Atlas of Procedures in Neonatology, 4th Edition

Tube Replacement


Gastric and Transpyloric Tubes

Allison M. Greenleaf

  1. Definitions
  2. Enteral feeding is defined as providing nutrients distal to the oral cavity (1).
  3. gastric tube is a tube inserted via the nose or mouth to the stomach (2).
  4. transpyloric tube is a tube passed through the pylorus to the duodenum or jejunum (2).
  5. Purpose (3)
  6. To provide a route for feeding
  7. To administer medications
  8. To sample gastric or intestinal contents
  9. To decompress and empty the stomach
  10. Background
  11. Coordinated suck and swallow does not develop until after 32 weeks' gestation (2).
  12. In preterm infants, enteral feedings stimulate the secretion of hormones that influence development of the gastrointestinal (GI) tract.
  13. Early introduction of feedings is associated with improved bone growth, glucose tolerance, bile flow, and lower risk of nosocomial infection (4).
  14. Early enteral feeding leads to lower cost and decreased length of hospital stay.
  15. Incorrect placement of gastric and transpyloric tubes (incidence as high as 21% to 43%) can lead to substantial morbidity and mortality (5,6 and 7).

Oral or Nasal Gastric Tubes

  1. Indications (3,8)
  2. Poorly coordinated suck and swallow
  3. Abnormal gag reflex
  4. Insufficient oral intake
  5. Respiratory symptoms that prevent oral feeding
  6. Contraindications
  7. Recent esophageal repair or perforation
  8. Limitations
  9. Size of nares
  10. Type and amount of respiratory support
  11. Congenital anomalies of the nasopharynx
  12. Equipment
  13. Suction equipment
  14. Cardiac monitor
  15. Infant feeding tube
  16. 3.5- or 5-French (Fr) feeding tube for infants weighing <1,000 g
  17. 5- or 8-Fr infant feeding tube for infants weighing >1,000 g
  18. ½-in adhesive tape, pectin-based skin barrier
  19. Sterile water or saline
  20. 5- and 20-mL syringes
  21. Stethoscope
  22. Gloves
  23. pH paper
  24. Precautions
  25. Measure and note appropriate length for insertion.
  26. Have suction apparatus readily available in case there is regurgitation.
  27. Do not push against any resistance. Perforation occurs even with very little force or sensation of resistance.
  28. Do not instill any material before verifying tube placement.
  29. Evaluate for possible esophageal perforation after insertion if there is:
  30. Bloody aspirate
  31. Increased oral secretion
  32. Respiratory distress
  33. Pneumothorax
  34. Stop the procedure immediately if there is any respiratory compromise.
  35. Ensure that the open tube drains below the level of the infant's stomach.


TABLE 38.1 Guidelines for Minimum Orogastric Tube Insertion Length to Provide Adequate Intragastric Positioning in Very Low-Birthweight Infants

Weight (g)

Insertion Length (cm)









Data from Gallaher KJ, Cashwell S, Hall V, et al. Orogastric tube insertion length in very low birth weight infants. J Perinatol. 1993;13:128.

  1. Special Circumstances
  2. Feeding with umbilical catheters in situ should be done with caution, as there are insufficient data to guide practice (4,9).
  3. Tubing should be vented between feedings if continuous positive airway pressure (CPAP) is in place.
  4. The pH of gastric secretions does not appear to be affected by the method of feeding (continuous versus bolus). Administration of acid-reducing medications such as H2-receptor antagonists or proton-pump inhibitors does increase the pH of gastric secretions, but the pH is rarely >6 (6,10).
  5. Technique
  6. Wash hands and put on gloves, maintaining aseptic technique.
  7. Clear infant's nose and oropharynx by gentle suctioning as necessary.
  8. Monitor infant's heart rate and observe for arrhythmia or respiratory distress throughout procedure.
  9. Position infant on back with head of bed elevated.
  10. Measure length for insertion by measuring distance from nose to ear to halfway between the xiphoid and umbilicus (4,6). Mark length on feeding tube with a loop of tape (Table 38.1) (11).
  11. Moisten end of tube with sterile water or saline.
  12. Oral insertion
  13. Depress anterior portion of tongue with forefinger and stabilize head with free fingers.
  14. Insert tube along finger to oropharynx.
  15. Nasal insertion (avoid this route in very low-birth-weight infants, in whom nasal tubes could cause periodic breathing and central apnea) (4).
  16. Stabilize head. Elevate tip of nose to widen nostril.
  17. Insert tip of tube, directing it toward occiput rather than toward vertex (Fig. 38.1).
  18. Advance tube gently to oropharynx.
  19. Observe for bradycardia.
  20. If possible, use pacifier to encourage sucking and swallowing.
  21. Tilt head forward slightly.
  22. Advance tube to predetermined depth.
  23. Do not push against any resistance.
  24. Stop procedure if there is onset of any respiratory distress, cough, struggling, apnea, bradycardia, or cyanosis.
  25. Determine location of tip. Injecting air to verify placement is not a reliable method, as the sound of air into the respiratory tract can be transmitted to the GI tract (4,6,12,13).
  26. Aspirate any contents; describe and measure; determine acidity by pH paper.
  27. Gastric contents may be clear, milky, tan, pale green, or blood-stained.
  28. Gastric fluid pH should be <6 (5,6,10).
  29. If the pH of the gastric aspirate is ≥6 or no aspirate is obtained, placement should be verified by radiography (5,14).
  30. Suspect perforation or misplacement if no air or fluid is returned, or if there is onset of respiratory distress, blood in the tube, or difficult insertion.
  31. Secure indwelling tube to face with ½-in tape. In preterm infants, apply the tape over a pectin-based barrier to prevent skin breakdown (15).
  32. For feedings, attach to syringe.
  33. For gravity drainage, attach specimen trap and position below level of stomach.
  34. For decompression, a dual-lumen Replogle tube, connected to low continuous suction, is preferred.
  35. Pinch or close gastric tube during removal, to prevent emptying contents into pharynx.



  1. Document patient response, with any physiologic changes observed, and that tube placement was verified.

FIG. 38.1. Anatomic view of the neonatal nasopharynx. The natural direction in tube insertion is toward the nasal turbinates, where it might stop and give an impression of obstruction. By pushing the nostril up, one can direct a tube toward the occiput with less trauma.

  1. Complications
  2. Apnea, bradycardia, or desaturation
  3. Obstruction of obligatory nasal airway
  4. Irritation and necrosis of nasal mucosa
  5. Epistaxis
  6. Ulceration
  7. Perforation (Figs. 38.2 and 38.3) (16,17 and 18)
  8. Posterior pharynx, particularly at level of cricopharnyx
  9. Esophagus
  10. Submucosal, remaining within mediastinum
  11. Complete into thorax
  12. Stomach
  13. Duodenum
  14. Misplacement on insertion (19)
  15. Coiled in oropharynx (Fig. 38.4A)
  16. Trachea (Fig. 38.4B)
  17. Esophagus (Fig. 38.4C–E)
  18. Eustachian tube (20)
  19. Displacement after insertion because of inappropriate length or fixation
  20. Pulling back into esophagus
  21. Prolapsing into duodenum
  22. Coiling and clogging of tube
  23. Grooved palate with long-term use of indwelling tube (4)
  24. Increased gastroesophageal reflux
  25. Infection (4,21,22)

Transpyloric Feeding Tube

  1. Indications
  2. Severe gastroesophageal reflux with risk of aspiration
  3. Gastric distention with continuous positive airway pressure
  4. Delayed gastric emptying
  5. Gastric motility disorders
  6. Sampling of duodenojejunal contents
  7. Intolerance to gastric feeds
  8. Contraindications
  9. Clinical condition that compromises duodenojejunal integrity: necrotizing enterocolitis, fulminant sepsis,


shock, patent ductus arteriosus, recent small-bowel surgery


FIG. 38.2. Two radiographic views demonstrating a typical nasopharyngeal perforation with extrapleural malposition of a nasogastric tube at the right lung base (arrows). Either a traumatic endobronchial intubation or primary trauma from the nasogastric tube accounts for the perforation.

  1. Limitations
  2. Long-term use may be associated with fat malabsorption, although recent studies suggest that there is no significant difference in growth over time (2,8).
  3. Equipment
  4. Feeding tube
  5. 3.5- or 5-Fr, 36-in silicone or Silastic tubes
  6. Silastic tubes are preferred. Polyvinyl chloride tubes are not recommended for long-term use because the plasticizers are leached, stiffening the tube (4). “Nonstiffening” polyurethane tubes lose some of their compliance when left in place but stay softer for longer periods than polyvinyl chloride tubes.
  7. 20-mL syringes
  8. ½-in tape, pectin-based skin barrier
  9. pH paper
  10. Continuous-infusion pump and connecting tubing
  11. Precautions
  12. When determining oral or nasal placement, individual assessment must be done to weigh the risks of compromising the nasal airway. Oral tubes are not at a significantly greater risk for dislodgement (23,24).
  13. Avoid pushing against any obstruction or resistance.
  14. Replace tubes as per manufacturer's recommendations. If the tube is stiff on removal, replace next tube sooner.
  15. If a tube has become partially dislodged, replace it rather than pushing it in farther.
  16. When using feedings that tend to coagulate in tubing, it may be necessary to flush the tube periodically with air or water.
  17. Use reliable infusion pumps that are safe for oral use by controlling rate and detecting obstructions.
  18. Limit infusion of hypertonic solutions and do not deliver bolus feedings beyond the pylorus.
  19. Consider the effect of continuous feedings on medication absorption.
  20. Special Circumstances
  21. See oral or nasal gastric tubes, E.
  22. Technique
  23. Insert orogastric tube as per gastric tubes above. Aspirate gastric contents.
  24. Measure distance from glabella to heels or from the nose to the ear to the xiphoid to the right lateral costal


margin (14,25,26). Mark point with tape on transpyloric tube.


FIG. 38.3. Posterior perforation of the esophagus demonstrated in postmortem examination of 26-week gestational-age infant. Upper probe is through perforation. Barium from a premortem study spilled through the perforation, causing pleuritis. Perforation may have occurred as a result of endotracheal intubation, suctioning, or passage of gastric tube and is more common in smaller premature infants.

  1. Turn patient onto right side and elevate the head of the bed 30 to 45 degrees (6).
  2. Inject 10 mL/kg of air through orogastric tube to distend stomach. Close orogastric tube (14,27).
  3. Pass transpyloric tube to predetermined depth.
  4. After approximately 10 minutes with infant remaining on right side, gently aspirate through transpyloric tube. Tube may be in position within duodenum if aspirate is
  5. Without air
  6. Alkaline
  7. Bilious (gold or yellow in color)
  8. Verify placement by checking pH of aspirate. If pH is >6 and the color of the aspirate is gold or yellow, the tube is likely in place and radiographic confirmation is not necessary. If no aspirate is obtained or the pH is ≤6, placement should be verified via radiography (5,10,14,28,29). The tip of the tube should be just beyond the second portion of duodenum (Fig. 38.5).
  9. Data are emerging regarding the use of bedside bilirubin testing as an added verification of placement. Studies suggest that intestinal bilirubin ≥5 mg/dL confirms placement (6,10,28).
  10. Avoid pushing to advance tube after initial placement. If tube is not in far enough, retape to give external slack and to allow peristalsis to carry tip to new position.
  11. Most often, if the tube does not cross the pylorus within the first ½ hour after passage, it is unlikely to pass in the next few hours, and it may be better to restart the procedure.
  12. After correct positioning, close transpyloric tube or start continuous infusion. Open gastric tube with syringe-barrel chimney or specimen trap to decompress stomach and to detect any transpyloric regurgitation.
  13. In larger infants, transpyloric tubes may be placed using a 6-Fr, unweighted, stylet-containing tube. This technique is not recommended for small infants.
  14. Transpyloric tubes may be placed with fluoroscopic guidance (6).
  15. Complications (3)(See also Oral or Nasal Gastric TubesF)
  16. Misplacement into tracheobronchial tree, esophagus, or stomach, or incorrect position within proximal duodenum (19) (see Fig. 38.4).
  17. Aspiration
  18. Pneumonia

The risk of aspiration with transpyloric feeding does not appear to be different from the risk with gastric feeding (8,24,30).

  1. Kinking or knotting of tube
  2. Hardening of polyvinyl chloride tube with leaching of bioavailable plasticizers
  3. Perforation of esophagus, stomach, duodenum (31,32)
  4. Perforation of kidney (33)
  5. Sepsis (21)
  6. Local infection (nasal colonization with staphylococci)
  7. Enterocolitis
  8. Staphylococcus(21)
  9. Necrotizing enterocolitis




FIG. 38.4. Radiographic examples of misplaced feeding tubes. A: Tube coiled in the oropharynx and upper esophagus, simulating an esophageal atresia. B: Tube into the left mainstem bronchus. C: Tube coiled in the lower esophagus. D: Tube doubled on itself in the stomach with its distal end in the esophagus (arrow). E: Tube only into the esophagus. A rush may be heard on auscultation over the stomach when air is injected through a tube lying in this position, making that an unreliable sign of gastric location.




FIG. 38.5. Radiographic demonstration of a transpyloric feeding tube that has passed the ligament of Treitz, well below the more appropriate level, increasing the risk of perforation or nutritional dumping.

  1. Development of pyloric stenosis (34)
  2. Formation of enterocutaneous fistula (35)
  3. Interference with absorption of medications (36)
  4. Malabsorption and GI disturbance (2,4,5,8)
  5. Fat malabsorption with nasojejunal feeds
  6. Dumping syndrome if hypertonic medications or feedings instilled too rapidly
  7. Gastrointestinal disturbance as characterized by abdominal distention, gastric bleeding, and bilious vomiting
  8. Intussusception (37)


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