Nasogastric tube insertion and verification

Overview & Definition

A two-year-old is admitted overnight with a small-bowel obstruction and needs her stomach decompressed, or a preterm infant on the neonatal unit cannot yet coordinate suck and swallow and needs milk by tube. In both cases the device is a nasogastric tube: a flexible, hollow tube passed through a nostril, along the floor of the nose, through the pharynx and oesophagus, to rest with its tip in the stomach. Its job is to open a safe route into the gut for feed, fluid or medicine, or to let gas and gastric contents out when the bowel is obstructed. [1] [8]

The procedure looks simple, which is exactly why it is dangerous. The nose, the pharynx and the opening of the airway sit within a centimetre or two of each other, so a tube aimed at the oesophagus can instead turn into the larynx and travel down the trachea into a bronchus. A child who is intubated, sedated, very young, or who simply cannot cough, gives no signal that this has happened. If feed or medicine is then poured down the tube, it fills the lung or the pleural space, and the child aspirates or develops a pneumothorax. The safety of the procedure therefore rests not on the insertion but on what you do afterwards: you verify the position, and you do it every time before anything goes down the tube. [4] [9]

The discipline comes from a patient-safety history. In the United Kingdom, a series of deaths and serious harms from feeding misplaced tubes led the National Patient Safety Agency, and later NHS England and NHS Improvement, to retire the old bedside checks and to make pH testing of the aspirate the standard. Feeding or medicating through a tube whose position has not been confirmed, or has been confirmed by a method that is no longer allowed, is now classified in the NHS framework as a Never Event: a serious, largely preventable incident that should not occur if the known safety barriers are in place. The same logic shapes Australasian, North American and European paediatric guidance. [1] [4] [8]

References11Show ledgerHide ledger

1. [1]Irving SY, Rempel G, Lyman B Pediatric Nasogastric Tube Placement and Verification: Best Practice Recommendations From the NOVEL Project. Nutr Clin Pract, 2018.PMID 30187517
2. [2]Northington L, Kemper C, Rempel G Evaluation of methods used to verify nasogastric feeding tube placement in hospitalized infants and children - A follow-up study. J Pediatr Nurs, 2022.PMID 34763985
3. [3]Kisting MA, Korcal L, Schutte DL Lose the Whoosh: An Evidence-Based Project to Improve NG Tube Placement Verification in Infants and Children in the Hospital Setting. J Pediatr Nurs, 2019.PMID 30798144
4. [4]Metheny NA, Krieger MM, Healey F A review of guidelines to distinguish between gastric and pulmonary placement of nasogastric tubes. Heart Lung, 2019.PMID 30665700
5. [5]Metheny NA, Pawluszka A, Lulic M Testing Placement of Gastric Feeding Tubes in Infants. Am J Crit Care, 2017.PMID 29092869
6. [6]Metheny NA, Stewart BJ, Smith L pH and concentration of bilirubin in feeding tube aspirates as predictors of tube placement. Nurs Res, 1999.PMID 10414681
7. [7]Metheny N, Reed L, Wiersema L Effectiveness of pH measurements in predicting feeding tube placement: an update. Nurs Res, 1993.PMID 8247814
8. [8]Longo MA Best evidence: nasogastric tube placement verification. J Pediatr Nurs, 2011.PMID 21726788
9. [9]Taylor SJ Feeding tube safety: National guidance ignores the 'elephant in the room'. Int J Risk Saf Med, 2025.PMID 39973429
10. [10]Andresen EN, Frydland M, Usinger L Deadly pressure pneumothorax after withdrawal of misplaced feeding tube: a case report. J Med Case Rep, 2016.PMID 26846268
11. [11]Knight RB, Webb DE, P Coppola C Pharyngeal perforation masquerading as esophageal atresia. J Pediatr Surg, 2009.PMID 19944236