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  1. Indications

      1. Enteric feeding. Gastric intubation for enteric feeding in the following situations:

          1. High respiratory rate. At some institutions, enteric feedings are used if the respiratory rate is >60 breaths/min to decrease the risk of aspiration pneumonia (controversial).

          1. Neurologic disease if it impairs the sucking reflex or the infant's ability to feed.

          1. Premature infants may have immature sucking and swallow mechanisms and tire before they can take in enough calories to maintain growth.

      1. Gastric decompression may be required in infants with necrotizing enterocolitis, bowel obstruction, or ileus.

      1. Administration of medications.

      1. Analysis of gastric contents.

  2. Equipment. Infant feeding tube (3.5 or 5F if <1000 g or 5 to 8F if ≥1000 g), stethoscope, sterile water (to lubricate the tube), a syringe (5–10 mL), 2-in adhesive tape, gloves, suctioning equipment, bag-and-mask ventilation with 100% oxygen.

  3. Procedure

      1. Monitor the patient's heart rate and respiratory function throughout this procedure.

      1. Place the infant in the supine position, with the head of the bed elevated.

      1. The insertion distance is determined by using minimum insertion lengths (Table 30–1) or by measuring the distance from the corner of the mouth or nose to the earlobe and to the point halfway between the umbilicus and end of the xiphoid. (This measurement proved to be the most accurate in one study.) Mark the length on the tube. Table 30–1 has recommendations for infants ≤1500 g.

      1. Moisten the end of the tube with sterile water.

      1. The tube can be placed in one of two positions.

          1. Nasal insertion. Avoid nasal insertion in very low birthweight infants because of increased incidence of respiratory compromise. One study revealed infants <2 kg demonstrated significant pulmonary compromise with nasogastric tube placement. Flex the neck, push the nose up, and insert the tube, directing it straight back. Advance the tube the desired distance.

          1. Oral insertion. Push the tongue down with a tongue depressor and pass the tube into the oropharynx. Slowly advance the tube the desired distance.

      1. Continue to observe the infant for respiratory distress or bradycardia.

      1. Determine the location of the tube. One method is to inject air into the tube with a syringe and listen for a rush of air in the stomach. One study found this method unreliable because a rush of air can occur when the tip is in the distal esophagus. Some clinicians recommended either palpating the tube in the abdomen or aspirating the contents to determine the acidity by pH tape. Gastric pH should be <6. If the pH is >6, placement should be questioned. If the location is still uncertain, obtain a radiograph. If feedings are to be initiated, the position should be verified by plain radiograph. See Figure 10–8 which shows the tip of the nasogastric tube properly positioned in the stomach.

      1. Aspirate the gastric contents and secure the tube to the face with benzoin and 2-in tape.

  4. Complications

      1. Apnea and bradycardia are usually mediated by a vagal response and resolve without specific treatment.

      1. Perforation of the esophagus, posterior pharynx, stomach, or duodenum. The tube should never be forced during insertion.

      1. Hypoxia. Always have bag-and-mask ventilation with 100% oxygen available to treat this problem.

      1. Aspiration can occur if feeding has been initiated in a tube that is accidentally inserted into the lung or if the gastrointestinal tract is not passing the feedings out of the stomach. Periodically check the residual volumes in the stomach to prevent overdistention and aspiration. (See ...

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