Orogastric Tube (OGT) Insertion Procedure in Neonates
Critical Recommendation
In general neonatal practice, nasogastric tubes (NGTs) are preferred over orogastric tubes (OGTs) due to reduced mucosal trauma from tube movement, but when OGT insertion is necessary, use a weight-based equation combined with the nose-ear-mid-umbilicus (NEMU) method for optimal tube placement. 1, 2, 3
Pre-Procedure Preparation
Patient Assessment and Positioning
- Position the neonate upright with the head level to create optimal anatomical pathway for tube insertion 4
- Ensure the infant is dressed and wrapped to reduce movement during the procedure 1
- Implement appropriate pain management strategies before insertion, as OGT placement is a painful procedure 5, 6
Pain Management
- Administer 24% oral sucrose (1 mL) lingually 2 minutes before OGT insertion to reduce pain response 6
- Consider inserting the OGT through a modified bottle nipple, which significantly reduces pain (71% vs 41% achieving pain scores <3) 5
- Use non-nutritive sucking with 30% glucose solution as an adjunct analgesic measure 5
- Implement non-pharmacological strategies including swaddling, patting, rocking, and calm music 1
Equipment Preparation
- Select appropriate tube size based on infant weight and gestational age 1
- Lubricate the tube well with water-based gel both externally and internally 4
- Have resuscitation equipment immediately available 1
Tube Measurement Methods
Optimal Approach for Accurate Placement
Combine the weight-based (WB) equation with the NEMU method to achieve the highest accuracy of proper gastric placement (80.8% strictly accurate placement). 2, 3
Weight-Based Equation
- This method achieves 96.2% placement within the stomach and 80.8% strictly accurate placement (tip 2-5 cm into stomach at T10 level) 2
- Particularly effective in extremely low birth-weight (ELBW) infants, reducing low tube placement from 53% to 34% 3
- The WB equation alone predicted optimal placement in 64% of ELBW infants 3
NEMU Method (Backup/Verification)
- Measure from nose to ear to midway between xiphoid process and umbilicus 2, 3
- When used alone, achieves 78.8% placement within stomach and 65.4% strictly accurate placement 2
- Mark the tube at the measured distance (typically 50-60 cm in term infants) 4
Insertion Technique
Standard Insertion Steps
- Slide the well-lubricated tube gently along the floor of the mouth toward the pharynx (10-15 cm) 4
- For cooperative older neonates, advance the tube 5-10 cm as they swallow 4
- Continue advancing until the preset mark reaches the lips 4
Modified Technique for Pain Reduction
- Insert the OGT through a modified bottle nipple while providing non-nutritive sucking, which reduces pain scores significantly (odds ratio 0.21 for pain prevention) 5
- This technique is simple, inexpensive, and feasible in routine practice 5
Safety Monitoring During Insertion
- Withdraw the tube immediately if the infant becomes distressed, starts coughing, or develops cyanosis 4
- Monitor for gagging, which occurs in approximately 51-69% of insertions 5
- Watch for signs of respiratory compromise throughout the procedure 4
Special Populations: Epidermolysis Bullosa (EB)
Critical Contraindication
Avoid OGT use entirely in neonates with epidermolysis bullosa due to increased movement against the fragile oral mucosal lining, which accelerates tissue damage and stricture formation. 1, 7
Alternative Approach for EB Patients
- Use NGTs instead of OGTs to minimize mucosal trauma 1
- Have an experienced EB staff member insert the well-lubricated NGT to reduce friction and avoid multiple passes 1, 4
- Oesophageal trauma from tube insertion can accelerate oesophageal stricturing in recessive dystrophic EB (RDEB) 1
If OGT Causes Bleeding in EB Patients
- Remove the OGT immediately as it perpetuates mucosal trauma 7
- Replace with a well-lubricated NGT inserted by experienced staff 7
- Secure the NGT with low-adherent film contact layer, then apply full-adherent tape to the film (never directly to skin) 1, 7
Tube Securement
Standard Securing Technique
- Once in proper position, remove any guidewire 4
- Secure the tube carefully to prevent dislodgement, which occurs in approximately 25% of cases 4
For Fragile Skin (EB or Premature Infants)
- Apply low-adherent film as contact layer against skin 1, 7
- Secure full-adherent tape to the film layer, avoiding any direct tape-to-skin contact 1, 7
- Use lasso technique if adherence remains problematic 1
Position Verification
Mandatory Confirmation Steps
- Check tube position before any use—this is essential for patient safety 4
- Radiographic confirmation is recommended before initial use to prevent complications from misplaced tubes 4
- Note that 59% of feeding tubes are placed incorrectly using traditional methods, emphasizing the need for verification 8
Position Assessment
- Optimal placement: tip within the gastric body 2
- Strictly accurate placement: tip 2-5 cm into stomach at T10 level, not looped back 2
- Misplacement definitions: tip above diaphragm (high) or near pylorus (low) 3
Maintenance and Monitoring
Long-Term Management
- Change long-term tubes every 4-6 weeks 4
- For NGTs (when used instead of OGTs), alternate nostrils to prevent complications 4
- Monitor for feeding intolerance including ongoing bleeding, abdominal distension, or hemodynamic instability 7
Ongoing Assessment
- Reassess feeding tolerance before resuming enteral nutrition 7
- Maintain dietetic input throughout enteral feeding use 1
- Consider continuous feeding regimens if feed tolerance is poor with gastroesophageal reflux or vomiting 1
Common Pitfalls and How to Avoid Them
Measurement Errors
- Avoid using NEMU method alone in ELBW infants—combine with weight-based equation to reduce misplacement from 53% to 34% 3
- Never perform blind insertion without proper measurement, which leads to the 59% misplacement rate seen with traditional methods 8
Insertion Technique Errors
- Never force the tube if resistance is met; withdraw slightly and try a different angle 4
- Do not continue using an OGT once bleeding is identified—switch to NGT immediately 7
Pain Management Oversights
- Do not skip analgesic measures—OGT insertion causes significant pain in preterm neonates (PIPP scores increase from 3-4 to 7-8 during procedure) 6
- Avoid administering analgesic solutions through the tube itself for procedural pain management 7
Population-Specific Errors
- Never use OGTs in epidermolysis bullosa patients—this is a critical contraindication due to mucosal fragility 1, 7
- In patients with recent variceal bleeding, avoid tube insertion for three days and use only fine bore tubes 4