Nasogastric (NG) Feeding Tube Insertion Training Video

Some children may require a nasogastric (NG) tube to receive the nutrients they need to grow. In this video series, clinicians in the Division of Gastroenterology, Hepatology and Nutrition at Children’s Hospital of Philadelphia present a overview of NG tubes — why a doctor may prescribe this treatment for your child, steps you need to follow before placing an NG tube in your child, troubleshooting any challenges with tube insertion, and teaching your older child how to self-insert the NG tube.

Transcript

Nasogastric (NG) Feeding Tube Insertion Training Video: An Introduction

Linda Bevington, RN: My name is Linda Bevington. I'm a patient-family educator at The Children's Hospital of Philadelphia. Your child's medical team has ordered a feeding tube for your child to provide food or medicine. This instructional video will guide you through the steps you need to learn to safely insert your child's tube at home.

The nasogastric tube is a soft, flexible tube. It gets inserted into your child's nose where it reaches the back of the throat. It then turns down the food pipe, otherwise known as the esophagus, where it ends up in the stomach. Once the tube is inserted, it only needs to be changed once a month. But there are some older children who choose to remove and insert it every day.

Here are the supplies that you will receive from your home care company: 

  • The feeding tube
  • Liquid skin protectant (this is optional and can be used on any child over the age of 1 month)
  • Skin barrier (also to protect the child's skin)
  • Plastic dressing to hold the tube in place
  • Scissors
  • A permanent marker to mark the tube
  • Lubricating jelly and a syringe
  • PH strips to check the placement of the tube 

PH paper comes as strips or on a roll. Syringes come in different sizes. Your nurse will teach you the correct size for your child. For purposes of this video, I am using a 10-milimeter syringe. 

The first step in placing an NG tube is to wash your hands. Make sure that you have all of your supplies. Open up the tube. Take it out of the package, and close the side port if it's not being used to flush the tube.

Next, we are going to flush the tube with water. This is to activate the lubricant so that the wire will not stick. Take your syringe. We're going to fill it up to 5 milliliters of water. Attach it to the tube, as you were instructed. And I'm going to push the water through the tube. Remove the syringe. Shake out the excess water. Then pull up on the wire, slightly, just to check the wire to make sure it moves freely.

Next, we need to measure because we need to know how far down the tube needs to go in order to be in the child's stomach. Start with the feeding hole, which is located on the side of the tube. Line up the feeding hole to the tip of the child's nose and hold it there. Bring the tube across the cheek to the bottom of the earlobe and hold it there. Letting go from the nose but holding at the earlobe, bring the tube across the child's chest, and you're looking for two landmarks: the belly button and the bottom of the breastbone, which should be easy to feel.

The bottom of the breastbone is also called the xiphoid process. Find the process. Hold the tube at that notch, and the tube needs to go halfway between the bottom of the breastbone and the belly button. Once I see the number, I'm going to hold on to it and then mark it with my marking pen.

Now, if you're measuring and your hand slips or the child moves, it's important to measure again. Also, children grow, and the tubes don't grow with them. So whenever you're changing the tube it's important to re-measure. Next, we're going to cut the tape and get everything ready. If you're using a skin protectant, you can place it on the child's cheek now. Choose the nostril you are going to use. If you're changing the tube, it's important to rotate and use the opposite side.

Apply the liquid skin protectant on the side of the cheek that you're going to use. It should dry quickly. Remove the skin barrier from the package. Bring it up to the child's cheek just to estimate the size that you need. You're going to cut it with the scissors and then bring it up again just to check to see if we need to trim it. We want to make sure it's not too close to the child's eye, lip or getting into their hair.

Take the tape out of the package. Cut it according to the size that you need. And I'm going to use the skin barrier as a guide to help me trim the plastic dressing.

Now I can apply the barrier. Peel off the backing and put it on the cheek next to the nostril that you're going to be using. Gently massage it and this will help it to stick better. 

So let's talk about positioning. You will need help holding your child. For an infant, it is best to swaddle them in a blanket. You can have their head elevated on a pillow, or you could hold them securely on your lap, or you can use an infant seat. The idea is that we want to make sure that their head is elevated. The person helping you should have a hand across them and a hand across their forehead. We'll also offer the baby a pacifier because that will help them swallow. 

Toddlers need to be held very securely. You can take your arm and place it across their arms, and you can take your other hand and place it firmly on the child's forehead. You may also need to cross your legs over their legs just to prevent kicking. 

An older child who can cooperate will sit and sip water through a straw while you insert the tube.

Nasogastric (NG) Feeding Tube Insertion Training Video: Tube Placement

Linda Bevington, RN: Your nurse will tell you the best way to hold your child.

Now it is time to put the tube in. We need to lubricate the tube because we want it to slide down the nasal passage without causing any irritation. Dip the tube in the lubricant. Move it around. Hold the tube in the hand that you write with. The other hand is just back, guiding and supporting the tube.

Making sure that someone is holding your baby securely, we're going to aim the tube towards the back of the throat, because that's the angle that it needs to go in at. I'm going to start slowly feeding the tube in, small movements, feeding it in, feeding it in, feeding it in, and stop when you reach your mark.

Then we're going to tape it down, so you can have your helper holding on to the tube. If you're having difficulty inserting the tube, if you're putting it in and it stops moving, try pulling back slowly and, once again, pushing the tube in again. You also want to make sure that the baby's head is in an upright position.

It is normal for the baby to cry, to want to move, and also to gag. These are normal and expected behaviors. 

But if you're pointing the tube in and the baby starts coughing, or there's a color change around the lips, or they're making choking sounds, that is not a normal sign, and you need to remove the tube right away. This can mean that the tube is trying to enter the breathing passage, so we need to take that tube out.

So remember the signs are coughing, choking, color change around the lips, trouble breathing, keeps gagging, or coughing after tube is placed or does not seem to be himself. 

Remember, when it doubt, pull it out.

If you're putting the tube in, and the tube comes out the child's mouth, you need to pull it out from the nose, re-lubricate, and try it again. Once the tube is in place, have your helper hold it so you can apply the tape. Remove the backing, and when you're applying it, try to get as close to your child's nostril as possible. Press down to get it to stick. Remove the paper. Press securely. You can now take the wire out. Hold the tube and pull on the wire. It should come out easily, and then we're going to close the port. You're going to save the wire and put it back in the package.

Now we need to check the placement. To do that, take the syringe, attach it to the port, push 3 milliliters of air into the tube, pull back on the plunger until you see some liquid come back into the syringe. And we will put the stomach fluid on to the pH strip. Completely cover the test area on the strip with the fluid. 

The pH of the stomach fluid should be arranged from 1 to 5. If the pH is greater than 5, do not use the tube. Wait 15 to 30 minutes then recheck the pH. If the pH remains greater than 5, take the tube out and reinsert it. If the pH is still greater than 5, do not use the tube and call your doctor or nurse practitioner.

If you're having trouble trying to get the fluid to come back, try these maneuvers. First turn your child on their left side. Sometimes moving the child is enough to reposition the tube. Once again, try to pull back. If you're still not getting any fluid, try to push 3 milliliters of air into the tube. This is a small amount of air, and it shouldn't cause any discomfort. Three milliliters of air goes into the tube, and then once again, try to pull back on the plunger to see if this works.

If you're still not getting fluid back, go ahead and repeat the air trick. And once again, try to pull back. If you still do not get any fluid back, then wait. Do not put anything into the tube. 

Wait 20 minutes before trying again. If nothing still, you can instill the air one more time, otherwise, you need to take the tube out because we need to get the fluid back to tell us if the tube is in the right spot. So, again, when in doubt pull it out.

Once I check placement, I need to flush the tube with water. This will help prevent it from getting clogged. The amount of water depends on the size of your child.

For an infant, I'm going to use 3 milliliters of water. Again, this is tap water. Push the water into the tube slowly. Close the port, and then lastly, let's secure the tube to your child. If we leave the tube hanging then we're more likely to have the tube come out.

This is where you can get creative, or you can do something as simple as taping the tube to your child's outfit. Just keeping it out of their way, taping it to the shoulder is a good idea. You could also pin it to their clothing as well. This way it will keep the tube secure and less likely to come out.

Once the tube is secure, it's ready to use, and at that point you're just cleaning up and putting your things away.

Nasogastric (NG) Feeding Tube Insertion Training Video: Family Demonstrations

Linda Bevington, RN: Now that you've seen a demonstration, let's watch a parent putting a tube in their own child. After that, you'll watch an older child inserting their own tube.

Patient: Then there is a wire. You got to pull it out when you're done with it. And then usually my mom or my dad, whoever is there, cuts the tape with the scissors in the back. And then you're done.

Linda Bevington, RN: We hope that is instructional video provides you with the skills, information, and encouragement needed to safely insert the tube in your own child at home.

If you're having any trouble inserting the tube, or have any concerns about the tube, please contact your child's healthcare provider.

Related Centers and Programs: Division of Gastroenterology, Hepatology and Nutrition