How to Start NGT Feeding
Once nasogastric tube position is confirmed, feeding can commence immediately according to the established nutritional care plan without dilution or starter regimens in patients who have had reasonable nutritional intake in the last week. 1
Pre-Feeding Requirements
Before initiating NGT feeding, three critical conditions must be met:
- Verify correct tube placement using pH testing (aspirate should be pH <5.5) prior to every use, or radiographic confirmation for initial placement 1, 2
- Confirm medical stability of the patient with stable hemodynamics and no escalating vasopressor requirements 1
- Assess refeeding risk in malnourished patients, as metabolic complications can be life-threatening 1
Common pitfall: Never rely solely on auscultation to confirm tube position—this method is unreliable and can lead to fatal complications if feeding is initiated into the lungs 2. Always use pH testing or radiography.
Timing of Initiation
Start NGT feeding within 24-48 hours of hospital admission when enteral nutrition is indicated 1, 3. The evidence strongly supports early feeding:
- In critically ill patients, initiate within 48 hours unless contraindicated by escalating vasopressor use or hemodynamic instability 1
- In stroke patients with dysphagia, early NGT feeding substantially decreases risk of death compared to delayed feeding 2, 3
- In mild to moderate acute pancreatitis, NGT feeding within 24 hours significantly reduces pain intensity, opiate requirements, and oral food intolerance 4
Contraindications to immediate feeding: Withhold NGT feeding in patients with uncontrolled shock, escalating vasopressor requirements, or hemodynamic instability until stabilization occurs 1.
Feed Prescription and Administration
Initial Feed Volume
No starter regimen or dilution is necessary in patients with recent adequate nutritional intake 1. This is a critical point where traditional practice has been proven wrong:
- Diluting feeds increases infection risk and creates osmolality problems 1
- Start at full-strength formula immediately once position is confirmed 1
- If no dietitian guidance available, use 30 mL/kg/day of standard 1 kcal/mL feed as a reasonable starting point, though this may be excessive in severely malnourished or metabolically unstable patients 1
Delivery Method
Gastric feeding permits higher feeding rates, hypertonic feeds, and bolus administration compared to post-pyloric feeding 1:
- Bolus feeding: 200-400 mL administered over 15-60 minutes, 4-6 times daily via syringe 1
- Continuous infusion: Via pump for more controlled delivery, particularly useful for high-calorie feeds 1
- Overnight pump-assisted feeding: Allows daytime activity and is often preferred for home enteral nutrition 1
Special Populations and Modifications
Refeeding Syndrome Risk
In severely malnourished patients, close monitoring is essential during the first few days 1:
- Monitor fluid status, glucose, sodium, potassium, magnesium, calcium, and phosphate closely 1
- Consider starting at lower rates (50-70% of target) and advancing gradually over 3-5 days 1
- Life-threatening complications are particularly common in the very malnourished 1
Post-Surgical Patients
Timing varies by nutritional status 1:
- Severely malnourished: Start within 1-2 days of surgery
- Moderately malnourished: Start within 3-5 days of surgery
- Well-nourished: Start within 7 days of surgery
Early enteral feeding after major gastrointestinal surgery reduces infections and shortens hospital stay 1.
Jejunal vs. Gastric Feeding
If post-pyloric (jejunal) feeding is required, use a graduated approach 1:
- Start with 10 mL/h of 0.9% sodium chloride for first 24 hours
- Begin enteral formula at 10 mL/h for 24 hours
- Increase by 20 mL/h daily until target reached (typically by day 6) 1
Monitoring and Troubleshooting
Position the patient at 30° or greater during feeding and maintain this position for 30 minutes after bolus feeds to minimize aspiration risk 1. For continuous feeds, keep the head elevated throughout feeding.
Monitor for feeding intolerance: nausea, vomiting, abdominal distension, or diarrhea 2. These occur in approximately 13-25% of patients but are usually manageable without stopping feeds 5.
Tube security is critical: Dislodgement occurs in 40-80% of NGT tubes without proper securement 2. Consider nasal bridles for high-risk patients (reduces dislodgement from 36% to 10%) 2, or specialized securing methods using low-adherent film as a contact layer to prevent skin breakdown 2.
Patient Education Before Discharge
Patients and caregivers must demonstrate competency in the following before discharge 1, 2:
- Feed administration technique
- Equipment handling and setup
- Basic troubleshooting for tube or equipment failure
- Recognition of complications requiring medical attention
Ensure continuity of care: Confirm that community caregivers are fully informed and that ongoing prescriptions for feeds and equipment are in place 1.