NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

Manual: Clinical Manual Document No.:

Section: Maternal Child Program Original Date: Oct 2009

Developed by: Maternal Child Program Revision Date(s):

Approved by: Review Date:

Cross Reference to:
NICU—Enteral Feeding Guidelines, Vital Sign Monitoring Guidelines,
Skin Care Guidelines, Oral Feeding Guidelines
Document Applies to: NICU and Paediatric’s

A printed copy of this document may not reflect the current, electronic version on Lakeridge
Health’s Intranet, ‘The Wave.’ Any copies of this document appearing in paper form should
ALWAYS be checked against the electronic version prior to use.

Preamble:

Critically ill or premature infants require a coordinated suck/swallow/breath mechanism,

sustain alert/awake behaviours, and maintain cardio respiratory stability in order to
achieve successful oral feeding. These mechanisms and behaviours develop through a
gradual maturation process. A critically ill or premature infant may require gavage
feeding until they reach readiness and maturational levels required to successfully oral
feed.

Definitions:

Orgogastric Tube or (OGT): a polyethylene or silasticweighted enteral f feeding tube that

is inserted into the oral cavity and passed through to the stomach for the purpose of
stomach decompression, feeding, or medication administration.

Nasogastric Tube or (NGT): a polyethylene or weighted enteral silastic feeding tube that
is inserted into the nares and passed through to the stomach for the purpose of stomach
decompression, feeding, or medication administration.

______________________________________________________________________________________________
This material has been prepared solely for the use at Lakeridge Health Corporation (Lakeridge Health). Lakeridge Health
accepts no responsibility for use of this material by any person or organization not associated with Lakeridge Health. No
part of this document may be reproduced in any form for publication without the permission of Lakeridge Health.
NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

Guidelines:
a) Initiation and Maintenance Guidelines:
 Insertion, position verification, tube utilization, and removal of a Nasogastric Tube
(NGT) or Orogastric Tube (OGT) will be performed by a Registered Nurse.

 Insertion of enteral tube and/or initiation of gavage feeding will be completed by

physician order OR based on a nursing assessment meeting the following
qualifications(AWHONN, 2006; PPPESO, 2008; PPPESO, 2008b):
o Gestational age greater than 34 weeks AND
o Free of signs and symptoms suggestive of respiratory distress (i.e.
respiratory rate greater than 60 breaths per minute) AND
o Hypoglycemic and unable to orally feed AND
o Inability to breast feed or bottle feed due to physiologic status AND
o Absence of oral feeding readiness cues (i.e. feeding behavioural cues,
infant sucking behaviours, absent or weak gag reflex, and
disorganized suck/swallow/breathing coordination)
 Continuous enteral feedings will be initiated as per physician order (AWHONN,
2006).
 Oral and nasal assessment and hygiene will be performed at least once a shift,
ideally every 3 to 4 hours or PRN (AWHONN, 2006; AWHONN, 2006b). Regular
assessment and care of skin around tube entry site and securing devices facilitates
early recognition of skin break down and supports implementation of skin care
practices (AWOHNN, 2006b).
 OGT insertion is required for all infants who are receiving bag/mask ventilation or
are receiving CPAP ventilation support (AHA/CPS/AAP, 2006). The OGT will remain
open to straight drainage unless otherwise ordered (AHA/CPS/AAP, 2006).
 The smallest size enteral feeding tube (i.e. 5 or 6 Fr) will be utilized to reduce
incidence of swallowing difficulties, blockage of nares, and gastroesophageal reflux
(AWHONN, 2006; Cloherty & Stark, 1991; Merentstein & Gardner, 1993; PPPESO,
2008; PPPESO, 2008b).

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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

 Larger size enteral feeding tubes will be utilized for gastric drainage or
decompression (i.e. 8Fr) (AHA/CPS/AAP, 2006; PPPESO, 2008).
 Utilization of enteral tubes for infants with certain conditions (i.e. facial or
tracheoesophageal congenital anomalies) will be done cautiously and in
consultation with a physician (AWHONN, 2006).
 Polyvinyl Chloride (PVC) tubes will be routinely changed every 72 hours—
alternating nares as possible (PPPESO, 2008).
 Weighted enteral feeding tubes will be changed every 4 to 6 weeks or by order of
the physician (PPPESO, 2008).
 Tube placement verification frequency recommendations (PPPESO, 2008; PPPESO,
2008b):
o Intermittent feeds: after tube insertion and prior to beginning each feed
o Continuous feeds: after tube insertion and every four hours
o Medication administration: after tube insertions, prior to medication
administration, prior to tube irrigation, or prior to any fluid instillation
 Tube placement will completed by(PPPESO, 2008; PPPESO, 2008b):
o Measurement of enteral tube via centimeter marking are nares OR
measurement of tube from nares to end of tube (if no centimeter marking
available)
o Auscultation of gastric ‘pop’ prior to EACH feeding
o Gastric pH testing and assessment of gastric aspirate after insertion, prior
to the first feeding session of a shift, and as needed for the duration of the
shift based on nursing assessment
o Weighted enteral feeding tube placement will be verified via x-ray
confirmation
 A registered nurse will remain present throughout the enteral feeding session
(Merenstein & Gardner, 1993; PPPESO, 2008b).
 An infant receiving enteral feedings will have a functional suctioning system and
emergency oxygen with a bag-mask set up at their bedside.
 Infants being continuously monitored will have monitors ON with audible alarms
set for duration of feeding to support assessment of tolerance and potential signs

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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

of feeding intolerance (i.e. change in oxygen requirement evidenced by decreases

in oxygen saturation, colour changes, and changes in heart and respiratory rates
(AWHONN, 2006; Cloherty & Stark, 1991; Merenstein & Gardner, 1993).
 Infants will be offered a pacifier during gavage feedings after informed consent
from parents is obtained. Non-nutritive sucking has been shown to accelerate
maturation of sucking reflex, lead to earlier initiation of oral feedings, and increase
daily weight gain (AWHONN, 2006; Boiron, Da Nobrega, Roux, Henrot, & Saliba,
2007; Cloherty & Stark, 1991).
 Bottle feeding or breast feeding attempts will last a total of 20-30 minutes with
the balance of the feeding administered via enteral tube (Kirk, Alder, & King,
2007; Merenstein & Gardiner, 1993; PPPESO, 2008b).
 During insertion and removal procedures infant’s eyes will be protected to reduce
risk for conjunctivitis (PPPESO, 2008).

b) Equipment:
1. Sterile feeding tube of appropriate size (Merenstein & Gardner, 1993;
PPPESO, 2008)
 5 Fr tube utilized for infants less than 1500 kgs
 6 Fr tube utilized for infants greater than 1501 kgs
 8 Fr tube utilized for gastric drainage or decompression
2. Clear, non-allergenic tape, transparent semi-permeable membrane
dressing, or other (i.e. Hypafix or Mepore)
3. 10 mL syringe
4. Non-sterile procedure gloves
5. Stethoscope
6. Measuring Tape
7. pH testing stripes
8. Water based lubricant or sterile water
9. Feeding system set-up (syringe, feeding bag, extension tubing, and/or
syringe/feeding pump)

c) Insertion Procedure:
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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

1. Prepare equipment, see section (b).

2. Complete abdominal assessment.
3. Position infant supine with head slightly extended and head of bed elevated.
4. Measure tube to determine distance.
• With the tube, measure from bridge of nose to the earlobe, then down to
the mid-point between the xyphoid process and the umbilicus. Mark the
tube at that point with a piece of tape.
5. Bundle infant leaving chest exposed.
6. Lubricate tip of the tube with sterile water just before insertion.
7. Immobilize infant’s head with one hand.
8. Gently insert tube via mouth or nose towards the pharynx and advance it down
until the tape marker is reached.
9. Remove tube if infant begins coughing, fighting, or becomes cyanotic. Reinsert
tube when infant is stable.
10. Check for correct placement, see section (d).
11. Anchor tube in place with a semi-permeable dressing.
12. Label tube with date and time of insertion.
13. For enteral tubes with NO cm markings—Measure length of tube from nose
to distal end and note measurement on patient chart.

Respources:
 Refer to Wong’s Nursing Care of Infants and Children, page 1133-1134 for
detailed procedure:
Hockenberry, M. J., & Wilson, D., (2007). Wong’s Nursing Care of Infants
and Children. Mosby Elsevier: St. Louis, Missouri.

 Refer to Neonatal Resuscitation Textbook, pages 3-26 to 3-28 for detailed

procedure:
American Heart Association (AHA), Canadian Paediatric Society (CPS), &
American Academy of Pediatrics (AAP). (2006). Neonatal Resuscitation
Textbook. 5th Edition. Canadian Paediatric Society: Ottawa, ON.

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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

d) Tube Position Verification:

1. Verification of placement utilizing measurement of an indwelling enteral
tube (PPPESO, 2008)
i. Feeding tubes with centimeter marking present
 Verify centimeter marking located at the nares and confirm
with prior data
ii. Feeding tube without centimeter marking present
 Verify position by measuring the length of enteral tube
remaining ‘outside’ (i.e. measure from nares to end of enteral tube
connecting port)

2. Auscultation of Gastric ‘pop’ (PPPESO, 2008; PPPESO, 2008b).

1. Position stethoscope over epigastric region (i.e. upper left quadrant)
of stomach
2. Using a 10 mL syringe, rapidly inject 1-2 mL (full-term) or 0.5-1 mL
(premature) of air into tube while auscultating for resultant ‘pop’ in
the stomach
3. If gastric ‘pop’ is not auscultated, repeat procedure with a slightly
larger volume of air
4. Always withdraw the same amount of air that was injected
5. Discard syringe
6. A gastric ‘pop’ by itself is not a reliable measure for confirmation of
proper enteral tube placement. Referred sounds can still be heard in
the stomach if the tube end is placed in the respiratory, intestinal, or
esophageal systems. This method of placement verification must
be used in conjunction with other verification methods, such
as the assessment of gastric pH.

3. Assessment of gastric pH procedure guideline (PPPESO, 2008; PPPESO,

2008b):
i. Obtain gastric aspirate:
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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

a. Intermittent Feeds or Medication Administration:

 Attach syringe to feeding tube and inject 1-3 mL of air to clear
tube
 Apply gentle suction and withdraw approximately 1 mL of
gastric contents
 Apply gastric contents on pH testing strip—ensure saturation of
testing square—remove excess fluid by placing strip on its side
—test pad may take up to 10 minutes for complete colour
change

b. Continuous Feeds:
 Turn feeding pump off and detach feeding tube
 Attach syringe to feeding tube and inject 1-3 mL of air to clear
tube
 Apply gentle suction and withdraw approximately 1 mL of
gastric contents
 Apply gastric contents on pH testing strip—ensure saturation of
testing square—remove excess fluid by placing strip on its side
—test pad may take up to 10 minutes for complete colour
change

ii. Gastric pH testing (May, 2007; PPPESO, 2008; PPPESO, 2008b):

c. Assess and document gastric contents:
 Gastric aspirates range in colour from clear/white/tan to
green/blood-tinged/brown. Consistency may be clear, cloudy,
or curdled looking
 Duodenal secretions tend to be yellow and clear
 Pleural aspirates are usually clear to yellow serous type fluid
and may be blood tinged from trauma
 Tracheobronchial secretions are usually mucousy/white to
yellow in colour

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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

d. Assessment of pH strip (May, 2007; PPPESO, 2008; PPPESO,

2008b):
 Compare test strip to chart included with test strip pack
 Match the colours of the test pad to the reference chart and
document resulting pH level
• The pH of gastric contents are less than or equal to 5
• Infants who have been feed recently, continuously, or
are receiving acid-suppressing medications may have a
gastric pH level equal to or less than 6
• Gastric pH levels of greater than 6 are more likely to
occur if the enteral tube is positioned in the duodenum
or respiratory system and should have the enteral tube
removed and re-inserted
 Discard the syringe used for gastric testing immediately after
use to reduce risk of colonization of gastrointestinal bacteria

e) Feeding:
1. Assemble equipment
 Sterile syringe of appropriate size for feed
 Expressed breast milk or formula
 Sterile water
 Feeding or syringe pump and extension tubing as required

2. Verify correct enteral tube placement

 Complete position verification procedures—see section (d)

 In addition to this, aspirate stomach for gastric residual from

previous feeding (PPPESO, 2008, PPPESO, 2008b)
o Assess colour, consistency, and amount of residual
o Re-feed residual unless otherwise ordered
o Gastric contents contain vital enzymes and nutrients.
Unless otherwise ordered or aspirate is bloody, green, bright

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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

yellow, or otherwise unusual in appearance—return the

contents to the stomach (PPPESO, 2008; PPPESO, 2008b).
o Incompletely digested aspirates of 2ml/kg, or a 1 hour
volume, 1 hour volume if on continuous feeding is considered
normal and should be returned to the infant (Merenstein &
Gardner, 1993)
o Feedings should be held and a physician notified if:
• Abnormal abdominal exam;
• Presence of bile, blood or coffee grounds in residuals;
• Abdominal girth has increased by 1 cm in infant less
than 28 weeks corrected age;
• Abdominal girth has increased by 2 cm in infant 28
weeks or greater corrected age;
• 25% residual of previous feed for a second consecutive
time OR residual is greater than 25% of previous feed
plus other abnormal signs

3. Complete gastrointestinal assessment (Cloherty & Stark, 1991; Merenstein

& Gardner, 1993; PPPESO, 2008; PPPESO, 2008b)
 Abdominal girth
 Appearance of abdomen (i.e. size, shape, an softness)
 Auscultation of all quadrants for bowel sounds
 Observe for: bowel loops, abdominal discoloration, abdominal
distention, emesis or increased gastric residuals, blood in stools, or
regurgitation (i.e. frequent swallowing, coughing, or arching)
 Weight gain/loss patterns

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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

4. Feeding Administration

 Intermittent Feedings (Cloherty & Stark, 1991; Merenstein & Gardner,

1993; PPPESO, 2008; PPPESO, 2008b):
1. Position infant prone, side-lying, or semi-upright (30 degree
angle) during and after feed
2. Measure feeding amount in graduated bottled
3. Attach syringe barrel to feeding tube
4. Fill syringe to desired amount of feed
5. Holde syringe barrel 6 to 8 inches above infants head
6. Allow feed to flow into stomach via gravity, enteral feedings
must never be administered under pressure
7. Administer feeding at a rate of 1-2 mL/kg/min or
approximately over 15-30 minutes
8. After completion, instill 1 to 2 mL of sterile water or air to clear
tubing and re-cap

 Continuous or Timed Feedings (Cloherty & Stark, 1991; Merenstein &

Gardner, 1993; PPPESO, 2008; PPPESO, 2008b):
1. Position infant prone, side-lying, or semi-upright (30 degree
angle) during and after feed
2. Measure feeding amount in syringe
3. Attach syringe to extension tubing and prime
4. Load syringe or tubing into feeding/syringe pump
5. Connect to enteral tube
6. Program pump to administer feeding volume at prescribed rate
7. Administer feeding
8. After completion, instill 1 to 2 mL of sterile water or air to clear
tubing and re-cap
9. Flush extension tubing

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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

 Extension tubing or feeding systems will be changed every 12

hours—if feeding amounts are small systems will be changed
every 8 hours
 All tubing will labeled for change requirements (i.e. date
opened)
 For continuous feedings—a maximum of 4 hours of feeding
volume will be hung for infusion

f) Drainage (AHA/CPS/AAP, 2006; PPPESO, 2008):

1. Assemble equipment (refer to previous section)
2. Verify placement (refer to previous section)
3. Leave tube open to drainage—a collection container may need to be
applied to the end of tube if there are copious secretions draining
4. Document drainage amounts on patient chart—consult with physician
if drainage amounts are profuse or increase incrementally over a shift
—replacement fluids may need to be given

g) Tube Removal (Cloherty & Stark, 1991; Merenstein & Gardner, 1993; PPPESO, 2008):
1. Obtain equipment as necessary
2. Explain procedure to parents if present
3. Position infant prone or lateral
4. Loosen tapes
5. Pinch tubing while withdrawing tube in a steady motion
6. Complete nasal and/or mouth care as required

h) Documentation:
• As per Lakeridge Health Corporation Documentation Standards.

References:

American Heart Association (AHA), Canadian Paediatric Society (CPS), & American
Academy of Pediatrics (AAP). (2006). Neonatal Resuscitation Textbook. 5th Edition.
Canadian Paediatric Society: Ottawa, ON.

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NICU—Enteral Tubes for Feeding or Drainage Care Guidelines

American Academy of Pediatrics (AAP) & American Heart Association (AHA). (2005).
Pediatric Advanced Life Support Professional Provider Manual. 5th Edition. American Heart
Association: Dallas, Texas.

Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), (2006).

Neonatal Orientation and Education Program—Module 4 Metabolic and Nutritional
Support. Association of Women’s Health, Obstetric and Neonatal Nurses: Washington,
DC.

Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), (2006b).

Neonatal Orientation and Education Program—Module 5 Skin and Skin Care. Association
of Women’s Health, Obstetric and Neonatal Nurses: Washington, DC.

Boiron, M, Da Nobrega, L., Roux, S., Henrot, A., & Saliba, E., (2007). Effects of oral
stimulation and oral support on non-nutritive sucking and feeding performance in
preterm infants. Developmental Medicine & Child Neurology. 49(6), 439-444.

Cloherty, J. P. & Stark, A. R. (eds.), (1991). Manual of Neonatal Care—Joint Program in

Neonatology, Harvard Medical School, Beth Israel Hospital, Brigham and Women’s
Hospital, and The Children’s Hospital of Boston. 3rd Edition. Little, Brown and Company:
Boston, USA.

Hockenberry, M. J., & Wilson, D., (2007). Wong’s Nursing Care of Infants and Children.
Mosby Elsevier: St. Louis, Missouri.

Karlsen, K. (2006). The S.T.A.B.L.E. Program. Post-resuscitation/Pre-transport

Stabilization Care of Sick Infants. Guidelines for Neonatal Healthcare Providers. 5th
Edition. S.T.A.B.L.E. Inc.: Park City, Utah.

Kirk, A. T., Alder, S. C., & King, J. D., (2007). Cue-based oral feeding clinical pathway
results in earlier attainment of full oral feeding in premature infants. Journal of
Perinatology. 2007(27), 572-578.

May, S., (2007). Testing nasogastric tube positioning in critically ill: exploring the
evidence. British Journal of Nursing. 16(7), 414-418.

Merenstein, G. B. & Gardner, S. L., (1993). Handbook of Neonatal Intensive Care. 3rd
Edition. Mosby Year Book: St. Louis, USA.

PPPESO, (2008). Gastric Tube Insertion. Perinatal Nursing Procedure by Perinatal

Partnership Program of Eastern & Southeastern Ontario. Accessed at:
http://www.pppeso.on.ca

PPPESO, (2008b). Gavage Feeding. Perinatal Nursing Procedure by Perinatal Partnership

Program of Eastern & Southeastern Ontario. Accessed at: http://www.pppeso.on.ca

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