Journal of Neonatal Nursing (2013) 19, 213e216

www.elsevier.com/jneo

Early discharge home from the neonatal unit with

the support of naso-gastric tube feeding
Julie Bathie*, Jane Shaw*

Neonatal Unit, The Jessop Wing, Sheffield Teaching Hospitals, Tree Root Walk, Sheffield S10 2SF, UK

Available online 13 March 2013

KEYWORDS Abstract This article discusses the potential benefits of early discharge home
Early discharge home; from the neonatal unit, with a naso-gastric tube in situ, to establish oral feeding
Naso-gastric tube at home. It describes a programme that has been implemented to promote this
feeding; and the initial outcomes and experiences.
Breastfeeding; ª 2013 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
Family centred care

Introduction is often around establishing oral feeding. This can

Some babies remain on the neonatal intensive care
unit (NICU) solely because they are unable to take
all their feeds orally. They require naso-gastric
tube feeds to supplement their nutritional needs
until they are mature enough to do so themselves.
If the fact that they receive a proportion of their
feeds via a naso-gastric tube (NGT) is the only
factor responsible for them remaining in the NICU,
discharge home part NGT fed and part orally fed
can be considered.
Many babies and families can spend prolonged
periods of time on the NICU. This can put many
pressures on the baby, parents and wider family.
Towards the later stages of a baby’s stay the focus
* Corresponding authors.
E-mail addresses: Julie.bathie@sth.nhs.uk (J. Bathie), jane.
shaw@sth.nhs.uk (J. Shaw).
mean that pressure is put on the quantity and volume
of oral feeds rather than the quality of the feeds. In
some situations we also see parents changing their
feeding intentions with the perception that they may
get home sooner. Many NICUs have limited or no
facilities for parents to stay on the unit with their
baby for 24 h a day in order to establish oral feeding.
This is particularly difficult for breast feeding
mothers and mothers of multiple births.
Early discharge of stable, preterm babies still
requiring supplementary NGT feeds has the poten-
tial benefits of uniting families sooner and facilitates
a more consistent approach to feeding by parents/
carers. Reducing the length of hospitalization for
preterm infants has been shown to have emotional
and psychological benefits for the family, and for the
infant’s development (Casiro et al., 1993). It has also
been demonstrated that home NGT feeding pro-
grammes have resulted in successful weight gain and

1355-1841/$ - see front matter ª 2013 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jnn.2013.01.005
214
that infants have not required hospital readmissions
relating to tube feeding (Evans, 1988; Wakefield and
Ford, 1994; Evanochko et al., 1996; Swanson and
Naber, 1997).
To ensure successful home NGT feeding, parents
need to be competent, confident, committed and
supported. This requires parents to be part of the
NGT feeding process from the beginning of their
baby’s feeding. They will need continued support
and training throughout their baby’s stay on the
NICU and in the community following discharge
home.
It should be noted that some parents do not
want to take a partially NGT fed baby home. Naso-
gastric tube feeding at home could be an
increased burden for some families and the pos-
sibility of complications relating to tube feeding
could arise (Collins et al., 2004). Infants also
require a higher level of support in the community
once discharged (Evans, 1988; Wakefield and Ford,
1994; Evanochko et al., 1996; Swanson and Naber,
1997).
Historically, in Sheffield, babies have sometimes
been discharged home early with a naso-gastric
tube to establish feeding at home but this was not
promoted and there was no formalised programme
to support this. In 2010 a multi-disciplinary group
was formed to consider this approach to babies
care and subsequently to support and develop a
programme. This group included a consultant
neonatologist, senior sister, family care sisters,
dietitian and speech and language therapist. In
late 2011, the option of early discharge was
introduced to families. The programme, informa-
tion and support has become more established
across the unit in 2012.
The early discharge programme
The objectives of the programme were:

Early discharge home for babies and their
families.

Decreased length of hospital stay.

Parents able to safely administer NGT feeds in
hospital and at home, with the provision of
support.

Parents to be supported within their own
homes.

Facilitation of positive patient and family
outcomes.

Increase in breast feeding rates.

Decrease in health care costs.
To be considered for the early discharge pro-
gramme the following criteria were set:
J. Bathie, J. Shaw
Babies should be considered for early discharge
home, part NGT fed and part orally fed if the fol-
lowing criteria have been met:

The baby resides in Sheffield or if out of area a
paediatric team on neonatal outreach team
can follow up.

The only factor responsible for the baby
remaining in the NICU is that they are receiving
part of their nutrition via a naso-gastric tube.

The baby’s weight is greater than 1500 g and they
are able to maintain their temperature (This is
within the current incubator to cot guidelines)

The baby is gaining weight adequately. This
will be a multi-disciplinary decision.

Parents are willing and committed to providing
NGT feeds at home.

Parents have met the NICU competencies cri-
teria for tube feeding.

Parents have been provided with the home NGT
feeding information pack and this has been
fully explained to them and documented as
being given.

Babies who have disordered or dysfunctional
feeding development rather than an immature
pattern should not be discharged home early as
they are likely to require a higher level of
specialist support for longer.
The discharge process is a continuous process. It
begins on admission and ends at the time of follow
up in the community. Parents should be part of the
tube feeding process from the onset of their baby’s
feeding. They will require continued support and
training throughout their baby’s stay on the NICU
and in the community following discharge home. In
Sheffield, the progamme has been divided into the
following steps:
Step 1
Begins as soon as oro/naso-gastric tube * feeding is
commenced. This will predominantly be in the
intensive care nursery but will be dependent on
where the baby is at the commencement of
enteral feeding and could be in the high depend-
ency nursery or the special care nursery.
The aim of step one is to familiarise parents with
NGT feeding. Parents should observe the prepara-
tion and administration of naso-gastric tube feeds.
Parents are encouraged to hold their babies in skin
to skin (kangaroo care) during tube feeds.
(* some babies may require an oro-gastric tube
due to the cpap mask but naso-gastric tubes are
introduced as soon as possible).
Early discharge home from the neonatal unit
Step 2
Begins when parents and nursing staff feel that
parents are competent and confident with step one.
This may predominantly be in the high dependency
nursery but will depend on the individual child and
family and could be in the special care nursery or
the intensive care nursery. The aim of this step is for
the parents to prepare and administer a NGT feed
under the supervision of nursing staff. Parents are
given the required equipment and encouraged to
hold the NGT during a feed. Nursing staff explain
and demonstrate the significance of pH levels and
support parents to check these.
Step 3
Begins when parents and nursing staff feel that
parents are competent and confident with steps one
and two. This will predominantly be in the special
care nursery but will depend on the individual child
and family. The aim of this step is to ensure that
parents will be able to change a NGT and understand
how to respond to any problems they might
encounter when changing a NGT. This includes
measuring a naso-gastric tube, passing a NGT on a
demonstration doll and passing a tube on their own
baby. If parents do not wish to pass a naso-gastric
tube they must have 24 h access to transport, in
order to travel to a hospital if required and the baby
must be receiving at least 50% of its 24 h feed volume
orally. Parents are also taught what to do if no
aspirate is obtained, the pH level is 5.5 or above,
what do to if the baby vomits during a feed and what
to do if they are unable to pass the NGT. At this stage
parents must also attend basic infant life support
training offered by the NICU.
Babies must receive a multi-disciplinary feeding
assessment from the special care sister and a
speech and language therapist prior to discharge.
As discussed earlier, babies who have disordered or
dysfunctional feeding development rather than an
immature pattern are not suitable for entry into
this programme.
Step 4
Begins when a baby is discharged home, NGT fed
and part orally fed. This will be at home and in
out-patient clinic. Support and monitoring of home
tube feeding will be coordinated by the neonatal
unit outreach sisters with support from the neo-
natal multi-disciplinary team (MDT).
The following documentation and procedures
have been developed to support the programme:
215

Gastric tube feeding e early discharge guide-
line. This is available on the hospital intranet
and all neonatal staff are aware via education
department.

Introductory leaflet in parent held feeding
diary (in process).

NICU competencies and criteria for parents.

Home tube feeding information pack.

Resuscitation training.

Tube insertion training.

Speech and language therapy assessment.

Support at home from family care sisters.

Weekly MDT meeting discussing planned early
discharges with a NGT and babies at home with
a naso-gastric tube in situ.
Outcomes
Parents have been very positive about being
involved in their babies care and have felt con-
fident and supported to take their baby home with
a naso-gastric tube. The programme has encour-
aged parents to be involved in their baby’s feeding
from the onset of their stay on the NICU.
The outcomes of the programme have not yet
been formally audited; however the following
informal data has been collected.
The number of babies discharged home on the
programme is:
2010 4
2011 19
2012 (JaneApril) 17
The numbers have increased as the programme
has become more established.
Based on the 17 babies discharged home in the
first four months of 2012 this has saved an estimated
135 nursing days. This is based on the number of
days to establish oral feeding plus 48 h**. The
average time to establish feeding at home has been
6 days and the longest time has been 21 days. No
babies have required readmission to hospital.
Informal data collection has also shown that
breastfed babies are taking less time to achieve
full oral feeds than bottle fed babies. Feedback
from family care sisters has been that this has
been because the breast feeding mothers have
been less focused on totals and volumes.
(** Current practice is that babies are dis-
charged home when they have been demand
feeding for 48 h and gaining weight).
216
Discussion
The practice of early discharge home with NGT
feeding has demonstrated initial success.
It has promoted the early involvement of
parents in their babies’ feeding, from the onset of
enteral feeding. Staff have a structured pro-
gramme and resources available to support fami-
lies. Families have felt confident when
administering NGT feeds when discharged home
and the majority of families have felt confident
when changing a naso-gastric tube.
The programme has meant that families have
been reunited sooner and parents have been in
control of their babies’ feeding sooner, allowing
them to recognise their babies’ feeding cues and
promote demand feeding. It has provided a more
consistent approach to the babies’ feeding.
Not all babies have been appropriate for the
programme due to other medical conditions or
specific feeding difficulties. Some families have
chosen not to be part of the programme and some
parents who initially did not want to consider
home NGT feeding have changed their minds as
they become more confident with NGT feeding
during their babies’ hospital stay.
Once the babies have been discharged home,
the number of visits provided by the family care
sisters has not increased.
In the first four months of 2012 the programme
has saved an estimated 135 nursing days. The NICE
cost impact and commissioning assessment sug-
gests a day of special care costs £476 per baby
(NICE, 2010). Based on the figures so far this is a
projected saving of £64, 260 in four months.
The team involved in developing the pro-
gramme aim to collect further data: To audit the
Available online at www.sciencedirect.com
J. Bathie, J. Shaw
number of babies discharged home on this pro-
gramme and the number of nursing days saved. To
measure the impact on breastfeeding rates and to
collect qualitative data from parents on their
experiences.
Acknowledgements
Shona Brennan e Neonatal Dietitian, Porus
Bustani e Consultant Neonatologist, Clare Cham-
bers e Speech and Language Therapist, Diane
Crossley e Family Care Sister, June Paulucy e
Family Care Sister, Lesley France e Family Care
Sister. DOTS Programme, Newborn Care Centre,
Australia
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