Inserting and managing feeding tubes


Oude-Reimer M, Frauenfelder O, Camba F, Ceccatelli M, Hankes-Drielsma I, Jørgensen E, Lopez Maestro M, Silva E

Target group

Infants and parents

User group

Healthcare professionals, neonatal units, hospitals, and health services

Statement of standard

Inserting and managing feeding tubes in infants is performed by a trained person and adjusted to infant’s needs and comfort.


Tube feeding either via a nasogastric or orogastric tube is vital for nourishment until the infant can take full feeds by breast or bottle. Feeding tubes are also used for decompression of air and administration of medication. The way in which the feeding tube is inserted and tube feed is given makes a difference to the infant’s food tolerance and comfort. Hypersensitive responses to oral stimulation and sensory defensive responses are two examples preterm infants can develop during tube feeding. (1)

Prolonged use of tube feeding is associated with reflux and difficulty making the transition to full sucking feeds (1), or later to taking solids. The presence of the tube may irritate the infant and stimulate the gag reflex. In the long term, tube fed infants may become used to this irritant, which can impair sensitivity and interfere with sucking and swallowing when oral feeding is introduced. Furthermore, healthcare professionals must be aware of the potential risks due to phthalate exposure in the neonatal unit. Therefore, materials should be identified and alternative devices should be considered. (2)

There is a small risk that the enteral feeding tube can be misplaced into the lungs or ethmoid during insertion, or move out of the stomach at a later stage. Misplacement can be recognised at an early stage, e.g. before the tube is used. There are several methods to check the placement of nasogastric feeding tubes. (3,4)


Short-term benefits

  • Reduced risk of complications due to inserting feeding tubes (4)
  • Reduced pain and discomfort during insertion of the tube (5) (see TEG Care procedures)
  • Reduced stress for parents (6)

Long-term benefits

  • Reduced problems with transition to oral feeding (1,7)
  • Improved sensory development (1)

Components of the standard

Component Grading of evidence Indicator of meeting the standard
For parents and family    
1. Parents are informed by healthcare professionals about the possibility of tube feeding. (8) A (Moderate quality)
B (High quality)
Patient information sheet
2. Parents are trained by healthcare professionals to recognise and act upon infant’s signs of discomfort during tube insertion. (8) (see TEG Care procedures, see TEG Infant- and family-centred developmental care) A (Moderate quality)
B (High quality)
Training documentation
3. Parents have the possibility to be present and to support their infant during tube insertion. (8) A (Moderate quality) Parent feedback
For healthcare professionals    
4. A unit guideline on managing and maintaining feeding is adhered to by all healthcare professionals. (9,10) B (High quality) Guideline
5. Theoretical and practical training on managing and maintaining feeding tubes is attended by all responsible healthcare professionals. (4,11–14) A (Moderate quality)
B (High quality)
Training documentation
For neonatal unit    
6. A unit guideline on managing and maintaining feeding tubes is available and regularly updated. (9,10) (see TEG Care procedures) A (Moderate quality)
B (High quality)
For hospital    
7. Training on inserting and maintaining feeding tubes is ensured. (9) (see TEG Patient safety & hygiene practice) A (Moderate quality)
B (Moderate quality)
Training documentation
8. Different tube sizes and tubes of safe material are available, so the size of the tube can be chosen on an individualised basis. (2) A (High quality) Audit report
9. Different fixation material matching with the individual infant are available. (15) B (Moderate quality) Audit report
For health service    
10. A national guideline on tube insertion, including material safety is available and regularly updated. (16) B (High quality) Guideline

Where to go

Further development Grading of evidence
For parents and family  
For healthcare professionals  
For neonatal unit  
For hospital  
For health service  
  • Facilitate research on phatalates in tubes use in vulnerable infants.
A (Low quality)

Getting started

Initial steps
For parents and family
  • Parents are verbally informed by healthcare professionals about tube insertion and management.
For healthcare professionals
  • Attend training on managing and maintaining feeding tubes.
For neonatal unit
  • Develop and implement a unit guideline on managing and maintaining feeding tubes.
  • Develop information material on tube insertion and management for parents.
For hospital
  • Support healthcare professionals to participate in training on managing and maintaining feeding tubes.
For health service
  • Develop and implement a national guideline on tube insertion, including material safety.

Inserting nasogastric and orogastric tubes: step by step: (17)

Explain procedure and infant’s possible reaction.  
Invite parents to support baby e.g. holding, sucking, grasping. Strengthens parents role in comforting and protecting their infant.
Select an appropriate tube.  
Make sure that you have everything ready at the cot side e.g. tube, materials for fixing, dummy, bedding support, person to assist if available. So you can give the infant your full attention and don’t leave the infant.
Remove old fixings with oil or water.  
Consider most comfortable position for the infant and for caregiver to insert smoothly. Side lying is likely to be preferred by the infant if this is compatible with other treatments. Make the infant comfortable and secure e.g. wrapping, arms tucked in, legs folded, surface for foot bracing. Consider possibility of the infant being supported on mother lap/in her arms. The choice of position and positioning supports make a difference to the infant’s ability to be still and calm. This is often easiest on the side and most difficult on the back. The calmer the infant the easier it is to insert the tube.
If the infant does not have an ET tube offer a dummy to encourage sucking before inserting tube. Sucking will help the infant to swallow tube.
Pace sliding the tube down to maintain minimum levels of arousal.  
Fix tube securely with skin friendly material. Use smallest possible pieces and place to avoid interference with eyelids and mouth. Minimise risk of damage to skin. To avoid irritation and disorganised behaviour.
Provide comfort. Stay with the infant until settled. Ensure rapid return to stability. Infants physiological reactions may be delayed.
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  2. Fischer CJ, Bickle Graz M, Muehlethaler V, Palmero D, Tolsa J-F. Phthalates in the NICU: is it safe? J Paediatr Child Health. 2013 Sep;49(9):E413-419.
  3. de Boer JC, van Blijderveen G, van Dijk G, Duivenvoorden HJ, Williams M. Implementing structured, multiprofessional medical ethical decision-making in a neonatal intensive care unit. J Med Ethics. 2012 Oct;38(10):596–601.
  4. Sorokin R, Gottlieb JE. Enhancing patient safety during feeding-tube insertion: a review of more than 2,000 insertions. JPEN J Parenter Enteral Nutr. 2006 Oct;30(5):440–5.
  5. McCullough S, Halton T, Mowbray D, Macfarlane PI. Lingual sucrose reduces the pain response to nasogastric tube insertion: a randomised clinical trial. Arch Dis Child Fetal Neonatal Ed. 2008 Mar;93(2):F100-103.
  6. Bracht M, OʼLeary L, Lee SK, OʼBrien K. Implementing family-integrated care in the NICU: a parent education and support program. Adv Neonatal Care Off J Natl Assoc Neonatal Nurses. 2013 Apr;13(2):115–26.
  7. Shaker CS. Infant-Guided, Co-Regulated Feeding in the Neonatal Intensive Care Unit. Part I: Theoretical Underpinnings for Neuroprotection and Safety. Semin Speech Lang. 2017;38(2):96–105.
  8. Davidson J, Aslakson R, Long A, et. al. Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU. Crit Care Med. 2017;45(1):103–28.
  9. Richards MK, Li CI, Foti JL, Leu MG, Wahbeh GT, Shaw D, et al. Resource utilization after implementing a hospital-wide standardized feeding tube placement pathway. J Pediatr Surg. 2016 Oct;51(10):1674–9.
  10. Roofthooft DWE, Simons SHP, Anand KJS, Tibboel D, van Dijk M. Eight years later, are we still hurting newborn infants? Neonatology. 2014;105(3):218–26.
  11. Nyqvist KH, Sorell A, Ewald U. Litmus tests for verification of feeding tube location in infants: evaluation of their clinical use. J Clin Nurs. 2005 Apr;14(4):486–95.
  12. Beckstrand J, Cirgin Ellett ML, McDaniel A. Predicting internal distance to the stomach for positioning nasogastric and orogastric feeding tubes in children. J Adv Nurs. 2007 Aug;59(3):274–89.
  13. Ellett MLC, Beckstrand J, Flueckiger J, Perkins SM, Johnson CS. Predicting the insertion distance for placing gastric tubes. Clin Nurs Res. 2005 Feb;14(1):11-27; discussion 28-31.
  14. Ellett MLC, Cohen MD, Croffie JMB, Lane KA, Austin JK, Perkins SM. Comparing bedside methods of determining placement of gastric tubes in children. J Spec Pediatr Nurs JSPN. 2014 Jan;19(1):68–79.
  15. Baharestani MM, Ratliff CR. Pressure ulcers in neonates and children: an NPUAP white paper. Adv Skin Wound Care. 2007 Apr;20(4):208, 210, 212, 214, 216, 218–20.
  16. National Health Service (NHS). Royal Cornwall Hospitals. Clinical Guideline for the care of a neonate, child, or young person requiring a naso/orogastric tube [Internet]. [cited 2018 May 23]. Available from:
  17. Warren I. FINE: Family and infant neurodevelopmental education. Grundlagen für familienzentrierte entwicklungsfördernde Betreuung. FINE Partnership. 2015.

November 2018 / 1st edition / next revision: 2023 Recommended citation

EFCNI, Oude-Reimer M, Frauenfelder O et al., European Standards of Care for Newborn Health: Inserting and managing feeding tubes. 2018.

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