GUIDELINE

TITLE
GASTRIC/JEJUNAL TUBES
SCOPE DOCUMENT #
Neonatal Intensive Care, Calgary Zone 2-G-1
APPROVAL AUTHORITY INITIAL EFFECTIVE DATE
Calgary Neonatal Care Committee January 1, 2003
SPONSOR REVISION EFFECTIVE DATE
Neonatal Intensive Care/Division of Neonatology, Calgary Zone May 25, 2017
PARENT DOCUMENT TITLE, TYPE AND NUMBER SCHEDULED REVIEW DATE
Not applicable August 17, 2021
NOTE: The first appearance of terms in bold in the body of this document (except titles) are defined terms – please refer to the
Definitions section.

If you have any questions or comments regarding the information in this document, please contact the Policy & Forms Department
at policy@ahs.ca. The Policy & Forms website is the official source of current approved policies, procedures, directives, standards,
protocols and guidelines.

OBJECTIVES

 To provide a standard for neonatal gastric/jejunal tube placement and usage.

 Clinical judgment may be exercised when a situation is determined to be outside the

parameters provided in this guideline. If a deviation from this guideline is determined to be
appropriate or necessary, documentation of the rationale shall be included on the patient’s
health record.

PRINCIPLES

 Neonates may have an orogastric (OG) or nasogastric (NG) tube placed in the stomach.
The tube may be used to:

o Support enteral feeding

o Administer medications

o Sample gastric contents

o Lavage the stomach

o Decompress the stomach

 In most situations, gastric tubes should be used in preference to transpyloric tubes. A

transpyloric tube may be orojejunal (OJ) or nasojejunal (NJ). Transpyloric tubes may be
appropriate for specific conditions including:

o severe gastro-esophageal reflux (GER)

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o dysmotility

o severe respiratory distress

 Transpyloric tubes are not an appropriate choice if decompression is required.

APPLICABILITY

Compliance with this document is required by all Alberta Health Services employees, members
of the medical and midwifery staffs, Students, Volunteers, and other persons acting on behalf of
Alberta Health Services (including contracted service providers as necessary) Calgary Zone,
Neonatal Intensive Care.

ELEMENTS

GASTRIC TUBES

1. Nasogastric (NG), Orogastric (OG)

Gastric tubes may be placed via either the nose or mouth. There are potential risks and
benefits associated with each method. There is currently no evidence to guide
preference for NG vs OG tubes.

1.1 NG tubes:

 Can cause partial nasal obstruction for obligate nose breathers

 Increase airway resistance

 May increase work of breathing

 Decrease gagging

 Make no contact with gums or palate

 Facilitate concomitant oral feeding

1.2 OG tubes:

a) May increase vagal stimulation resulting in apnea/bradycardia

b) Most often NG tubes will be used in preference to OG tubes. Consider

OG placement for infants with the following circumstance:

 The nare is too small and will be obstructed by the NG. The NG
should occupy less than 50% of the opening.

 On CPAP

 Ventilated

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 Excoriated nares

 Choanal atresia

1.3 Gastric tube size selection

 There is no evidence to guide indwelling feeding tube size selection. In

accordance with current practice, gastric tube size selection will most
commonly be:

o 4 Fr tube for infants less than 1000 grams

o 5 Fr tube for infants 1000 to less than 1800 grams

o 6.5 Fr tube for infants 1800 to less than3000 grams

o 6.5 or 8 Fr tube for infants 3000 grams and greater

*Consider using a smaller gastric tube if an infant displays signs of not tolerating a larger
tube.

1.4 Gastric tube positioning

 Accurate positioning of OG and NG tubes in the body of the stomach is

important to ensure and safe and effective tube function in neonates.

1.5 Estimation of gastric tube length

 Despite accurate measurement, malpositioning has been reported as

frequently as 55% of the time. Gastric tube malposition is associated with
significant morbidity and mortality. Potential adverse effects include apnea,
bradycardia, discomfort, abdominal distention, malabsorption, failure to gain
weight and diarrhea.

a) Nose-ear-xiphoid (N-E-X) is a historical measurement technique that

should no longer be used for NG/OG tube insertion-length prediction in
neonates.

b) Nose-ear-umbilicus (N-E-M-U) method is an acceptable technique for

estimating insertion length of NG and OG tubes in neonates.

 Starting at the distal tip of the tube, measure from the tip of the
nose to the tip of the ear lobe and then to a point midway between
the xiphoid process and the umbilicus.

 Mark the tube with tape or maintain measurement with thumb and
finger until the gastric tube can be taped securely in place (refer to
Figure 1).

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Figure 1: Measurement for NG/OG Feeding Tube Insertion Depth (N-E-M-U

Method).

Xiphoid
Process

Umbilicus

 Many studies have demonstrated this technique alone is

inadequate to ensure 100% safe NG/OG tube placement.

 In addition to the N-E-M-U method for NG/OG insertion-length

prediction, verify the position with Freeman's weight-based
formula (2012)

OG tube length (cm) = 3 X weight (kg) +12

NG tube length (cm) = 3 X weight (kg) + 13

Quick guide:

Weight Insertion Length

(grams) (cm)
400-750 13.25-14.25
750-1000 14.25-15
1000-1250 15-15.75

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1250-1500 15.75-16.5

*If there is a discrepancy between

N-E-M-U and the weight based
formula, choose the deepest
insertion length and confirm
gastric tip position with the next
available radiograph.

1.6 Radiological assessment of gastric tube placement

 Currently, radiographic evaluation is the "gold standard" for checking the

gastric feeding tube position in neonates. It is not feasible to routinely take a
radiograph for the purpose of confirming gastric tube placement.
Assessment of the OG/NG tube placement should occur with each
radiograph that is taken for another purpose. Strive to have the NG/OG
inserted and insertion length documented prior to every radiograph in the
NICU.

 Any abnormally placed feeding tube on a routine radiograph may suggest an

underlying urgent condition in which feeding is contraindicated (for example,
esophageal perforation).

1.7 Insertion of gastric tube: Procedure

Equipment

o Gastric tube sizes 4, 5, 6.5, 8, 10 or 12 Fr

o Note: The size is dependent on the response of the infant, weight,

gestational age and the purpose of using the tube.

o Appropriate syringe (no greater than 10 mL)

o Stethoscope

o Clean gloves

o Securement tapes

o Sterile water as a lubricant

a) Perform hand hygiene. Assemble equipment

b) Perform hand hygiene.

c) Ensure non-pharmacologic measures to support neonate during the

procedure. Not limited to swaddling, cuddling, parental support, non-
nutritive sucking, 24% sucrose.

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d) Measure and calculate tube placement depth.

e) Position the infant on right side or in a prone position with head elevated
or may be held in a sitting position in parents or nurse's arms.

f) For NG insertion, lubricate the tube with sterile water.

g) Hold the gastric tube 1-2 inches (2.5-5.0 cm) from the tip.

h) Gently advance (never force) the tube. Insert the tip into the oropharynx
or nasopharynx, pushing the tube in a downward arc into the esophagus
until reaching the pre-measured mark.

i) If resistance is not met continue to advance quickly until you reach the
point you have identified.

j) If resistance is met, withdraw slightly and try to reinsert slowly and gently;

k) Do not force the tube if you cannot insert it.

l) In the case of unsuccessful NG placement, try the same procedure with

the other nare.

m) Passage of the gastric tube may stimulate the vagal nerve, causing
apnea and/or bradycardia. Tactile stimulation will usually resolve the
vagal symptoms, however, the tube may have to be withdrawn if the
symptoms persist.

n) Verify tube placement with a 1-2 mL injection of air while auscultating

over the stomach. With the same syringe, gently aspirate air and visually
inspect the presence of stomach contents.

o) Secure to the face following guideline 2-S-1: Skin and Wound Care

p) Document the procedure and the infant response.

1.8 Securement (Figure 2).

 Regardless of the technique to guide gastric tube placement, correct

placement should be confirmed:

 By auscultation

 Assessment of tube aspiration for stomach contents

 Noting the measured point of insertion in an approved location (gastric

tube tracking tool or the front of the NICU flow sheet

 Verify the correct measured point of insertion prior to initiation of every

feed or Q3-4H for continuous feeds or drainage

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 When chest and abdominal radiographs are taken for other purposes,
confirm gastric tip location

Figure 2: NG/OG Securement

OG Tube Securement NG Tube Securement

1.9 Troubleshooting

 Dark green or bilious aspirates:

 Notify the physician/nurse practitioner of assessment, +/- x-ray and note

the OG/NG on the most recent radiograph (query could the tube be
beyond the stomach with the tip in the pylorus or duodenum).

 Apnea, bradycardia, clinical signs and symptoms of gastro-esophageal

reflux:

 Discuss with physician/nurse practitioner the assessment, note the

OG/NG on the most recent radiograph (query could the tube be too
shallow with even one of the ports in the esophagus).

1.10 Documentation

 Document the procedure and infant response; refer to policy 1611 Clinical
Responsibility for Documentation of Health Information.

1.11 Dwell time for OG/NG

 May be left in situ for 24 hours to 14 days.

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 Gastric tubes are single use.

2. GASTRIC DECOMPRESSION

 The purpose of the NG/OG may be continuous or intermittent air or gastric

content drainage.

 Fluid, electrolytes, and acid/base imbalances may occur due to gastric losses.
Monitor for gastric losses and obtain physician orders if necessary for the
following:

o Serum electrolytes,

o Blood gases for pH, HCO3 - and Base Excess,

o Signs and symptoms of dehydration,

o Replacement of fluid.

 Despite accurate NG or OG placement, "open to air" or "straight drainage" has

been shown to leave substantial residual gastric air in the low birth weight infant.
Tubes smaller than 8 Fr may provide too much resistance for air to escape
spontaneously or smaller tubes may be more easily blocked by feedings and
secretions. For all neonates, but particularly those with a OG/NG smaller than 8
Fr, manual removal of air and associated patency check is required.

2.1 Gravity decompression: Procedure

Size of gastric tube for gravity decompression:

 5 Fr for infants less than 1800 grams

 6.5 Fr for infants 1800 - 3000 grams,

 8 Fr for infants greater than 3000 grams.

Equipment

 20 mL syringe

 Appropriately sized gastric tube

 Scissors

 Tape

 2X2 gauze square

a) Insert gastric tube according to procedure "Insertion of Gastric Tube",

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b) Remove plunger from syringe and place a folded gauze square in the
syringe opening

c) Place syringe on end of gastric tube.

d) If the drainage volume exceeds the capacity of the syringe with gauze
technique or output is to be accurately measured, consider utilizing a
sump tube to straight drainage.

e) Position at a level below that of the stomach.

f) Aspirate every 3-4 hours to ensure patency.

g) Chart infant's response to procedure, amount, colour, and consistency of

any gastric drainage.

2.2 Intermittent active decompression: Procedure

a) Size of gastric tube for intermittent active decompression:

 4 Fr tube for infants less than 1000 grams

 5 Fr tube for infants 1000 to less than 1800 grams

 6.5 Fr tube for infants1800 to less than3000 grams

 6.5 or 8 Fr tube for infants 3000 grams and greater

This procedure is the same as gravity decompression with the following

exceptions:

 Air is actively aspirated from the gastric tube.

 An infant receiving enteral feeds may require intermittent active

decompression. In this case, the gastric tube may be 4, 5, 6.5 or
8 Fr.

 May be of particular use with infants on CPAP

 Every 1-2 hours, open the gastric tube and actively remove
(aspirate) any air that has accumulated in the stomach.

 Frequency will be individualized to each infant's needs and

documented in the plan of care.

 A larger volume syringe may be more effective to successfully

remove air with a smaller size gastric tube (i.e. A 10 mL syringe
may be more useful than a 5 mL syringe).

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 The gastric tube may be left open to gravity decompression

following intermittent active decompression.

 If no air can be removed with active decompression, consider

advancing the gastric tube by 0.5 cm.

2.3 Suction decompression (please refer to Appendix A)

a) Size and type of gastric tube for suction decompression:

*drainage holes are spaced differently in different brands of tubes. Therefore,

the type of tube is specified relative to the size of tube require (Refer to Figure 3).

 6 Fr for infants less than 1800 grams (Salem Sump tube to be used)

 8 Fr for infants 1800-3000 grams (Salem Sump tube to be used)

 10 Fr or 12 Fr for infants greater than 3000 grams (Replogle tube to be

used)

b) Suction Decompression Procedure:

 Physician or Nurse Practitioner order for sump decompression.

 Insert sump tube as an oral gastric tube; refer to Insertion of

Gastric Tubes

Note: If esophageal atresia is suspected, insert tube gently until

resistance is felt.

 Tape tube securely with adherence to 2-S-1: Skin and Wound

Care.

 Write on kardex/NG tracking tool and progress notes, the marking

at the lip.

 Check q3-4h that the tube is at the proper marking.

 Connect sump tube to a plastic tubing connector, refer to Figure 4.

 Connect adaptor to the sterile specimen trap.

 Connect the specimen trap to wall suction referring to Figure 4.

 Turn wall suction on to 20 - 40 cm of H2O unless otherwise as

ordered to deliver intermittent suction.

 Position sump tube air vent above the level of the infant, securing
in place.

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c) Instructions to maintain the sump air vent patency

 The air vent may be injected with air as needed, if gastric drainage
collects in the air vent or if the tube is not draining and patency is
questionable. Inject 1-2 mL of air with a syringe attached to air
vent utilizing a blue catheter adapter.

 If the tube is patent, the injected air and gastric drainage should
visibly move during intermittent suction within the sump tube.

d) Instructions to maintain the sump tube patency

 Obtain a physician order prior to irrigating any gastric tube if the

infant has an acute abdominal diagnosis.

 Sump may be flushed with 1 mL of room temperature normal

saline to ensure patency if it is not draining.

 Irrigate with a syringe attached to sump utilizing blue catheter

adapter.

 Change sump tube only with a physician/nurse practitioner order.

e) Documentation

 Infant tolerance to procedure.

 Volume & characteristics of drainage every 6 hours or as ordered.

 Record total drainage on 24 hour record.

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Figure 3: Sump Cross Section

Figure 4: Sump Connected to Specimen Trap and Suction

Specimen Trap
Suction

Sump Tube
5-in-1 Adapter

3. LAVAGE: Procedure

3.1 Obtain physician/nurse practitioner order.

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3.2 Follow procedure Insertion of Gastric Tube.

3.3 Gently aspirate the gastric contents and discard.

3.4 Instill prescribed solution and amount into stomach; ensuring solution is at room
temperature. Typically this will range from 2-10 mL

3.5 Gently aspirate previously instilled solution and gastric contents into syringe.

3.6 At this point the gastric tube may be secured in place or removed depending
upon the clinical situation.

3.7 Document: the procedure, the volume of prescribed solution instilled the volume
and characteristics of gastric aspirate removed and the infant's tolerance of
procedure.

4. GAVAGE FEEDINGS VIA GASTRIC TUBE

Gavage feeds are indicated for infants with:

 Poorly coordinated suck and swallow

 Abnormal gag reflex

 Insufficient oral intake

 Respiratory symptoms that prevent oral feeding

4.1 Indwelling Vs Intermittent Gavage Tube Feeding

 Feeding tubes should usually be indwelling. When an intermittent tube is

to be used consider:

o The size would usually be 6.5 or 8 Fr tube

o Generally, only use intermittent placement if the infant is expected

to receive less than 1 feed by gavage tube for a single day; refer
to policy 2-O-2: Oral Feeding.

 Gavage feeds should never be plunged or actively pushed into the

stomach.

 There is no single best way to deliver gavage feeds to neonates. Usually

feeds will be administered by intermittent boluses either by feeding pump
or gravity.

 Intermittent gavage feeding strategies are most physiologic, promoting

cyclical surges of gastrointestinal hormones such as gastrin, gastric
inhibitory peptide and enteroglucagon which might affect the

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gastrointestinal tract development and function, metabolic homeostasis

and growth.

 Intermittent feeds given by bolus have been shown to lead to airflow and
respiratory instability in VLBW infants, with a hypothetical cause of
abdominal loading.

 Rate of feed delivery will be modified based upon clinical indications.

o A slower feeding rate (greater than 20 minutes) may be more

advantageous to minimize respiratory instability.

4.2 Suggested Infant Positioning After Feeding to Minimize Specific Types of Feed
Intolerance in the NICU

Type of Feed Intolerance Best Position After Feeding to Minimize Intolerance

GERD Left lateral or prone

Gastric residuals Right lateral
GERD & gastric residuals Prone combined with right and left lateral based on
infant cues and tolerance.
*If possible, kangaroo care with a parent is preferred during and after feeding

4.3 Intermittent feeding through a gastric tube

a) Procedure

 Verify correct tube placement prior to every feed by aspirating for

stomach contents or auscultating for a 1 mL air injection. Before
each feeding, the gastric tube will be visually inspected for
appropriate markings.

 Connect the gastric tube to the milk drip tubing OR the syringe
barrel.

 Pinch the tube and fill barrel of syringe with required amount of
milk.

 Hold tube in place at infant's mouth or nose with one hand,

release the tubing and elevate the syringe barrel to allow milk to
flow by gravity.

 If the milk does not start flowing by itself, use the plunger to gently
fill the tubing to start the feed and then remove the plunger.

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Note: Never push feed into infant's stomach, as aspiration of feed

may occur.

 Control the flow of the feed by altering height of the syringe barrel.

Note: The feed should be administered at a rate of

1mL/kg/minute over at least 5-30 minutes and adjusted according
to the infant's response

 If the baby is cueing, encourage NNS throughout feeding to

improve gastrointestinal function.

b) Discontinuing the Feed

 For indwelling gavage feeds:

o Pinch the tube when the feed is completed, disconnect the

syringe or the milk drip tubing and cap the feeding tube.

 For intermittent gavage feeds:

o Pinch the tube when the feed is completed and remove the
tube quickly.

 Burp infant; where appropriate, maintain the infant in an upright

position for 5-15 minutes after the feeding to facilitate gastric
emptying, burping and reduction in regurgitation

 Position infant to sleep.

c) Changing the tubing

 Change NG/OG tubes every 14 days or as needed.

d) Documentation

 Amount of feeding,

 Tolerance to feed,

 Type of feeding.

4.4 Continuous gavage feed

 Continuous feeds generate less physiologic stress (Dsilna, 2008), may be

a conservative strategy for GERD (Sherrow, 2015), and result in less
energy expenditure. They limit the amount of time to vent air and are
difficult to assess for patency without disrupting the feeding.

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 Continuous gavage feedings of EBM may contribute to some nutritional

loss and bacterial growth due to the method used to deliver it to the
infant; selected nursing interventions might minimize these biochemical
alterations:

o Nutrient Loss: use the smallest lumen capacity and position the
pump so the syringe is inverted with the tip facing upward (Arnold,
1999).

o Bacterial Growth: it is recommended that fresh breast milk be

used, if possible, as frozen breast milk has fewer anti-infective
properties

o EBM and Human Fortifier: shake gently every hour when noting
the volume infused. Ensure fortified milk has not settled to the
bottom of the oral syringe during a continuous feed.

a) Risk Management: (Administration of Feeding Via Intravenous (IV) Pump

Labelled as Feeding Pump)

 While it is recommended that all continuous milk drips be infused by a

feeding pump, at present there is no acceptable neonatal feeding
pump for neonates; When IV pumps are being used for gastric
feedings clearly label the feeding tube, tubing and pump as "Enteral
Feeding Only"

b) Equipment

 Indwelling feeding tube

 Syringe: large enough to hold 4 hours of infant's feeding

 IV syringe pump labeled as feeding pump

 Ordered feed

 Label to mark tubing as OG/NG and not as IV

c) Procedure for continuous gavage feeding

 Preparation

 Assemble equipment.

 Warm milk in milk warmer to body temperature.

 Fill syringe with enough milk for 4 hours of feed plus tubing
(approximately 3mL) and purge through tubing.

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 Place the syringe in a syringe pump.

 Prime syringe pump according to manufacturer instructions.

 Place the syringe so that the tip is pointing upward to have the
milk highest in fat flowing to the top so the infant receives this milk
first (Arnold, 1999).

d) Tube Placement:

 Check tube placement by ensuring it is secured at the appropriate

measurement Q3-4H and with each feed.

e) Feeding

 Connect enteral connection tubing to the gastric tube ensuring the

connection is tight.

 Label enteral connection tubing: "Enteral Feeding Only"

f) Changing the System

 Change the pump tubing and syringe every 4 hours

g) Documentation

 Amount and type of feedings

 Amount and type of aspirate

 Infant response to feedings

 Physician/NNP notification, if required

5. ASPIRATES

 Refer to Clinical Practice Guideline 2-G-2: Gastric Residuals for management of

aspirates

6. MEDICATION ADMINISTRATION

 Oral medications should be added directly into the gastric tube.

 For further information refer to Clinical Practice Guideline 2-M-1: Medication

Administration for correct procedure.

7. ORAL/NASAL JEJUNAL (OJ) TUBES

7.1 Jejunal (Oral or Nasal) or Transpyloric Tubes

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 Jejunal tubes provide continuous enteral feedings when an infant does

not or cannot tolerate intermittent or continuous gavage feedings
delivered to the stomach. In most situations, gastric tubes should be
used in preference to transpyloric tubes, although transpyloric tubes may
be appropriate for select infants (such as those with severe gastro-
oesophageal reflux).

 Jejunal tubes are placed in the upper small bowel (transpyloric tube).

 Enteral feeds are delivered directly to the main site of nutrient absorption
and the risk of reflux may be reduced.

 Transpyloric feeding avoids the gastric phase of digestion that may

reduce nutrient availability and impact upon secretion of intestinal
hormones and growth factors. Significant problems with placement of the
tube beyond the pylorus, gastrointestinal perforation, NEC and
malabsorption have been associated with transpyloric feeding.

 Transpyloric tubes are difficult to position and their position must be

confirmed by radiography. Also, the tube may subsequently migrate back
to the stomach.

 As some medications may be better absorbed from the stomach, an OG

tube may need to be passed into the stomach in order to deliver these
medications; consult pharmacy for individual infant's plan.

 Avoid oral suctioning; if necessary, use a sweeping motion rather than up

and down motion.

 OJ tubes are only changed/replaced according to physician/nurse

practitioner decision. Typically they are never changed.

7.2 Equipment

 5 Fr silicone pediatric duodenal tube with weighted tip (suggested weight

less than 3000 grams)

 6 Fr silicone pediatric duodenal tube with weighted tip (suggested weight

greater than 3000 grams)

7.3 Procedure for Insertion of Oral/Nasal Jejunal Tubes

a) Preparation

 Prepare the tube for easier advancement by doing one of the

following:

 Flush the OJ tube with sterile water; or

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 Put it in the fridge for a few minutes to stiffen the tube.

b) Measurement

 Measure the distance from the tip of the infant's nose to earlobe,
and then midway between the xiphoid process to umbilicus and
mark tube with small strip of tape (refer to Figure 5)

 Recheck this measurement.

 Measure the approximate gastro-jejunal distance from the xiphoid

process to the right lateral costal margin; refer to Figure 6.

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Figure 5: First Measurement for OJ/NJ Tube Placement (Tape #1)

Tube measurement:
½ way between
Xiphoid and Umbilicus Umbilicus

Xiphoid

Figure 6: Second Measurement for OJ/NJ Tube Placement (Tape #2)

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Figure 7: Tip and End Tape Marks for OJ/NJ Tube Placement

c)

d)

c) Insertion

 Lubricate tube end with water-soluble lubricant.

 With firm, steady motion, advance the tube to the first tape.

 Check for placement in the stomach by inserting air and

auscultating.

 Remove tape # 1 and advance by 1 cm/hr until the marking of

tape #2 is reached; tape securely to chee.(See Figure 7).

 Note: This tube is still in the stomach; migration to the jejunum

will generally take more than 4 hours.

 To facilitate movement of the tube through the pylorus position

infant on right side and elevate head 30.

d) Position of Tube

 An abdominal x-ray may be done to document the tube's position.

e) Feeding

 Commence feeds as ordered by physician/NNP.

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f) Checking Tube Position

 Check tube position Q3H by measuring the length of tubing left

outside the baby.

g) Medication Administration

 Consult with the physician/NNP/pharmacy regarding medications;

insert an OG tube into the stomach to give the medications, if
required.

Note: Some medications may need to be administered into the stomach

 Clear the OG tube with 0.5 mL normal saline or water after

administering medications.

h) Documentation

 Record the procedure and infant tolerance on the infant record.

DEFINITIONS

None

REFERENCES

 Alberta Health Services Resources:

o Expressed Breast Milk: Safe Management
o Neonatal Intensive Care: 2-G-2 Gastric Residuals
o Neonatal Intensive Care: 2-M-1 Medication Administration
o Neonatal Intensive Care: 2-O-2 Oral Feeding
o Neonatal Intensive Care: 2-S-1 Skin and Wound Care
o Policy 1611: Clinical Responsibility for Documentation of Health Information
 Non-Alberta Health Services Documents:
o Arnold, L.D.W. (1999). Recommendations for collection, storage and handling of a
mother's milk for her own infant in the hospital setting. Hospital Milk Storage
Recommendations, 3rd Edition.
o Blondheim O, Abbasi S, Fox WW, Bhutani VK. (1993). Effect of enteral gavage feeding
rate on pulmonary functions of very low birth weight infants. J Pediatrics, 122, 751-5.
o Brennan-Behm, M., Carlson, G.E., Meier, P. & Engstrom, J. (1993). Caloric loss from
expressed mother's milk during continuous gavage infusion. Neonatal Network, 13(2),
27-32.
o Chan, J. & Ferraro, A.R. (1991). The use of transpyloric feeding in the NICU: A national
survey. Neonatal Network 10(3), 37-41.
o De Boer JC, Smit BJ. (2009). Nasogastric tube position and intragastric air collection in
a neonatal intensive care population. Advances in Neonatal Care. 9(6), 293-8.
o Dodd, V. & Froman, R. (1991). A Field Study of Bacterial Growth in Continuous
Feedings in the Neonatal Intensive Care Unit, Neonatal Network, 9(6), 17-22.

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GASTRIC/JEJUNAL TUBES May 25, 2017 2-G-1

o Ellett ML, Choen MD, Perkins SM, Smith CE Lane KA, Austin JK. (2011). Predicting the
insertion length for gastric tube placement in neonates. JOGNN, 40, 412-421.
o Elser HE. (2012). Positioning after feedings: What is the evidence to reduce feeding
intolerances? Advances in Neonatal Care, 12 (3), 172-175.
o Freeman D, Saxton V, Holberton J. (2012). A weight-based formula for the estimation
of gastric tube insertion length in newborns. Advances in Neonatal Care, 12(3), 179-
182.
o Greer, F., McCormick, A. & Loker. J. (1984). Changes in Fat Concentration of Human
Milk During Delivery by Intermittent Bolus and Continuous Mechanical Pump Infusion.
The Journal of Pediatrics, 105 (5), 745-749.
o Hamosh, M., Ellis, L.A., Pollock, D.R., Henderson, T.R. & Hamosh, P. (1996).
Breastfeeding and the working mother: effect of time and temperature of short-term
storage on proteolysis, lipolysis, and bacterial growth in milk. Pediatrics, 97(4), 492-498.
o Lemons, P. (2001). Breastmilk and the hospitalized infant: guidelines for practice.
Neonatal Network, 13(2), 27-32.
o Lemons, P.M., Millar, K., Eitzen, H., Strodtbeck, F. & Lemons, J. (1983). Bacterial
growth in human milk during continuous feeding. The American Journal of Perinatology,
1(1), 76-80.
o McDonald MG, Ramasethu J. (2007). Atlas of Procedures in Neonatology.
Philadelphia: Lippincott Williams and Wilkins.
o Maggio L, Costa S, Zecca C, Giordano L. (2012). Methods of enteral feeding in preterm
infants. Early Human Development, 88S2, S31-33.
o Mendes TB, Mezzacappa MA, Toro, AA, Ribeiro JD. (2008). Risk factors for
gastroesophageal reflux disease in very low birth weight infants with bronchopulmonary
dysplasia. Jornal de Pediatria. 2008; 84(2): 154-9.
o Merenstein, G. & S. Gardner. (2002). Handbook of Neonatal Intensive Care. Mosby, St.
Louis.5th ed.
o Monash Newborn South Health. (2008). Evidence-based practice guideline for the
management of feeding in Monash Newborn. . Victoria, Australia.
o Quandt D, Brons E, et al. (2013). Improved radiological assessment of neonatal
feeding tubes. Arch Dis Child Fetal Neonatal Ed. 98, F78-80.
o Robbin S & Meyers R. (2011). Infant feedings: Guidelines for preparation of human
milk and formula in health care facilities. American Dietetic Assocation.
o Soylu G, Wiseman NE, El-Sayed Y, Yi, M, Baier RJ. (2013). Radiographic confirmation
of feeding tube placement: A diagnostic tool identifying gastrointestinal anomalies.
Neonatal Network, 32(2), 89-94.
o Schwartz, R. et al (1987). A meta-analysis of critical outcome variables in nonnutritive
sucking in preterm infants, Nursing Research 36(5), 292-295.
o Waqllace T, Steward, D. (2014). Gastric tube use and care in the NICU. Newborn and
Infant Nursing Reviews, 14, 103-108.
o Williamson, M.T. & Murti, P.K. (1996). Effects of storage, time, temperature, and
composition of containers on biologic components of human milk. Journal of Human
Lactation, 12(1), 31-35.

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VERSION HISTORY

Date Action Taken

March 01, 2005 Revised - Complete
July 01, 2015 Non-substantive change
August 17, 2016 Revised - Complete
September 29, 2016 Non-substantive change
May 25, 2017 Revised

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APPENDIX A
Suction Decompression

See Gastric/Jejunal Tubes Guideline 2-G-1 (pages 10-12)

□ 6 Fr for infants less than 1800 grams (Salem Sump tube to be used)
□ 8 Fr for infants 1800-3000 grams (Salem Sump tube to be used)
□ 10 Fr or 12 Fr for infants greater than 3000 grams (Replogle tube to be used)

Set-Up for Insertion and Checking Placement:

□ Occlude air vent when checking placement and when pulling off stomach contents.
□ Use blue Catheter/Syringe Adapter to attach syringe to catheter.

6Fr or 8Fr Salem Sump or 10Fr or 12Fr Replogle

Air vent Channel
(Blue Funnel)

Blue
Catheter
Adapter

Air vent
Channel (Blue)
Blue Suction
Catheter Channel
Suction Channel Adapter (Clear)
(Grey funnel)

Suction Set-Up for Intermittent Suction Decompression:

Suction turned to “INT” (intermittent)

Wall suction 20 - 40 cm of H2O unless

otherwise ordered to deliver intermittent
suction

Suction regulator attached to red canister.

Specimen trap attached to red canister.

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Infant/bed Set-Up According to Tube Size and Brand

6Fr or 8Fr Salem Sump (two different brands shown here)

Blue Air vent Channel

Left open to air
Above the level of the infant

Suction tubing connecting wall suction to

specimen trap

Use biconical adaptor

(packaged with catheter)
Attach to grey suction channel
Connect to specimen trap (suction)

Suction tubing connecting wall suction to

specimen trap

Use biconical adaptor

(packaged with catheter)
Attach to clear suction channel
Connect to specimen trap (suction)

Blue Air vent Channel

Left open to air
Above the level of the infant

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10Fr or 12Fr Replogle

Suction tubing connecting wall suction to

specimen trap

Clear Suction Channel

Connect directly to specimen trap (suction)

Blue Air vent Channel

Left open to air
Above the level of the infant

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