What are the guidelines for nasogastric tube feeding in patients with various ages, weights, and medical conditions?

Nasogastric Tube Feeding Guidelines

Indications for Initiation

Nasogastric tube feeding should be initiated in patients who cannot meet nutritional requirements orally and are expected to require enteral support for less than 4-6 weeks. 1

Key indications include:

• Dysphagia with aspiration risk 1
• Inadequate oral intake with malnutrition 1
• Neurologic disorders causing severe swallowing dysfunction 1
• Comatose states requiring nutritional support 1

Tube Selection and Placement Technique

Use fine bore tubes (5-8 French gauge) for feeding to minimize nasal trauma and pressure injuries. 1, 2

• Placement must be performed by trained, technically experienced staff to minimize misplacement risk 1
• For maxillofacial trauma, nasal obstruction, coagulopathy, or recent nasal surgery, use orogastric rather than nasogastric route 3
• Position verification is mandatory before every use using pH testing (pH ≤5.0 indicates gastric position) 3, 4
• Radiographic confirmation is required before initiating feeding 3
• Auscultation alone is unreliable and should not be used for placement confirmation 3

Feed Administration Protocol

Position patients at 30° or greater during feeding and maintain upright for 30 minutes post-feeding to minimize aspiration risk. 1

Dosing recommendations:

• Standard dosing: 30 ml/kg/day of 1 kcal/ml feed 1
• This may be excessive in undernourished or metabolically unstable patients and should be adjusted 1
• Concentrated feeds (1800 kcal in 1 liter) can be delivered overnight via continuous infusion to allow daytime mobility 5
• Continuous drip administration using a pump is preferred over bolus feeding 1

Tube Maintenance and Replacement

Long-term NG tubes should be changed every 4-6 weeks, alternating between nostrils. 2

Essential maintenance practices:

• Flush tubes with water before and after every feed or medication to prevent blockage 2
• Daily reevaluation of tube necessity with removal as early as possible 2
• Check gastric residue periodically to assess tolerance 6
• Ensure adequate skin fixation as tube dislodgement occurs in 48.5% of cases without proper securing 1, 6
• If frequent dislodgement occurs despite proper fixation, consider using a nasal loop 1, 2

Monitoring and Complication Prevention

Close monitoring of fluid, glucose, sodium, potassium, magnesium, calcium, and phosphate is essential to prevent refeeding syndrome. 1

Common complications and their frequencies:

• Tube dislodgement: 48.5% 6
• Electrolyte alterations: 45.5% 6
• Hyperglycemia: 34.5% 6
• Diarrhea: 32.8% 6
• Constipation: 29.7% 6
• Vomiting: 20.4% 6
• Tube clogging: 12.5% 6
• Lung aspiration: 3.1% 6

Prevention strategies:

• Use protective mittens in confused patients to prevent self-removal 6
• Attempt duodenal placement in unconscious patients to reduce aspiration risk 6
• Avoid hyperosmolar drugs, crushed tablets, potassium, iron supplements, and sucralfate as they cause tube blockage 2
• Administer medications as elixirs or suspensions rather than syrups 2
• Blocked tubes can often be cleared with warm water or alkaline pancreatic enzyme solution 2

Oral Intake During Tube Feeding

Tube-fed patients should be encouraged to maintain oral intake as far as safely possible. 1

Benefits of continued oral intake:

• Provides sensory input and swallowing training 1
• Improves quality of life 1
• Enhances oropharyngeal cleaning 1
• In patients with recent-onset anorexia, tube feeding may disinhibit appetite and double voluntary oral intake 5

Transition to Long-Term Access

For patients requiring enteral nutrition beyond 4-6 weeks, transition to percutaneous gastrostomy (PEG) or jejunostomy. 1, 2

• The 4-6 week timeframe is somewhat arbitrary and primarily aims to avoid premature gastrostomy 2
• In selected cases, well-tolerated NG tubes can be used for longer periods if individualized assessment supports this 2
• PEG is associated with lower dislodgement risk and possibly better quality of life 2
• In stroke patients with unfavorable prognosis, semi-invasive NG feeding may be more appropriate initially than PEG 1

Discharge Planning Requirements

Before discharge, ensure comprehensive coordination with community carers and confirm feed/equipment availability. 1

Required patient/caregiver training:

• Quantity and type of enteral feeding to administer 2
• Total daily fluid requirements 2
• Duration of administration 2
• Pump operation 1, 2
• Infection control measures 1
• Proper tube fixation techniques 2
• Personal care and impact on daily activities 2

Ethical Considerations

Enteral tube feeding must never be started without considering all ethical issues and must be in the patient's best interests. 1

• In patients with poor prognosis, carefully weigh the benefits versus burdens of tube feeding 1
• Consider patient preferences, advance directives, and goals of care 1
• Reassess appropriateness regularly throughout the feeding course 1