What are the guidelines for nasogastric (NG) tube placement in children?

Nasogastric Tube Placement in Children

For children requiring nasogastric tube placement, use the smallest tube possible through the smallest nostril, verify placement with radiographic confirmation (not auscultation), and consider NG tubes primarily for short-term use (<2-3 weeks), transitioning to percutaneous gastrostomy for longer-term needs. 1

Indications and Timing

• NG tubes are indicated when oral intake is inadequate and enteral nutrition is needed for periods expected to last less than 2-3 weeks 1
• For anticipated needs exceeding 2-3 weeks, percutaneous endoscopic gastrostomy (PEG) should be preferred as it demonstrates superior nutritional efficacy and reduces complications 1
• In acute settings, NG tubes can deliver oral rehydration solution at 15 mL/kg/hour for infants unable to drink but not in shock 1, 2
• For severely ill children with respiratory compromise, NG tubes should be avoided as they may compromise breathing, particularly in infants with small nasal passages 1

Equipment Requirements

Emergency departments must stock nasogastric tubes in appropriate pediatric sizes 1:

• Infant size: 8 French
• Child size: 10 French
• Adult size: 14-18 French

Placement Technique

The smallest tube should always be passed through the smallest nostril to minimize respiratory compromise 1

• In infants and young children, even appropriately sized NG tubes can impair breathing due to small nasal passages 1
• For babies unable to drink, NG tubes can be used to administer fluids at controlled rates (15 mL/kg body weight/hour) 1
• In children with glycogen storage disease requiring overnight feeds, parents should be trained in NG tube insertion, or a gastrostomy tube should be placed for reliable access 1

Verification of Placement - Critical Safety Issue

Radiographic confirmation is the gold standard and only certain method to verify NG tube placement 3, 4

• Auscultation of air insufflation should NOT be used despite its continued widespread practice, as research since the 1980s has demonstrated unreliability with success rates of only 80-85% 3, 5, 4
• In home settings, 44% of parents still use auscultation and 26% report at least one tube misplacement, with 35 parents describing symptoms of pulmonary misplacement 5
• pH measurement of gastric contents (pH <5) is more reliable than auscultation but still not definitive 5, 4
• X-ray verification should be obtained after initial placement and when there is any question about tube position 3, 6

Special Considerations for Respiratory Compromise

In children with pneumonia or significant respiratory distress, NG tubes should be avoided entirely 1:

• Nasogastric tubes compromise respiratory status, particularly in infants and severely ill children 1
• If enteral feeding is essential in severely ill children, intravenous fluids should be used instead 1
• When NG feeds are necessary despite respiratory concerns, use the smallest possible tube and consider continuous rather than bolus feeds to reduce respiratory stress 1

Gastric Decompression During Resuscitation

• During bag-mask ventilation, gastric inflation can interfere with effective ventilation and cause regurgitation 1
• Pass an NG or orogastric tube to relieve gastric inflation if oxygenation and ventilation are compromised 1
• The tube should be passed after intubation when possible, as gastric tubes interfere with gastroesophageal sphincter function 1
• If a gastrostomy tube is present, vent it during bag-mask ventilation to allow gastric decompression 1

Home Management and Long-Term Use

• Home healthcare practice for pediatric NG tubes lacks standardization, with significant variation in placement verification methods 5, 7
• Long-term NG tubes should be changed every 4-6 weeks, alternating nostrils 8
• Parents require comprehensive education on proper placement technique, verification methods, and recognition of complications 5, 7
• For children requiring enteral feeding beyond 4-6 weeks, strongly consider percutaneous gastrostomy or jejunostomy placement 1, 8

Common Pitfalls to Avoid

• Never rely on auscultation alone for placement verification—this outdated practice persists despite clear evidence of unreliability and risk of pulmonary misplacement 3, 5, 4
• Do not use NG tubes in severely ill children with respiratory distress when IV access is available 1
• Avoid using larger tubes than necessary, as this increases respiratory compromise 1
• Do not delay transition to PEG when enteral feeding needs extend beyond 2-3 weeks 1
• Never apply suction to nasojejunal tubes, as they are not designed for this purpose and can cause mucosal damage 8