Nasogastric tube feeding at home

Your child has had a nasogastric (NG) tube inserted because they are unable to take some or all their nutritional and fluid requirements orally.

A NG tube is designed for tube feeding and is placed through the nose, down the oesophagus and into the stomach. The position of the NG tube must be checked and confirmed before starting a feed, giving a flush or giving medication. You will have been learned how to use the tube safely whilst in hospital.

When your child goes home from hospital

• You will be given 7-14 days supply of your child’s feed and feeding equipment.
• Your dietitian will arrange for you to have further supplies delivered monthly to your home from Nutricia Homeward.
• If your child’s feeds are prescribed by your GP then your Dietitian can arrange for the feed to be delivered to your home by Nutricia Homeward. Alternatively, you can choose to pick the feed up from a local chemist.

Within one-two weeks of getting home from hospital

Nutricia Homeward

Nutricia Homeward will call you to arrange your first delivery of feeding equipment and feed (unless you have chosen to collect this from your local chemist). Nutricia Homeward will then contact you each month to check your stock levels and confirm your deliveries. Please contact Nutricia Homeward if you have any equipment queries.

Dietitians

Our Dietitians will call you to check that you’ve received your delivery and that feeding is going ok at home. They’ll also arrange an outpatient appointment within the first few months and regular follow up appointments. Please contact the Dietitians if you have any feeding queries.

Paediatric Community Nurses

Please contact the Paediatric Community Nurses for assistance with tube position and tube replacement. Out of hours please call ward 3 Stoke Mandeville Hospital. (Contact details follow).

Checking the tube position

Each time you use the NG tube you will need to check that it is in the correct position in the stomach. Stomach fluid is acidic, and you will need to check this with Universal pH indicator paper. The pH should be 5.5 or below. If the pH is higher than 5.5 then do not use the tube and contact the community nurses or paediatric ward.

Testing the tube position should be done:

• Before you start a feed
• Before giving medication and water via the tube
• After an episode of vomiting or violent retching
• If you are concerned that the tube has moved
• If you are planning to give part of the feed orally before using the tube it is important to check the tube position before any feeding
• A minimum of once a day

Clean your hands and gather all the equipment you’ll need first:

• 20-60ml enteral syringe
• Universal pH indicator strips and colour chart
• Water for flushing (see separate advice on water flushes)
• Feed at correct temperature

Consider if the tube has moved:

• Is it the same length as usual?
• Is the marker at your child’s nose in the same place?
• Is the tape secure?

How to check the NG tube position:

• Attach the syringe to the tube. Pull back gently on the plunger until a small amount of fluid (aspirate) appears in the syringe, enough to cover the end of the indicator stick (approximately 0.5-1ml)
• Squirt the aspirate on the pH stick and check for a colour change (usually within 10-15 seconds). The pH should be at 5.5 or below. If the pH is higher than 5.5 then do not use the tube and contact the community nurses or paediatric ward.

If all the above checks are confirmed, it is safe to use the tube.

What do I do if I can’t get an aspirate?

• Lie your child on their left side
• Insert 1-5ml of air into the tube using the syringe
• Wait 15-30mins and then check the tube position again
• Give your child a dummy to suck or give mouth care if your child is nil by mouth (this stimulates acid secretion)

If you are in any doubt that the tube is in the correct position do not feed. Contact the paediatric community nurses or paediatric ward.

Feeding via the NG tube

• Check the expiry date of the feed
• Wash your hands and gather your equipment
• Ensure your child is positioned with their head above the level of their stomach. Preferably sit or support them at an angle of at least 30°. Babies maybe fed in baby seats offering firm support, such as a car seat.
• Check the position of the tube using universal pH indicator paper
• Only use the tube if you are confident that it is in the correct position
• Flush the tube with water before and after feed and medicines to prevent tube blockages. See your child’s feeding plan for volumes of water required (see separate advice on water flushes).
• Only put the prescribed feed, water and liquid medicines down the tube, unless otherwise advised by a healthcare professional
• If your child shows any signs of shortness of breath (more than usual), sudden pallor, vomiting or coughing, stop the feed immediately and seek medical attention

Gravity Bolus feeding:

• Attach enteral syringe without the plunger to the feeding tube
• Slowly pour the amount of feed required into the syringe
• If the feed is running too quickly or slowly alter the height of the syringe slightly. A feed should normally take between 15 – 30 minutes.
• When the feed is finished, remove the syringe
• Flush the feeding tube with water (see separate advice on water flushes)

Feeding using a pump:

If a pump feed has been recommended for your child, you will receive adequate training on your Nutricia feeding pump.

Feed Hanging times

There is always a risk of the feed becoming contaminated once it has been opened. Therefore, it is important to follow the guidelines below:

• If you are decanting a feed into a flocare (single use) container/reusable bottle, the feed should be given straight away and finished within 4 hours.
• Do not reuse or make additions to the feed containers. If additional feed or fluid is required, then it should be given using new feeding equipment.
• If you are using a sterile ready to hang feed that attaches directly to a feeding set, this may be used for up to 24 hours. The feed can be capped off between feeds and stored in the fridge until the next feed is due.

Feed storage

Storing your liquid feed:

• Keep sealed bottles at room temperature and out of direct sunlight
• If you are decanting any liquid feed from the bottle into a reservoir, you can refrigerate the remaining feed in the original bottle for up to 24 hours.
• If you are using a foil sealed ready to hang bottle, you can refrigerate the bottle between feeds (for up to 24 hours) with the giving set attached and cap on
• All refrigerated feeds should be taken out of the fridge 1 hour before the next feed is due to allow it to come to room temperature
• Discard any unused open feed after 24 hours

Storing your powdered feed:

• Between use replace the container lid
• Store at room temperature
• Once opened record the date on the tin and throw away any unused feed after a month (or as recommended by the manufacturer)

Storing your reconstituted feed (powder feed which is given in liquid form)

• Feed should be made up just before it is needed
• Follow the instructions on the tin unless otherwise directed by the dietitian

Giving medicine down the tube

• Only medicine prescribed to be administered via the tube should be given
• During the delivery of medication stop the feed
• Flush before and after each medication

Water flushes

• It is important the tube is flushed between each feed. See your child’s feeding regimen for normal water flushes
• Children over 1 year of age can use freshly drawn tap water (unless otherwise advised by a health professional)
• Children under 1 years of age must use cool boiled water and children who are immune suppressed must use sterile water (these can be stored, for a maximum of 24 hours in the fridge)
• Do not give bottled mineral water as these can contain high quantities of electrolytes
• Water flushes will normally need to be increased if your child has a fever or if the weather is very hot, please discuss with your Dietitian or Community Nurse

Advice on hygiene

Your child’s feeding tube provides a good environment for bacteria and other germs to grow. This can lead to stomach upsets and chest infections. It’s therefore important to follow hand hygiene guidelines when handling the tube and feeding system (which includes bottles, giving sets and syringes) to reduce the risk of contamination and infection. Wash your hands thoroughly every time you handle the feeding system or tube.

Single use/ reusable equipment:

• Giving sets, flocare containers and ready to hang feed bottles are all single use
• Reuseable bottles can be sterilised and reused up to 30 times
• Syringes supplied will be reusable syringes (unless otherwise advised by a health professional). These need to be washed after each use, see below. These can be used up to 30 times or as per the manufacturer’s instructions.

Washing Your Child’s Re-Usable Equipment (if using)

• Wash in hot soapy water
• Pump the plunger of the syringe in and out several times, then separate the barrel and plunger
• Use a soft, clean brush to remove any debris
• Soak in the water for 1 minute
• Rinse well under running water
• Dry excess water off with clean paper towel
• Allow to air dry on clean paper towel
• Once dry, store in a clean, lidded container until needed
• If your child is under 1 year of age the syringes will need to be sterilised before use

Disposal of equipment

Feeding equipment such as giving sets, feed containers and syringes will need to be properly disposed of. Ready to hang bottles and feed containers should be rinsed out and recycled- the rest can be disposed of in general waste. Please check with your local council regarding recyclability.

General Advice

• Your child should brush their teeth twice a day
• If your child is not able to take any nutrition or fluids by mouth, ensure their lips are kept moist by using a moisturiser or lip balm
• Your child can bathe and shower with the nasogastric tube in place

Constipation or Diarrhoea

Some children do have altered bowel movements after starting tube feeding. This should settle as their body adjusts to the feed. If your child continues to have diarrhoea or strains to pass stools, contact your Dietitian or Community Nurse.

Feeling Sick

Stop the feed and flush the tube with their normal amount of water. Sit the child in an upright position for an hour. If the child has not been sick after the hour, restart the feed at half the normal rate and slowly increase to normal rate over the next few hours as tolerated. Ensure the child’s head is elevated to at least 30° angle. If the child continues to feel uncomfortable and sick speak with your Dietitian or Community Nurse.