SDMS ID: P2010/0388-001 WACSClinProc4.

12 Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Purpose: Insertion of a gastric tube into the stomach is for the following reasons: Enteral feeding Gastric decompression Administration of medication. The incidence of incorrect tube placement into the respiratory system is low, the consequences can be catastrophic. Confirming correct position prior to use is mandatory. Equipment: Appropriate size tube o Nasogastric tube: 6G >3500g o Orogastric tube: Naso and Orogastric Tube Placement, Testing and Feeding New guidelines Insertion and maintenance of naso and orogastric tube in infants Midwives, registered nurses and medical staff, QVMU Naso and orogastric tube, pH testing, parents feeding

5G <3500g 5G <1500g size 6G >1500g size 8G free drainage

Permanent marker Lubricant 2ml syringe Litmus paper Tape for securing Sucrose if appropriate Strategies: Swaddling in a side-lying or supine position reduces the stress of the procedure. If there is any signs of respiratory distress or the infant is on ventilatory support by CPAP, an OGT not NGT must be inserted. Observe the infant for colour changes throughout the procedure. Passing an oral/nasal tube can stimulate a vagal response. Resuscitation equipment must be readily accessible. Procedure: The correct method of measurement for naso and orogastric and tube insertion is to measure from the tip of the nose to the ear lobe and then to midway between the end of the xiphoid process and the umbilicus. The measurement is most accurate if taken with the infant in the supine position. The measured length can be marked on the tube with a permanent marker.
Gastric Tube Placement and Insertion May-11 1 WACSClinproc4.12

Nasogastric Insertion Insert nasally in a backward direction. If resistance persists after a reattempt then try the other nostril. Secure the tube. Orogastric Insertion Insert the tube orally and secure centrally. Tape the tube to the top lip where possible to prevent interference to the tongue. If resistance is met during the insertion, stop advancement and adjust direction of tube slightly before reattempting. Confirming Position of Tube The position of the tube should be verified in the following situations: Initial insertion Prior to bolus feeds, medications Four hourly for continuous milk feeds, synchronised with syringe changes. Following episodes of coughing, vomiting, retching. If displacement is suspected ie loose tape. The following is no longer recommended: The whoosh test (injecting air down the tube and listening) is not to be used as a primary method of testing but can be used to dislodge the exit-port of the feeding tube from the gastric mucosa. No more than 2ml should be used. The presence of aspirate obtained from the gastric tube does not rule out misplacement. Procedure: Check for signs of tube displacement: loose tape, permanent mark on tube at nares Aspirate using a 2ml syringe and gentle suction Obtain 0.5 ml aspirate Test on litmus paper acid will turn blue litmus paper pink If unable to obtain an aspirate see flow chart (appendix 1) If there is any query about the placement and/or clarity of the colour change on the litmus paper the feed should not be commenced. Risk Assessment/Limitations of pH Testing Factors that may contribute to a high gastric pH and inhibit colour change: The presence of amniotic fluid in an infant < 48 hours of age. Infants on continuous milk feeds and 2 hourly feeds Medications that reduce or alter the stomach acid Presence of medication or milk left in the feeding tube Changing Tubes Gastric tubes may be left in place for up to seven days. Silastic tubes may be left in place for 4 weeks. Documentation The date and time of insertion, site, measured distance at the nares and size of tube inserted should be documented in the newborns medical record.

Gastric Tube Placement and Insertion May-11

WACSClinproc4.12

Tube Feeding by Parents Parents can perform gastric tube feeds within Womens and Childrens Services in the following situations: The newborn is not ventilated (including nasal CPAP) Newborn is tolerating full enteral feeds and medically stable Parents have expressed a willingness to take on the procedure and have received education as per the parent learning package and demonstrated competency. Medical/CNC approval has been obtained. Attachments
Attachment 1 Attachment 2 Attachment 3 Attachment 4 Attachment 5 Attachment 6 Confirming Gastric Tube Placement in Infants Flowchart Flowchart for Decision Making Background Information Parent Learning Package for Tube Feeding Parent Competency Criteria References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _________________________

Gastric Tube Placement and Insertion May-11

WACSClinproc4.12

ATTACHMENT 1 Recommended procedure for checking the position of naso and orogastric feeding tubes in newborns.

Gastric Tube Placement and Insertion May-11

WACSClinproc4.12

ATTACHMENT 2 Flowchart for Decision Making

ACTION Check for signs of tube displacement (if not initial insertion) RATIONALE The tube may have coiled up in the mouth or if there is more tube visible than previously documented, the tube may have kinked. Loose tape may indicate movement. If the tube has been displaced, it will need repositioning or repassing before feeding. The most likely reason for failure to obtain acidic gastric aspirate is dilution of gastric acid by enteral feed. Also consider: Is the visible length of the tube the same as documented at insertion? What is the volume of aspirate? Document all information Documenting helps the clinical decision making process. The tube size and length should be recorded each time the tube is passed or adjusted. Turn the baby on to its side may facilitate the tip of the nasogastric tube entering the gastric fluid pool. Injecting air through the tube may dislodge the exit-port of the feeding tube from the gastric mucosa. Care must be taken that no more than 2ml of air is inserted. If the tube is in the oesophagus, advancing it may allow it to pass into the stomach. If the tube has been inserted too far, it may be in the duodenum. Consider withdrawing a few centimetres and re-aspirating. The position of the tube at the nose should already have been recorded and marked, if the tube is insitu. If the mark has not moved then advancing or retracting may not make a difference. Document the length of the tube is moved. If this is an initial insertion then consider replacing or repassing the tube. If the tube has been insitu already, seek advice. Consider whether the length of the tube has changed. Record all decisions and their rationale.

No clear colour change on litmus paper

Problem obtaining aspirate Injection 1-2 ml of air using a syringe. This is NOT a testing procedure. Advance or retract the tube by 1-2 cm. Stop if there is any resistance or obstruction

If you still cannot obtain aspirate

Gastric Tube Placement and Insertion May-11

WACSClinproc4.12

ATTACHMENT 3 BACKGROUND INFORMATION The following methods of confirming tube placement are no longer recommended Auscultation of air insufflated through the feeding tube (whoosh test) There are many reports on the ineffectiveness of this method. The auscultation method requires staff to distinguish between air passed through the tube via the oesophagus into the stomach and air passed via the main bronchus into the lungs; a position not anatomically far from the stomach. There is no evidence to suggest that it is easier or more reliable to differentiate between oesophageal and bronchial insertion in neonates. Interpreting absence of respiratory distress as an indicator of correct positioning. Observing for signs of respiratory distress in ineffective in detecting a misplaced tube. Small bore tubes can enter the respiratory tract with few, if any symptoms. Monitoring bubbling at the end of the tube Looking for bubbling at the proximal end of the tube is unreliable because the stomach also contains air and could falsely indicate gastric placement. Observing the appearance of feeding tube aspirate Research and anecdotal evidence indicate that relying on the appearance of feeding tube aspirate is unreliable as a primary testing method as gastric contents can look similar to respiratory secretions.

Gastric Tube Placement and Insertion May-11

WACSClinproc4.12

ATTACHMENT 4 Learning Package for Parents on Gastric Tube Feeding 1. What is a gastric tube? A gastric tube is a long flexible tube inserted via the nose or mouth into the stomach. It is used to deliver expressed breast milk or infant formula directly to the stomach. It is secured to the infants cheek if inserted via the nose and either the chin or upper lip if inserted via the infants mouth. 2. Care of the tube The tape securing your infants tube may need changing if it is lifting off the skin, if it becomes soiled, or if your infants skin become irritated. You can help the nurse to change the tape. Use a small amount of olive oil, place on a cotton wool ball to help remove the tape from the skin. When securing the tube, the tape should be placed carefully to avoid causing pressure on the side of the nostril or the lip. In nasally inserted tubes, place the tape close to the nose prevents little fingers from pulling the tube out. Mittens may need to be worn by larger infants. Placing the fixamull tape over a comfeel disc helps prevent irritation and skin damage. 3. How to Give a Bolus or Gravity Feed Wash your hands for 10-15 seconds with soap and water and dry thoroughly or apply aquagel. Check the tube position by gently withdrawing 0.5 ml of fluid from the stomach with a 2 ml syringe. Place the fluid on the blue litmus paper and observe for the pink colour change. You must NOT start the feed until the position is confirmed by the colour change. Ensure the milk is warmed to room temperature. Position yourself so your infant is facing you during the feed so you can act promptly in the event of vomiting or distress. Kink off the tube and attach the syringe to the feeding port. Fill the syringe with milk taking care not to overfill the syringe. Fill only to the 10ml or 20ml mark, not the top. Un-kink the tube to allow the milk to run slowly through the tube and into the stomach. You may need to give a gentle push with the plunger to start the flow then remove the plunger and let the milk flow by gravity. Flow speed is adjusted by changing the height of the syringe, the higher the syringe, the faster the flow. To prevent regurgitation, the rate of flow may need to be stopped temporarily in smaller infants. For example after each 10ml, wait a few minutes. Add more milk before the syringe is empty to stop air entering the stomach. Too much air in the stomach may cause bloating and pain. When the milk has been given, slowly flush the tube with 1-2ml of air to prevent tube blockages. Kink off the tube and remove the syringe. Replace the cap firmly on the feeding port. Hold, cuddle and wind your infant only if necessary, otherwise leave them to sleep. Dispose of syringes, rinse feeding bottles and place in containers provided. If your infant has trouble breathing or coughs excessively during the feed, stop the feed immediately and tell your nurse if distress continues.
Gastric Tube Placement and Insertion May-11 7 WACSClinproc4.12

If your infant needs thickened feeds, the formula or milk may not flow easily through the tube. Talk to your nurse if this is a problem. 4. Mouth Care It is important to keep your infants mouth clean and moist. Mouth care should be given as necessary every day and is the ideal time to check your infants mouth for infections or ulceration. You will need: Swab sticks or cotton buds Sterile water or expressed breastmilk What to do: Moisten the swab with water or milk and clean the gums with firm outward strokes. Never insert swab sticks or cotton buds further than the cotton tip. Clean the lips. 5. Nose Care Perform on a daily basis as necessary: Clean the edges of both nostrils gently with a cotton bud moistened with water once a day and whenever there is nasal discharge or crust present. Check nostrils each day for redness, pain, ulceration or bleeding. If these occur the tube will need to be replaced in the other nostril. 6. Bathing Your infant can be bathed as usual, make sure the cap of the tube is firmly closed and the tube is firmly secured.

Gastric Tube Placement and Insertion May-11

WACSClinproc4.12

ATTACHMENT 5 Parent Competency Criteria

Parent (s) received and read learning package

Signature of Parent(s): Signature of Staff:

Parent(s) witnessed the following (x3) Testing of gastric aspirate to confirm tube position Tube feeds Parent(s) supervised while testing and feeding by the tube until competent (minimum x3) Troubleshooting: Parents can state common problems associated with tube feeding and what they should do.

Staff signature:

1.

2.

3.

1. Staff signature: 1.

2.

3.

2.

3.

1. Unable to obtain aspirate to check placement? Action: tell the nurse 2. Milk not flowing down the tube? Action: tell the nurse 3. Infant vomiting or distressed? Action: kink the tube to stop the feed and alert the nurse 4. Tape lifting or not securing the tube adequately? Action: tell the nurse who will assist with resecuring the tape 5. Infant has a colour change Action: Kink the tube to stop the feed and alert the nurse 6. Monitoring alarming Action: Kink the tube to stop the feed and alert the nurse

Staff signature:

Gastric Tube Placement and Insertion May-11

WACSClinproc4.12

ATTACMENT 6 REFERENCES Health for Kids Paediatric Evidence Centre 2006 Evidence Request #P0014 Placement of feeding tubes in infants. Online: http://www.mihsr.monash.org/hfk/paedevid.html Health for Kids Paediatric Evidence Centre 2005 Evidence Request #P0001 Aspiration of nasogastric tubes in infants. Online: http://www.mihsr.monash.org/hfk/paedevid.html Health for Kids Paediatric Evidence Centre 2006 Evidence Request #p0016 Assessment of position of feeding tubes in infants. Online: http://www.mihsr.monash.org/hfk/paedevid.html Hedberg Nyqvist K, Sorrell A & Ewald U 2004 Litmus tests for verification of feeding tube location in infants: evaluation of their clinical use. Journal of Clinical Nursing, 14, 486-495. MacPhee M (ed) 2006 An evidence-based approach to nasogastric tube management: Special considerations. Journal of Paediatric Nursing, vol 21, no 5, 388-393. Smith P 2006 Implementing the change Litmus paper to pH paper. Journal of Neonatal Nursing 12, 86-90. UK National Patient Safety Agency Advice 2005 Patient safety alert 09, Reducing the harm cause by misplaced naso and orogastric feeding tubes in babies under the care of neonatal units. Online: http://www.npsa.nhs.uk/display?contentId=4216 Wilkes-Holmes C, 2006 Safe placement of nasogastric tubes in children. Paediatric Nursing: vol18, no.9, 14-17.

Gastric Tube Placement and Insertion May-11

10

WACSClinproc4.12