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Pediatric Nasogastric Tube Placement and Verification: Best

Practice Recommendations From the NOVEL Project: CONSENSUS
RECOMMENDATIONS

Article in Nutrition in Clinical Practice · September 2018

DOI: 10.1002/ncp.10189

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Special Report
Nutrition in Clinical Practice
Volume 00 Number 0
Pediatric Nasogastric Tube Placement and Verification: Best xxx 2018 1–7

Practice Recommendations From the NOVEL Project

C 2018 American Society for

Parenteral and Enteral Nutrition

DOI: 10.1002/ncp.10189
wileyonlinelibrary.com

Sharon Y. Irving, PhD, CRNP, FCCM, FAAN1,2 ; Gina Rempel, MD, FRCPC3,4 ;
Beth Lyman, RN, MSN, CNSC, FASPEN5 ; Wednesday Marie A. Sevilla, MD,
MPH, CNSC6 ; LaDonna Northington, DNS, RN, BC7 ; Peggi Guenter, PhD, RN,
FAAN, FASPEN8 ; and The American Society for Parenteral and Enteral Nutrition

Abstrac
t
The placement of a nasogastric tube (NGT) in a pediatric patient is a common practice that is generally perceived as a benign
bedside procedure. There is potential risk for NGT misplacement with each insertion. A misplaced NGT compromises patient
safety, increasing the risk for serious and even fatal complications. There is no standardized method for verification of the initial
NGT placement or reverification assessment of NGT location prior to use. Measurement of the acidity or pH of the gastric aspirate
is the most frequently used evidence-based method to verify NGT placement. The radiograph, when properly obtained and
interpreted, is considered the gold standard to verify NGT location. However, the uncertainty regarding cumulative radiation
exposure related to radiographs in pediatric patients is a concern. To minimize risk and improve patient safety, there is a need to
identify best practice and to standardize care for initial and ongoing NGT location verification. This article provides consensus
recommendations for best practice related to NGT location verification in pediatric patients. These consensus recommendations
are not intended as absolute policy statements; instead, they are intended to supplement but not replace professional training and
judgment. These consensus recommendations have been approved by the American Society for Parental and Enteral Nutrition
(ASPEN) Board of Directors. (Nutr Clin Pract. 2018;00:1–7)

Keywords
enteral nutrition; misplacement; NG feeding tube; pediatric

Introduction when initially placed or for reverification of NGT location

before use in pediatric patients. There is a need to identify
In 2014, a report on 255,140 hospital discharges in the
best practice and standardize care for initial and ongoing
United States revealed that 25% of all patients receiving
verification of NGT location to decrease the risk of a
enteral nutrition (EN) were children. Of those, 6% of the
misplaced NGT. Therefore, the objective of this article is
to
total number of patients were under 12 months of age.1 This
report indicates that a significant number of hospitalized
From the 1 University of Pennsylvania School of Nursing,
children require feeding tube placement for the adminis- Philadelphia, Pennsylvania, USA; 2 Department of Critical Care
tration of EN. A 2016 study reported that Nursing, The Children’s Hospital of Philadelphia, Philadelphia,
approximately Pennsylvania, USA; 3 Rady Faculty of Health Sciences, Max Rady
25% of hospitalized pediatric patients require a temporary College of Medicine, University of Manitoba, Winnipeg, Canada;
4 Children’s Hospital Winnipeg, Winnipeg, Manitoba, Canada;
feeding tube.2 The most common enteral feeding tube 5
Nutrition Support Team, Children’s Mercy Hospital, Kansas City,
used in hospitalized children is a nasogastric tube (NGT).2 Missouri, USA; 6 Division of Pediatric Gastroenterology, Children’s
Insertion of an NGT is a high-volume practice commonly Hospital of Pittsburgh, University of Pittsburgh Medical Center,
performed by nurses as a blind procedure, without the use Pittsburgh, Pennsylvania, USA; 7 University of Mississippi Medical
of technology to guide or visualize the internal path of the Center School of Nursing, Jackson, Mississippi, USA; and 8 Clinical
Practice, Quality, and Advocacy, American Society for Parenteral
tube. Although the vast majority of blind NGT insertions
and Enteral Nutrition (ASPEN), Silver Spring, Maryland, USA.
result in successful placement in the intended location—
This article originally appeared online on xxxx 0, 0000.
the stomach—each tube can potentially be misplaced, even
when the procedure is performed by a healthcare provider Corresponding Author:
Sharon Y. Irving, PhD, CRNP, FCCM, FAAN, Assistant Professor,
experienced in NGT placement. A misplaced NGT compro-
University of Pennsylvania School of Nursing, Claire M. Fagin Hall,
mises patient safety, increasing the risk for severe and even 418 Curie Blvd., RM 427, Philadelphia, PA 19104.
fatal complications.3-6 Clinicians practicing in the United Email: ysha@nursing.upenn.edu
States lack guidance for best practice to verify NGT location
2 Irving et al Nutrition in Clinical Practice 00(0) 2
develop and disseminate recommendations for best practice misplacements in pediatric patients in the United States, it
related to NGT location verification in pediatric patients is well recognized that even 1 undetected, misplaced NGT
based on the available literature. may have major implications for the individual patient, the
The consensus recommendations presented here are not family, and the entire healthcare system.21
intended as absolute policy statements. Use of these prac- Although the reporting of NGT misplacements is incon-
tice recommendations does not in any way guarantee any sistent in the United States, the National Health Service
specific benefit in outcome or survival. The professional (NHS) in the United Kingdom has issued a series of Patient
judgment of the attending health professional is the primary Safety Alert (PSA) reports, the most recent in 2016.22
component of quality medical care delivery. Because con- In that 2016 PSA report spanning 5 years (2011–2016),
sensus recommendations cannot account for every variation there were 95 occurrences of NGT misplacement, with 32
in circumstances, practitioners must always exercise pro- deaths from the over 3 million NGT (or orogastric tube)
fessional judgment when applying these recommendations placements recorded.22 The most common error cited was
to individual patients. These consensus recommendations the inaccurate interpretation of a radiograph used to verify
are intended to supplement, but not replace, professional NGT position. Other errors cited include the use of unap-
training and judgment. proved methods for NGT placement verification, nursing
error in performing pH testing, and communication failures
Background for which the NGT location was not checked before use.
Failure at the organizational level to implement previously
The literature is replete with case reports in both pediatric identified processes to ensure correct NGT placement was
and adult patients describing NGT misplacements.5 An determined to be a primary cause of the misplacements.
early account of submucosal placement of an NGT that Thus, a mandate was issued by the NHS to declare NGT
occurred in an adult patient under anesthesia was reported misplacement a never event, and a PSA was directed to
by Daly in 1953 and again by Lind et al. in 1978.7,8 Compli- organizations emphasizing the seriousness with which NGT
cations in adult patients related to NGT placement can be placement is to be regarded, holding both the provider and
found from the 1970s through the present day.8-11 Similar the organization accountable for patient safety related to
reports of misplaced NGTs in children describe insertions NGT location verification.22,23
into the esophagus,4,12,13 pylorus,4 pharyngeal mucosa,14,15
intracranium,16 and most commonly the respiratory tract.17
Both gastric and bladder perforation related to NGT Current Practice
misplacement have been described in children.18,19 These Correct NGT placement begins with accurate measurement
reports of misplaced NGTs in both adult and pediatric of the length of the tube to be inserted into the patient to
patients demonstrate the risks associated with insertion, reach the stomach. Two methods commonly used by nurses
emphasizing that NGT placement is not always a benign to determine NGT depth are the Nose→Earlobe→Xiphoid
procedure, as is often perceived. process→Midline of the Umbilicus (NEMU) method and
Although NGT misplacements have frequently been the Nose→Earlobe→Xiphoid (NEX) method of measure-
described in the United States, it is difficult to quantify ment. When the 2 methods were evaluated, the NEMU
an actual number of misplacements, particularly in chil- method demonstrated superior accuracy (97% vs 59%) over
dren. There are limitations to state reporting mechanisms, the NEX method for placement in the stomach.24 Upon
a lack of a national reporting system, and a presumed closer evaluation, use of the NEX method often resulted in
hesitancy among institutions to provide public access to high esophageal NGT misplacement, increasing the risk of
such information. Without a denominator for the number aspiration and jeopardizing patient safety.24,25
of NGTs placed and a definitive number of misplacements, Current practice to verify NGT location is variable
it is virtually impossible to accurately quantify the number among institutions, patient care units, and providers.2,11,26
of NGT misplacements that occur. Pennsylvania is one of Commonly used methods for NGT location verification
few states where reporting of NGT misplacements is include: auscultation, aspiration with visual inspection
required. A of gastric fluids, pH testing of gastric secretions, and
2017 Pennsylvania Patient Safety Authority report radiography.27 Safety and practice alerts warn against
describes
the use of auscultation28 and visual inspection of
166 enteral tube misplacements documented from 2011–
gastric aspirate29 as the means of NGT location
2016.20 In this report, 10.2% of the misplacements occurred
verification be- cause neither method is confirmatory, and
in pediatric patients, with many of these misplacements
either can give false affirmation of correct NGT
associated with adverse events.20 This report is one of placement. Despite these warnings and practice alerts,
few references that quantifies the number of enteral tube recent studies found that these methods are still widely
misplacements in a defined time period, thus depicting the used by nurses caring for both pediatric and adult
scope of the problem for verification of NGT location. patients.2,30
Despite the lack of robust prevalence data describing NGT
Use of Radiographs to Verify NGT less than 12 months of age having the highest prescription
Placement rate for H2 RA medications.40
A true gastric aspirate is necessary to obtain an accurate
The current gold standard to verify NGT placement is a pH measurement; therefore, a second issue to consider
properly obtained and interpreted radiograph. concerns reverification of correct NGT location in those
However, uncertainty regarding cumulative radiation patients receiving continuous enteral feeding. These patients
exposure related to radiograph frequency,31 as well as may require a period of cessation of formula infusion and
concerns over the ac- curate and consistent interpretation water or air flush of the NGT to ensure accuracy when
and reporting of NGT location by both radiologists32,33 obtaining a gastric aspirate to measure pH, although there
and nonradiologists,34 raise questions regarding the use of are no data available to support or refute this
radiography for NGT location verification as the gold practice. A limitation to using gastric pH to assess NGT
standard in pediatric pa- tients. Accurate NGT location location arises if the tube is misplaced into the
by radiographic verification depends on clearness of the esophagus, where it is difficult to withdraw secretions.
image, interpretation, and the accuracy and clarity of More importantly, if esophageal placement occurs, the pH
the radiographic report. The report should contain of any aspirate may mimic that of gastric secretions due
information on the path of the NGT and the exact to aspiration or reflux at the time of pH testing, which
location of the tube tip that indicates its readiness for carries a high risk of false representation of NGT
use.32 Concerns of radiation exposure, the variability of placement. Similarly, distal migration of the NGT to the
technique, and the lack of standardization for the level of the pylorus or beyond can also result in difficulty
amount of radiation used has led many institutions to use obtaining a gastric sample to test pH for accurate gastric
the as low as reasonably achievable35 concept for placement. Although the use of pH measurement for tube
pediatric imaging. Given these factors, radiograph is often tip verification is the best evidence- based method, there
not the first-line method used to verify NGT placement in are issues—as outlined above—that need to be
many children’s hospitals.2 However, it is the standard by considered.
which all other methods of verification are compared for
accuracy in establishing NGT location.
Other Methods Used for NGT
Use of Gastric pH to Verify NGT Placement Verification
Measurement of the acidity of the gastric aspirate is an The use of an electromagnetic sensor-guided device for
evidence-based method used to verify NGT placement. NGT placement verification in pediatric patients is contro-
Commercial products to measure pH from gastric aspi- versial. A PSA issued in the United Kingdom described 2
rate show variance in measurement increments of 0.5–1.0. patient deaths associated with the use of an electromag-
Studies have demonstrated that obtaining a pH 5.5 from netic sensor-guided device.41 The PSA mandates gastric pH
measurement to accompany the use of the electromagnetic
gastric aspirate obtained from an NGT is a reliable
sensor-guided device to verify NGT placement. A limitation
indicator that the tube is properly placed in the
associated with this device is tube size. Currently, the
stomach.4,23,29,36-38
smallest tube that accompanies the device is 8 French,
Standard practice in the United Kingdom is to obtain a gas-
which is often too large for many pediatric patients.
tric pH measurement as the primary method to determine
Also, the external sensor necessary for use with the device
NGT location; a pH value of 1–5.5 is considered indicative
may be too large and too heavy to be placed on the chest
of correct gastric placement for an NGT.22 of smaller infants and children. Safety concerns with the
An issue to consider when using gastric aspirate pH use of the electromagnetic sensor-guided device include
measurement to determine NGT location is the use of
injury to the intestinal intima42 and inconsistency
histamine-2 receptor antagonists (H2 RAs) and/or proton
between the actual tube location and the image projected
pump inhibitors (PPIs). These classes of medications lower
by the device.43,44 A US Food and Drug Administration
gastric acidity and can result in a pH measurement > 5.5,
(FDA) alert issued in January 2018, regarding use of an
causing concern about tube misplacement.4 However, a
electromagnetic sensor- guided device for NGT placement,
discrepancy of accurate gastric aspirate pH measurements
recommends user train- ing from the manufacturer with
when these medications are used has not been validated in
mandated competency in device operation, and use of
the literature. A recently completed retrospective study of
neonates demonstrated that 97% of 6979 pH measurements an additional method of NGT location verification.45
Studies in the United States have demonstrated the use
obtained in 1024 infants were 5.39 Whereas not many of
of an electromagnetic sensor- guided device to be helpful
the infants received a PPI or H2 RA, 95% and 92% of those for the placement of transpyloric feeding tubes in adult and
who did had pH 5, respectively. Additionally, a 2016 pediatric patients46,47 ; however, definitive data for
retrospective study from a large medical record database successful NGT placement in pediatric patients is limited.
reports a significant increase in H2 RA and PPI prescriptions
in children over a 6-year (2005–2011) period, with children
Figure 1. NGT placement and verification decision tree.
NG, nasogastric.

The use of ultrasound technology as a noninvasive is needed. Its portability, absence of radiation, and
substitute for radiologic imaging to verify NGT placement noninvasive properties make ultrasound a potentially
shows promise. A recent study in a pediatric intensive useful method for verifying NGT location. An additional
care unit demonstrated 100% sensitivity with the use of method for verification of NGT placement, capnography,
ultrasound for correct placement of NGTs at the bedside has demonstrated enteral placement with 98% accuracy
when operated by a radiologist.48 Further investigation in one study49 ; however, it is not currently recommended
into the feasibility and applicability of ultrasound to verify to be used as an independent method to verify NGT
NGT location in children at the bedside by nonradiologists placement.
Recommendations - Difficulty placing the NGT
- NGT placement in any patient at high risk
Based on the available evidence and as outlined in Figure
of misplacement. This includes those with
1, the following are recommendations for best practice
known history of facial fractures, neurologic
standards to verify NGT location in pediatric patients:
injury/insult/baseline abnormality, respiratory
Provide education concerns, decreased or absent gag reflex, and
those who are critically ill.
- Education should be provided for all clinicians - In any patient whose condition deteriorates
placing NGTs within institutions and across shortly after NGT placement
care settings.
- Education should include competency valida- Improve interpretation and communication about
tion for placement, pH measurement, decision the radiograph.
making to determine need for radiographic
eval- uation, documentation of tube placement, - The radiograph requisition should clearly re-
and patient tolerance of the procedure. quest “NGT placement verification” or similar
- Competency-based education should be in place language.
for providers interpreting radiographs to verify - The radiograph report should contain a state-
NGT placement. ment of the tube path, the location of the tube
tip, and confirmation that the tube is positioned
Use appropriate NGT placement and securing in the desired location and is appropriate for
methods. use.

- Use the Nose→Earlobe→Xiphoid process→ Future Considerations

Midline of the Umbilicus (NEMU) method for
determination of NGT insertion length. Challenges persist surrounding the placement and location
- Document the centimeter marking on the tube, verification of NGTs in pediatric patients. The following
where it exits the nose or mouth, once cor- are potential solutions to be considered:
rect tube placement is confirmed periodically
depending on the policy of the healthcare set- Adoption of these recommendations with units and
ting. institutions implementing them to meet their specific
- In an NGT with a stylet in place prior to inser- needs
tion, if the NGT has been flushed with sterile Partnering with key stakeholders for technology and
water to facilitate stylet lubrication and product development to allow for placement verifica-
removal after insertion, aspirate the entire fill tion and reverification in real time for the duration of
volume of sterile water and discard. A second NGT use
aspiration is necessary to obtain gastric Research on best practice for ongoing reverification
secretions for pH testing. of correct NGT placement, including data on fre-
quency of assessment for reverification of correct
Measure gastric pH. NGT location for patients on intermittent feedings
and/or continuous feedings and/or NGT medication
- Use gastric pH testing as the first-line method administration
for NGT location verification. Standardized, mandated, state and federal reporting
- A gastric pH value of 1–5.5 without a change mechanisms for NGT misplacements, followed by a
in the patient’s clinical status is indicative of root cause analysis to evaluate the misplacement and
gastric placement. to ascertain opportunities for improved education
- When used intermittently for enteral feedings and practice
and/or medication administration, establish a
schedule for frequency of NGT location confir- Conclusions
mation.
- When used continuously for enteral feeding, de- Placement of NGTs in pediatric patients to facilitate provi-
termine the need for frequency of confirmation sion of EN, medication administration, and fluid infusion
with documentation of NGT location. is a common practice performed by nurses without the use
of technology. Despite the frequency of NGT placement, it
Consider a radiograph for any patient in whom carries the potential of patient harm if the tube is misplaced.
there is any concern for correct NGT placement, Various methods for determining location verification exist.
such as: Radiography is the gold standard and measurement of
gastric pH is a validated method; however, there is no 19. Mattar MS, al-Alfy AA, Dahniya MH, al-Marzouk NF. Urinary
standardization in the United States on best practice for bladder perforation: an unusual complication of neonatal nasogastric
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alerts/na sogastric-tube-misplacement-continuing-risk-of-death-severe-
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