Indwelling Feeding Tubes

• Wash your hands with soap and water or use an alcohol based sanitizer
• Collect all of your supplies
• If marking the length of the feeding tube with tape, cut a small piece now
• Measure the length of the feeding tube to be inserted:
• For a tube inserted through the nose into the stomach (a nasogastric or NG tube): Use the feeding tube to measure from the tip of the nose to the ear lobe, and from the ear lobe to a point midway between the tip of the breastbone and the navel (belly button)
• For a tube inserted through the mouth into the stomach (an orogastric or OG tube): Use the feeding tube to measure from the corner of the mouth to the ear lobe, and from the ear lobe to a point midway between the tip of the breastbone and the navel (belly button)
• Remember that as your child grows, this measurement will change
• Mark this length with the small piece of cut tape or with a permanent marker
• Lubricate the tip of the feeding tube with water-soluble lubricant (never use Vaseline or any oil-based substance)
• Position your child as tolerated:
• Infant
• Wrap your baby snugly in a blanket and place them on a safe surface with the head slightly raised
• Allow infant to suck on a pacifier and try to position baby on their side
• This can make the insertion of the feeding tube easier
• Child
• Position your child lying down with their head raised slightly and in a neutral or slightly flexed position to make it easier for the feeding tube to pass through
• If necessary, have someone hold the child’s arms when the feeding tube is being inserted
• Gently insert the feeding tube into the child’s nose or mouth with a firm, steady force — directing the feeding tube towards the back of the nose for a nasogastric tube or towards the back of the throat for an orogastric tube — and then direct the feeding tube downward
• Pause at the back of the throat and wait for your child to swallow
• Keep inserting the feeding tube until the place on the feeding tube marked with the tape or marker reaches the nose (if placing a nasogastric tube) or mouth (if placing an orogastric tube)
• Never force the feeding tube
• If the feeding tube does not go in readily, remove it
• Change your child's position, lubricate the tip of the feeding tube and try again
• If placing a nasogastric tube, you may need to use the opposite nostril
• Remove the feeding tube right away if your child is:
• Coughing
• Wheezing
• Changing color
• Cannot catch their breath
• Cannot talk 
• If you see the (nasogastric) feeding tube coming out of their mouth
• Cuddle and comfort your child for a few minutes, then try again
• Once the feeding tube is in, keep it in place with a small piece of tape until you check the tube's placement (see below)
• If the feeding tube is correctly in place, lay the next part of the tube along the outside of your child's cheek — on the same side as the nostril where the tube was inserted or on the same side of the mouth that the tube is in (for an OG tube)
• Position the tube so that it is not pulling on the nostril or mouth
• Tape the feeding tube securely with the transparent dressing
• Using the tape measure, measure the remaining length of the tube from the nose or mouth until the end
• Write down the measurement of this extra tube length and keep the information handy because you will use it later to help make sure the tube is in the proper place
• Hold and comfort your child

Supplies for Feeding

• Appropriate size and type of syringe
• Formula or breast milk warmed to room temperature
• Feeding container and tubing (for continuous feeding or feeding delivered by  a pump)
• Infusion pump (for continuous feeding or feeding delivered by a pump)
• Stethoscope and 5 ml syringe to check placement of the feeding tube

Preparation for Bolus Feeding by Gravity or Infusion Pump

• Wash your hands with soap and water or use an alcohol based sanitizer
• Collect all of your supplies
• Prepare your child's formula or breast milk as instructed by your doctor, nurse or dietician
• Warm the bottle of formula or breast milk in a pan of warm water
• Never warm formula or breast milk in a microwave
• Test the temperature of the formula or breast milk by dropping a few drops on the inside of your wrist (it should feel warm, not hot)
• Check the placement of the feeding tube
• Always check before giving anything in the tube
• Position your child for the feeding:
• Hold your infant during the feeding, maintain eye contact and offer the pacifier to help them continue to learn feeding skills and connect the sucking with the feeling of being full
• Older infants or toddlers who can sit on their own may be placed in a highchair during the feeding
• For feedings during the night, keep the head of your child's bed raised 6 to 8 inches by placing a pillow under the mattress and place your child on their right side to promote digestion and prevent reflux
• If you put your child in bed after a feeding, keep them on their side with the head of bed raised for 30 minutes after the feeding

Bolus Feeding by Gravity

• Remove the plunger from the syringe
• Connect the open end of the feeding tube to the open syringe
• You may place a piece of twill tape around the top of the syringe to hang it (from a safe and stable spot close to the child) during the feeding, or you may hold the syringe in your hand
• Do not hold or hang the syringe more than 18 inches above the level of your child's stomach or they may vomit
• Pinch the feeding tube near the end connected to the syringe while you pour the formula or breast milk into the syringe
• Stop pinching the feeding tube and allow the formula or breast milk to flow through the tubing by gravity
• The height of the syringe and the size of the feeding tube affect how fast the formula or breast milk goes into the stomach
• The higher the syringe, the faster the formula or breast milk will flow; the lower the syringe, the slower it will flow
• Formula or breast milk will flow slower in a smaller size feeding tube and faster in a larger size feeding tube
• If the formula or breast milk does not start to flow, you may need to put the plunger into the syringe and gently push to get it to start flowing, and then remove the plunger
• Keep adding more formula or breast milk before the syringe is empty to prevent air from entering your child's stomach
• Unless your doctor instructs you to do otherwise, feed your child slowly over 20 to 30 minutes, the time it would take for your child to bottle feed, to help prevent vomiting or diarrhea
• If your child vomits during the feeding, stop the feeding immediately by lowering the syringe and pouring the formula or breast milk back into the bottle
• Wait until the vomiting stops and recheck the feeding tube placement
• When the child is ready, resume the feeding and put in the formula or breast milk more slowly
• If the tube comes out when he vomits, reinsert it
• Follow the feeding with 5 to 10 ml of water (or the amount prescribed by your doctor or nurse) to rinse the feeding tube to prevent clogging and minimize the chance of bacteria growing in the feeding tube
• When necessary, you may leave the syringe attached and the tubing open to the air to allow for burping, then close the end of the feeding tube
• Syringes can be washed with dish soap and hot water, rinsed well and air dried and you may then reuse them
• A bolus feeding may also be given using the continuous feeding bag and tubing by adjusting the roller clamp on the tubing to let the formula or breast milk drip in over 20 to 30 minutes, or the period of time ordered by your doctor
• Rinse the feeding bag and tubing as instructed and cover the end of the tubing to keep it clean until your child's next feeding or store the feeding bag in the refrigerator between feedings
• If you are using the continuous feeding bag for breast milk, it is recommended that you store the feeding bag and tubing in the refrigerator between feedings without rinsing it to prevent losing any nutrients from the breast milk that may be coating the tubing

Bolus Feedings by Infusion Pump

If your child cannot handle 20- to 30-minute feedings and vomits, you may need to use a special infusion pump to deliver formula or breast milk. With the pump, you can give the formula or breast milk over a longer period of time. Before your child leaves the hospital, you will receive detailed instructions by the company who supplies the infusion pump on how to use it.

• Fill the feeding bag and tubing with the warmed formula or breast milk as instructed
• Check the tube for correct placement
• Connect the feeding tube to the end of the tubing connected to the infusion pump
• Turn the pump on to the desired rate and start it
• Position your child as described above
• When the feeding is done, turn off the pump and close the roller clamp on the pump tubing
• While pinching the feeding tube near the end where it is connected to the infusion pump tubing, disconnect the feeding tube from the tubing connected to the infusion pump and close the feeding tube
• Follow the feeding with 5 to 10 ml of water or amount prescribed by your doctor or nurse to rinse the feeding tube to prevent clogging and minimize the chance of bacteria growing in the tube
• Your infant may need to be burped after the feeding
• Close the end of the feeding tube as you hold and burp them
• An alternate method is to attach a syringe to the end of the feeding tube and leave it open to the air to allow for burping and afterwards, close the end of the feeding tube
• Rinse the feeding bag and tubing as instructed and cover the end of the tubing to keep it clean until your child's next feeding, or store the feeding bag in the refrigerator between feedings
• If you are using the continuous feeding bag for breast milk, it is recommended that you store the feeding bag and tubing in the refrigerator between feedings without rinsing it to prevent losing any nutrients from the breast milk that may be coating the tubing

Preparation for Continuous Feedings by Infusion Pump

• Wash your hans with soap and water or use an alcohol-based sanitizer
• Collect all of your supplies and the infusion pump
• Prepare your child's formula or breast milk as instructed by your doctor, nurse or dietician
• Measure enough formula or breast milk for 4 hours and the amount needed to fill the pump tubing
• Warm the bottle of formula or breast milk in a pan of warm water
• Never warm formula or breast milk in a microwave
• Test the temperature of the formula or breast milk by dropping a few drops on the inside of your wrist (it should feel warm, not hot)
• Check the placement of the feeding tube as noted above at the beginning of the feeding, before giving any medications in the tube and every four hours to make sure that the feeding tube is in the correct place
• Position your child for the feeding:
• Your infant should be held at different times during the continuous feeding while you maintain eye contact
• Offer the pacifier to help them continue to learn feeding skills
• Older infants or toddlers who can sit on their own may be placed in a highchair during mealtime for the feeding
• If your child is placed in their bed, keep the head of the bed raised 6 to 8 inches by placing a pillow under the mattress and keep the child on their right side to promote digestion and prevent reflux
• Fill the feeding bag and tubing with the warmed formula or breast milk as instructed
• Connect the feeding tube to the end of the tubing connected to the infusion pump
• Turn the pump on to the desired rate and start the feeding
• As the bag empties every 4 hours, discard any formula or breast milk remaining in the bag and add another 4-hour supply of freshly warmed formula or breast milk
• Never add new formula or breast milk to formula or breast milk already in the bag
• Sometimes the feeding tube can slip under the take, so always check the placement of the feeding tube as noted above at the beginning of the feeding, before giving any medications in the feeding tube and every 4 hours to make sure that the feeding tube is in the correct place
• Every 8 hours and whenever medications are given through the feeding tube, flush the feeding tube with 5 to 10 ml of water (or the amount prescribed by your doctor or nurse) to prevent the feeding tube from clogging
• Change the feeding bag and setup every 24 hours

Type of Water to Use for Formula Preparation & Flushes

• You  should consult with your doctor on the most appropriate type of water to use in the area where you live to prepare your child's formula.
• Ask your doctor whether water used in preparing formula should be sterilized first
• If sterile water is recommended, your doctor will also advise you when you no longer have to sterilize water
• The American Academy of Pediatrics and the U.S. Food and Drug Administration's guidelines state that sterile water can be prepared at home by using tap water that has been brought to a boil, allowed to boil for one minute and then cooled before being used for formula preparation
• If using non-sterile bottled water for formula preparation, sterilize the water by bringing it to a boil for one minute and then cool before using it
• Commercially prepared nursery water will indicate on the label if it is sterile or non-sterile
• The American Dental Association recommends the use of fluoride-free or low-fluoride water when preparing infant formula from liquid concentrate or powder
• Examples are bottled water labeled “purified,” “demineralized,” “deionized,” “distilled” or “reverse osmosis filtered”
• If using nursery water, check the label for “low fluoride”
• When using water for flushing the feeding tube, use the same type of water that your doctor recommends for preparing your child's formula
• If the formula you prepared is not being fed to your child immediately, refrigerate it right away and keep it refrigerated until use
• Follow the instructions on the formula container regarding the length of time prepared formula can be stored in the refrigerator before it needs to be thrown away

Guidance for Long-Term Tube Feedings

• If your child will need tube feedings for an extended period of time, you may want to explore long-term feeding options with your child's physician
• Additionally, you may want to explore with the child’s team what feeding therapies may be available to help your child with their specific feeding issues