Enteral Tube Program

Home Care Instructions for Inserting Nasogastric (NG) Feeding Tubes

Your child is going home with a nasogastric (NG) feeding tube. An NG feeding tube is needed to give your child liquid food when he or she is unable to take enough food by mouth. The tube is put into the nose, into the food pipe (esophagus), and then into the stomach. This information sheet gives you instructions on how to insert a nasogastric (NG) feeding tube, how to make sure the tube is properly placed and what to do if you have concerns or problems.
Nasogastric tubes are routinely changed once a month or when the tube has unexpectedly fallen out. There are some patients that insert the tube every night and remove it in the morning.
Your child’s nasogastric (NG) tube is to be replaced only if you have been instructed on how to replace it by your child’s doctor or nurse.
If the tube falls out unexpectedly, and you have not been taught how to replace the tube, call your child's doctor or nurse to arrange a plan for tube replacement.

Preparation

Do not give your child anything to eat or drink for at least 30 minutes before inserting the tube.
Wash your hands.
Gather the following items:
feeding tube
small cup of water
30-60 mL syringe
pHydrion Vivid™ 0-9
Water soluble lubricant such as K-Y Jelly^®.
Hytape^® (pink tape)
Tegaderm™ (if instructed)
Duoderm^® extra thin (if instructed)
Cut 4-5 pieces of tape.

How to Insert the Tube

Tell your child what you will be doing.
To measure the NG tube for the distance you will be inserting it:
hold the tip of the tube at the end of your child's nose;
extend the tube to the child's earlobe;
extend the tube to the child's stomach (midway between the belly button and lower edge of the breastbone); and
mark the length measured with a piece of tape or a marker on the tube. If your child has a tape sensitivity, you may be instructed to apply a small dressing (i.e. Duoderm^®) to the child’s cheek to protect the skin.
Once you know the proper length to insert the tube, you may use this same distance/markwhen you replace the tube the next time.
Position your child.
For an infant, use an infant seat or a mattress with a pillow under the top part of the mattress to raise the head. You may wrap your child in a blanket so he or she is unable to pull the tube out.
For an older child, ask him or her to sit in a chair. If someone is available to help, have that person hold your child’s arms and head.
Dip the tip of the tube in water to moisten. This activates the outer coating to make it slippery to make it easier to insert the NG tube.
Note: If the NG tube is the type that has a wire (stylet) that helps to guide the tube, it is important to check that the stylet is securely placed in the tube before putting it into your child’s nose. Push about 1-3 mL of water into end of stylet. This activates the inner coating of the tube to make it slippery to assist in the removal of the stylet.
Gently insert the tube into one nostril with a steady motion. Direct the tube up and back.
DO NOT force the tube. If the tube does not go in easily, stop for a few seconds, and try again. You may try the other nostril. If you still cannot get the tube to pass easily, call the Children’s Hospital doctor or nurse who is managing your child’s feedings.
Your child is likely to gag during this procedure. When this happens, stop for a few seconds until the gagging stops. Then continue passing the tube. If your child is able to help, ask him or her to swallow or drink a few sips of water. Sucking on a pacifier may help an infant.
Your child may cough as the tube is being inserted, but the coughing should stop. Remove the tube immediately if your child has severe coughing, blueness, difficulty breathing or vomits.
Insert the tube until the mark is reached. Then tape the tube to the skin above the upper lip and cheek. (See Figure1).
Make sure the tube is not rubbing against the nostril to avoid skin irritation.

Figure 1

How to Check the Placement of the Tube

Do not use the tube for feedings until you have checked and are sure that the tube is placed in your child’s stomach. (It is possible the tube may be accidentally placed in your child’s windpipe.)

After inserting an NG tube, you must check the ph of stomach contents to make sure the tube is in your child’s stomach.
Thereafter prior to giving a feeding or medication you must check the length of the tube to see if the tube has moved since insertion.

How to check pH (level of acid) of stomach contents (“juices”).
This is the most reliable way of checking that the tube is in the stomach.

Attach a 30-60ml syringe to the end of the tube
Withdraw (pull back on) the syringe plunger slowly to pull back stomach juices
Apply 1-2 drops of the stomach juices to pH paper.
A pH of 0-5 suggests the tube is properly placed in the stomach.

Problem Solving:

What if I cannot draw back stomach contents?

If you are unable to draw back, try using the larger syringe. You may also try pushing in 5cc of air and then try to draw back the stomach contents. Also, you can place your child on his/her LEFT side and wait about 5 minutes. This position helps the tube to fall below the fluid level in the stomach. Try to get stomach contents again and check for pH.
If you are still unable to draw back stomach contents, do not use the tube. Take the tube out, reinsert and check the pH.
If you are still unable to draw back stomach contents, do not use the tube and call the Children’s Hospital Doctor/Nurse who is managing your child’s feedings. You may need to bring your child to the hospital to have an x-ray to check proper placement.

What if I check the pH and it is greater than 5?

If your child is on stomach acid-blocking medications (For example, proton pump inhibitors such as Protonix^®, Prilosec^®, Prevacid^® to name a few, H2 blockers such as Zantac^®, Tagamet^®, and Pepcid^® or antacids such as Maalox^®, Mylanta^®, Milk of Magnesia^®) the stomach acid pH may be greater than 5. If your child is on these medications, try to check the pH just before you give these acid blocking medications.
If you check the pH and it is greater than 5, do not use the tube and wait 1-2 hours and recheck the pH.
If the pH is still greater than 5, do not use the tube and call the Children’s Hospital Doctor/Nurse who is managing your child’s feedings. You may need to bring your child to the hospital to have an x-ray to check if the tube is properly placed in the stomach.

Once the pH has been checked and is found to be less than 5, gently pull out the stylet (if the tube has one).

Check the length of the tube from the nose to the end of the tube and record this number. You must check the length of the tube before every feeding or medication. If the number is different, then the tube may have moved out of place since insertion.

Important Tips

If your child has severe coughing, blueness, or difficulty breathing REMOVE the tube.
Never insert the stylet when the tube is in your child.
If your child vomits, you mustrecheck placement by checking pH of stomach contents.
Always check (length of tube) before giving any medications or feedings. If the tube is longer or shorter than when you placed it, recheck the pH.
If the tube is clogged, attach a 50-60 ml syringe filled with 20 ml of warm water. Gently push on the plunger. Remove the tube and insert a new one if you cannot unclog the tube. NEVER use the stylet to unclog the tube!
You may use the same tube 2-3 times. Do not use the same tube for longer than 1 month.
Change the tube to your child’s other nostril when you need to put in a new tube.
Gently clean the edges of your child’s nostrils at least once a day with cloth moistened with warm water.
Use liquid medications whenever possible. Always flush before and after medications. If you must give pills/tablets, crush them thoroughly. Powder is to be mixed well with warm water.
If you need to remove the tube, remove the tape. Then pinch the tube and pull it out gently and quickly.

Follow these steps if reusing the same tube:

Wash the tube with warm water and a small amount of soap. Rinse well.
Check the tube for cracks, tears or kinks. If you see any of these, discard the tube.
Check the stylet to make sure it is not bent. If it is bent, throw it away, and use a new tube.
Insert the stylet into the tube if the stylet is not bent. If the stylet does not go in easily, coat it with a water soluble lubricant. This will ease placement and removal of the stylet.
Prior to insertion of the tube coat the tip with a small amount of water soluble lubricant. This will make it easier to insert the NG tube.

When to Call the Doctor or Nurse:

Call your Children’s Hospital Doctor/Nurse who is managing your child’s feedings if you:

have any questions or concerns
are unable to insert the tube. If your child is followed by a visiting nurse, call the Visiting Nurse Agency (VNA) first. Many VNA’s are authorized to re-insert NG tubes. Your child’s primary care doctor may also help you reinsert the tube.
See "How To Check the Tube Placement" section.

On evenings, nights, weekends or holidays, call the Children’s Hospital’s Page Operator at 617-355-6369. Ask to speak to the doctor on call for the department that manages your child’s feedings.