Blind Pediatric NG Tube Placements

Alert reviewed December 2019

Action needed

• Immediately discontinue insertion of an air bolus with over the abdomen to assess/verify NG tube placement.

• Consider discontinuing nose-ear-xiphoid (NEX) as a predictor of NG tube insertion length.

• Consider x-ray verification when indicated (e.g. high-risk situations, difficult placement, when other non-radiologic methods are not confirmatory).

• Review the ECRI Hotline Response: Nasogastric Tube Misplacement and Complications in Pediatrics.

• Evaluate your NG tube placement practices against industry standards.

• Participate in national initiatives to develop and implement reliable, best practices to prevent NG tube-related complications (2013 ASPEN Summit in process).

• Participate in collaborative opportunities with vendors for adoption of new verification technologies.

Known complications

NG tube placement can lead to complications such as esophageal perforation, bronchopulmonary intubation, pneumothorax, hydrothorax, empyema and pneumonia. In addition, intracranial placement may occur in patients with facial fracture or facial trauma.

Target audiences

• Pediatric clinicians

• Nutritionists

• Nurses/nursing leaders

• Quality and safety leaders

• Home health clinicians

• Hospital leaders

High-risk patients

Pediatric patients at highest risk for incorrect tube placement include neonates, any children with neurologic impairment, or who are obtunded, sedated, unconscious, and/or critically ill, and those with reduced gag reflex or static encephalopathy.

Incidence and research

• More than 1 million enteral intubations occur annually, according to The Journal of Parenteral and Enteral Nutrition (January, 2011).

• The most common method of insertion of nasogastric (NG) tubes is blind passage.

• Researchers found 1.3 to 2.4 percent of NG tubes were malpositioned and 28 percent of those resulted in respiratory complications (pneumonia, pneumothorax), in a study of more than 2,000 feeding tube insertions, Sorokin et al. (2006). “Malpositioned” was defined as placement external to the gastrointestinal tract.

• Other studies reported NG tube misplacements in children between 20.9 and 43.5 percent (Ellett et al. 2005).

• It is difficult to verify NG tube placement errors in children because of differing definitions across studies, observed Farrington et al. (2009). Additionally, poor reporting of tube misplacement has prevented the adoption of protocols to prevent such errors (Metheny 2007).

Additional NG tube safety alerts

The United Kingdom’s National Patient Safety Agency (NPSA) issued a Patient Safety Alert, “Reducing the harm caused by misplaced nasogastric feeding tubes,” in 2011 as a result of patient deaths and patient harm due to misplaced feeding tubes.

The NPSA also issued an alert specific to neonates providing recommendations and guidance for this vulnerable population.

Other organizations, such as the American Association of Critical Care Nurses (AACN) and the American Society for Parenteral and Enteral Nutrition (ASPEN), have recognized the complications resulting from NG tube misplacement and have implemented practice alerts and best practices based on evidence.

Related links

• A Call to Action: The Development of Enteral Access Safety Teams (Nutrition in Clinical Practice; May 7, 2014)

• Nasogastric Tube Placement and Verification in Children: Review of the Current Literature (Nutrition in Clinical Practice; April 15, 2014)

• Nasogastric Tube Placement and Verification in Children: Review of the Current Literature (Critical Care Nurse; April 15, 2014)

For additional resources, contributors and sources, download the PDF.