Pediatric Nasogastric Tube Placement and Verification: Best Practice Recommendations From the NOVEL Project

Abstract

The placement of a nasogastric tube (NGT) in a pediatric patient is a common practice that is generally perceived as a benign bedside procedure. There is potential risk for NGT misplacement with each insertion. A misplaced NGT compromises patient safety, increasing the risk for serious and even fatal complications. There is no standardized method for verification of the initial NGT placement or reverification assessment of NGT location prior to use. Measurement of the acidity or pH of the gastric aspirate is the most frequently used evidence-based method to verify NGT placement. The radiograph, when properly obtained and interpreted, is considered the gold standard to verify NGT location. However, the uncertainty regarding cumulative radiation exposure related to radiographs in pediatric patients is a concern. To minimize risk and improve patient safety, there is a need to identify best practice and to standardize care for initial and ongoing NGT location verification. This article provides consensus recommendations for best practice related to NGT location verification in pediatric patients. These consensus recommendations are not intended as absolute policy statements; instead, they are intended to supplement but not replace professional training and judgment. These consensus recommendations have been approved by the American Society for Parental and Enteral Nutrition (ASPEN) Board of Directors.

Dispelling Myths and Unfounded Practices About Enteral Nutrition

“…Summary/Recommendations: New ASPEN recommendations were developed by the NOVEL Project for pediatric patients . Based on the available evidence, the following are recommendations for best‐practice standards to verify NGT location in pediatric patients: Provide education to all staff who place or confirm placement of an NGT. Use appropriate NGT placement and securing methods, such as using the Nose→Earlobe→Xiphoid process→Midline of the Umbilicus (NEMU) tube‐measurement method in children. Measure gastric pH (a gastric pH value of 1–5.5 without a change in the patient's clinical status is indicative of gastric placement). Consider a radiograph for any patient in whom there is any concern for correct NGT placement, such as: Difficulty placing the NGT NGT placement in any patient at high risk of misplacement.…”

“…9 Summary/Recommendations: New ASPEN recommendations were developed by the NOVEL Project for pediatric patients. 12 Based on the available evidence, the following are recommendations for best-practice standards to verify NGT location in pediatric patients:…”

Addressing Frequent Issues of Home Enteral Nutrition Patients

“…Although intermittent NET placement by HEN adults using a self‐insertion technique may be preferred by some patients, more frequently competent HCPs place tubes and confirm placement with radiographic tests in adults to avoid inappropriately positioned tubes . Adults and children have the same risks for tube dislodgement; however, blind placement of NETs by registered nurses occurs more frequently in hospitalized children than adults . There is no standard method that ensures correct NET placement in pediatric patients.…”

“…20 Adults and children have the same risks for tube dislodgement; however, blind placement of NETs by registered nurses occurs more frequently in hospitalized children than adults. 21 There is no standard method that ensures correct NET placement in pediatric patients. However, consensus statements identified in the NOVEL (New Opportunities for Verification of Enteral Tube Location) project recommend initial and scheduled gastric pH testing for verifying the correct placement of NETs.…”

“…However, consensus statements identified in the NOVEL (New Opportunities for Verification of Enteral Tube Location) project recommend initial and scheduled gastric pH testing for verifying the correct placement of NETs. 21 Because of concerns from frequent radiation exposure, radiographic confirmation should be limited to those patients for whom there is difficulty placing the tube, those with facial fractures or neurological injuries, patients with critical illness, and patients with respiratory problems or who have no gag reflex. Radiographic testing is also suggested for those who deteriorate shortly after the tube is placed.…”