Nasogastric Tube Placement and Verification in Children: Review of the Current Literature

Abstract

Placement of a nasogastric enteral access device (NG-EAD), often referred to as a nasogastric tube, is common practice and largely in the domain of nursing care. Most often an NG-EAD is placed at the bedside without radiographic assistance. Correct initial placement and ongoing location verification are the primary challenges surrounding NG-EAD use and have implications for patient safety. Although considered an innocuous procedure, placement of an NG-EAD carries risk of serious and potentially lethal complications. Despite acknowledgment that an abdominal radiograph is the gold standard, other methods of verifying placement location are widely used and have success rates from 80% to 85%. The long-standing challenges surrounding bedside placement of NG-EADs and a practice alert issued by the Child Health Patient Safety Organization on this issue were the stimuli for the conception of The New Opportunities for Verification of Enteral Tube Location Project sponsored by the American Society for Parenteral and Enteral Nutrition. Its mission is to identify and promote best practices with the potential of technology development that will enable accurate determination of NG-EAD placement for both the inpatient and outpatient pediatric populations. This article presents the challenges of bedside NG-EAD placement and ongoing location verification in children through an overview of the current state of the science. It is important for all health care professionals to be knowledgeable about the current literature, to be vigilant for possible complications, and to avoid complacency with NG-EAD placement and ongoing verification of tube location.

Following the Evidence

“…Most infant formulas have a pH of approximately 6.6, and when mixed with gastric secretions, can raise pH measurements of aspirates, 22 although the difference is not statistically significant. 23 The pH of breast milk ranges from 7.0 to 7.4, depending on the age of the infant.…”

“…Currently, only one method, x-ray study, provides 100% accuracy in determining enteral tube tip location 4,11,14,18,22 and is considered the criterion standard by which to compare other verification methods. 31,35 A variety of other methods have been studied, but none afford the conclusive findings that an x-ray study provides.…”

Procedures for measuring and verifying gastric tube placement in newborns: an integrative review

“…Intestinal absorption problems and alimentary intolerance related to GT positioning in the pylorus or duodenum can also occur. Moreover, difficulties encountered in the trajectory can cause puncture injuries to the esophagus or respiratory tract 2 . The occurrence of errors in GT placement is very frequent: studies show proportions of 47.5 to 59% inadequate placement between neonatal and pediatric patients 3 - 4 .…”

Posicionamento de sonda enteral em neonatos segundo técnica modificada de mensuração

“…However, when it is placed near the pyloric junction and in the duodenum, it can cause malabsorption, diarrhea and inadequate weight gain. (8) Different techniques of measurement of the tube are identified in different neonatal services and in the literature, and there is no consensus on the best method for the correct placement in the gastric cavity. (3,9) The aim of this study was to evaluate the effectiveness of the measurement of enteral tube using the nose -ear -xiphoid (NEX) technique by disregarding the distal orifices of the tube, for placement in the gastric cavity of newborns.…”

“…However, in neonatology, newborns cannot be exposed to multiple radiographs for this purpose, since they already do this exam to perform other diagnoses. (8) Thus, to reduce newborns' exposure to radiation, other methods for tube placement and verification should be considered, such as real-time visualization. (7) Several techniques are used to measure the enteral tube without real-time direct visualization, but none of them is error free.…”