition. 2017 Apr 18;4:12.
- Mehall JR, Kite CA, Gilliam CH, Jackson RJ, Smith SD. Enteral feeding tubes are a reservoir for nosocomial antibiotic-resistant pathogens. Journal of pediatric surgery. 2002 Jul 1;37(7):1011-2.
- Hurrell E, Kucerova E, Loughlin M, Caubilla-Barron J, Hilton A, Armstrong R, Smith C, Grant J, Shoo S, Forsythe S. Neonatal enteral feeding tubes as loci for colonisation by members of the Enterobacteriaceae. BMC Infectious Diseases. 2009 Dec;9(1):146.
- Hurrell E, Kucerova E, Loughlin M, Caubilla-Barron J, Forsythe SJ. Biofilm formation on enteral feeding tubes by Cronobacter sakazakii, Salmonella serovars and other Enterobacteriaceae. International journal of food microbiology. 2009 Dec 31;136(2):227-31.
- Gómez M, Moles L, Melgar A, Ureta N, Bustos G, Fernández L, Rodríguez JM, Jiménez E. Early gut colonization of preterm infants: effect of enteral feeding tubes. Journal of pediatric gastroenterology and nutrition. 2016 Jun 1;62(6):893-900.
- Cirgin Ellett ML, Cohen MD, Perkins SM, Smith CE, Lane KA, Austin JK. Predicting the insertion length for gastric tube placement in neonates. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2011 Jul 1;40(4):412-21.
- Longo MA, Society of Pediatric Nurses (SPN) Clinical Practice Committee, SPN Research Committee. Best evidence: nasogastric tube placement verification. Journal of pediatric nursing. 2011 Aug 1;26(4):373-6.
- Larson EL, Cimiotti JP, Haas J, Nesin M, Allen A, Della-Latta P, Saiman L. Gram-negative bacilli associated with catheter-associated and non-catheter-associated bloodstream infections and hand carriage by healthcare workers in neonatal intensive care units. Pediatric Critical Care Medicine. 2005 Jul 1;6(4):457-61.