• Inform all staff on the advised procedure for the use of short term Naso-gastric tube (NGT) feeding at home.

• Assist with the training of parents prior to discharge using ngt competencies to ensure they are confident to carry out this procedure at home.

• Provide a plan of care following discharge to facilitate weaning from ngt onto full oral feeds.

• Ensure parents are aware of support and actions to take if they incur any difficulties once discharged home.

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition. Print copies must be destroyed after use.

Abbreviations

Multiple birth and low birth weight babies frequently experience extended length of hospital stay within the neonatal unit (NNU) environment due to their inability to establish oral feeds¹. This results in increased demand on neonatal cots²; and extended periods of time away from their caregiver and has been shown to affect growth development and parental mental health³. A proposed solution is to offer families an opportunity to provide Naso-gastric feeds at home while establishing oral feeds.

The early introduction of short-term Naso-gastric tube feeding has proven not only to have financial and resource benefits but has physical and psychological benefit to the whole family unit⁴. It restores a sense of control over their baby’s care and progress; and helps the family by not having to travel to and from the NNU and creates less disruption for siblings¹.

1. Baby now >34+6 weeks corrected gestation

2. Medically well and stable (fit for discharge)

3. Maintaining temperature in a cot for 48 hours

4. Gaining weight (actual weight unimportant) and following centile – unless under 14 days of age, then this needs to be discussed with consultant in charge/outreach team.

5. Clinically stable with no monitoring for at least 48 hours (excluding apnoea alarms)

6. Tolerating feeds by Naso-gastric tube and breast/bottle

7. Feeding at least 3 hourly.

8. Able to take at least 2 sucking feeds with good co-ordination in the 24 hours pre discharge given by the parents/carers (if bottle feeding, using own bottles from home)

9. Baby tolerating and following clear feeding plan monitored by the home team.

10. The neonatal home team can provide a good quality, safe service, with appropriate staffing levels and equipment.

11. A checklist and risk assessment are completed, and all criteria are met

1. Family who are willing to undertake Naso-gastric tube feeding and give 24-hour care.

2. Parents/carers must have confidently completed the ‘NGT feeding’ competencies

3. An individualised risk assessment has been undertaken to reduce the potential practical problems, including home assessment - heating, hygiene, support, and current safeguarding concerns

4. Telephone availability in case of an emergency

5. Own transport in case of need for Naso-gastric tube replacement

6. Understand and speak the English language

7. Do not have colour deficiency (colour blind) (for testing pH)

8. Parents/Carers have undertaken resuscitation training

Staff teaching the use of a Naso-gastric tube should be competent health care professionals who are experienced in passing and using Naso/Oro gastric tubes in accordance with the local guidelines.

Prior to discharge the neonatal outreach service should have the capacity and staffing levels needed to provide the support required for the baby/ies discharge.

All Parents will be given an NGT Home Feeding Programme Information Pack containing their competencies, feeding charts, care plans, written information on how to administer the feeds, and contact details for the Neonatal Outreach Team.

The Neonatal Outreach Team will have telephone contact and/or a home visit the day after discharge, and the neonatal unit co-ordinator could make contact if needed and the baby is discharged on a Saturday. During 7.30am – 5pm Monday – Friday, families will be advised to contact the Neonatal Outreach Team for any further advice.

Outside of these hours, families will be directed to contact the neonatal unit (03006134357) for advice. Advice sheets will be available in the ‘Home NGT feeding’ folder in pharmacy room. (See Appendix B-D for troubleshooting flow-charts and Appendix E for telephone advice sheets).

In addition to the parent tube feeding competencies, there are some key safety themes that should be discussed with the parents:

• Nutricare Naso-gastric tubes at home can be used for up to 90 days and parents will be given sterilisable syringes with written instructions on how to use them.

• Lighting - There is an increased risk of misinterpretation of pH in poor/low lighting levels.

• Risk of strangulation/entanglement (NPSA 2012). Nurses are to minimise the risk by using the shortest length of tube possible. Parents to check external tube placement when not in use.

All parents should document the feeds on a home feeding chart within their parent information pack. Note that as part of the initial criteria, the baby should be capable of taking at least 2 sucking feeds with good co-ordination (and if bottle feeding using their own bottles from home) in the 24hours before expected discharge from hospital.

If breastfeeding, the positioning, and attachment should be witnessed by a member of the. Outreach or Feeding Team if not carried out already prior to discharge.

Each baby will be assessed on an individual basis as to how quickly to wean the Naso-gastric tube feeding. Parental input will be used to guide when the outreach team feel able to start reducing NGT feeds. This will be dependent on feed volumes taken and weight gain.

Occasionally babies will not make the progress expected during home NGT feeding and, under certain circumstances, it may be in the baby’s or parent’s best interests to readmit the baby to hospital.

Reasons for readmission may include:

• baby is not gaining weight despite appropriate changing of feeding plan,

• baby is not sucking or uncoordinated and not making progress,

• parents are not coping with NG feeding,

• NGT being frequently displaced,

• problematic GOR,

• home team concerns,

• assessment or further specialist intervention.

Babies may also become unwell whilst receiving home tube feeding. Whilst many babies may be able to continue with sucking feeds during an intercurrent illness, others may need to have a period when they increase the number of tube feeds or revert to being fully tube fed. Others will require admission.

Babies are discharged from the Outreach Services at least one week after the removal of the NGT with evidence of successful oral feeding and weight gain.

Parents/Carers will be invited to give feedback on the service via a parent feedback survey.

This guideline applies to all clinical staff employed or contracted by Frimley Health NHS (National Health Service) Foundation Trust who provide care to neonates. Staff have a responsibility to ensure that they are aware of this guideline and its contents. They should clearly document their rationale if they have not complied with the recommendations detailed in this guideline. It is the responsibility of department managers, consultants, team leaders and education leaders to ensure staff are aware of this guideline.

1. Bissell, G. and Miall, L. (2009) ‘Changing practice by the earlier introduction of tube feeding at home’, Infant, 5(5), pp 150-154. Available at: https://www.infantjournal.co.uk/journal_article.html?id=5954 (Accessed: 18/08/2023).

2. Hubbard, M. (2006) 'Reducing admissions to the neonatal unit: A report on how one neonatal service has responded to the ever increasing demand on neonatal cots', Journal of Neonatal Nursing, 12 (5), pp. 172-176. Available at: https://doi.org/10.1016/j.jnn.2006.07.004 (Accessed: 18/08/2023).

3. Flacking, R. et al. (2012) 'Closeness and separation in neonatal intensive care', Acta Paediatrica, 101(10), pp. 1032-1037. Available at: https://doi.org/10.1111/j.1651-2227.2012.02787.x (Accessed: 18/08/2023).

4. Khair, J. (2003) ‘Managing home enteral tube feeding for children. British Journal of Community Nursing, 3(8), pp. 118-126. Available at: https://doi.org/10.12968/bjcn.2003.8.3.11097 (Accessed: 18/08/2023)

5. National Patient Safety Agency (2012) Harm from flushing of naso gastric tubes before confirmation of placement, NPSA/2012/RRR001. Available at: https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=101753 (Accessed: 18/08/2023)

Baby Criteria

• Medically well and stable (fit for discharge)

• Maintaining temperature in a cot for 48 hours

• Gaining Weight (actual weight unimportant) and following centile

• Clinically stable with no monitoring for at least 48 hours (excl apnoea alarms)

• Tolerating feeds by Naso-gastric tube and breast/bottle

• Feeding at least 3 hourly

• At least 2 sucking feeds with good co-ordination in 24 hours pre expected discharge given by the parents/carers (if bottle feeding in own bottles)

• Clear home team feeding plan in place

Family Criteria

• Family is willing to undertake Naso-gastric tube feeding and give 24-hour care

• Parents/carers must have completed the ngt competency

• Safe home environment (inc heating, hygiene, support). If safeguarding individual assessment by home team carried out.

• Telephone availability in case of an emergency

• Own transport in case of need for Naso-gastric tube replacement

• Understand and speak the English language

• Have normal colour vision (for testing pH)

• Parents/Carers have undertaken resuscitation training

NNU Criteria

• The neonatal home team can provide a good quality, safe service, with appropriate staffing levels and equipment.

Criteria Complete/Ready for discharge ...………………………. (Home Team Signature)

During Outreach Team working hours (7.30am – 5pm) parents with queries about home tube feeding should contact the Neonatal Home Team (03006139869), there is an answer machine should they wish to leave a message about non-urgent matters out-of-hours.

Between 5pm and 7.30am parents will contact the neonatal unit (03006134038) if they require advice, the likely scenarios and suggested responses are as follows:

Tube has come out

Babies should be able to continue with sucking feeds to see them through to the morning.

• Ask about:

  • baby’s usual feeding pattern

  • baby’s current sucking

• Assess:

  • how dependent is the baby on the NGT?

  • can baby safely wait until morning to have NGT replaced?

• Advice:

  • baby to continue with sucking feeds only overnight and have a new NGT cited in the morning (Please leave a message on the home team mobile) OR

baby to be brought to neonatal unit to have new NGT inserted

Tube is not aspirating

• Ask:

• whether they have tried any “tricks” as suggested on the trouble shooting guide

• Advice:

  • turn baby on to the side and re-aspirate

  • turn baby on to the other side and try again to re-aspirate inject 1 ml of air into tube and re-aspirate

  • give a sucking feed, wait 10 minutes then re-aspirate

  • try inserting or withdrawing the tube 1-2 cm then re-aspirate

If all of these have been tried, then advise DO NOT TUBE FEED and assess whether baby can safely wait until the morning to have the tube replaced:

• Ask about:

  • baby’s usual feeding pattern

  • baby’s current sucking

  • Assess:

    • how dependent is the baby on the NGT?

  • Advice:

    • baby to continue with sucking feeds only overnight and have a new NGT cited in the morning (Please leave a message on the home team mobile) OR

    • baby to be brought to neonatal to have new NGT inserted

Aspirate pH is greater than 5.5

Babies should be able to continue with sucking feeds to see them through to the morning.

• Ask:

  • whether they have tried any “tricks” as suggested on the trouble shooting guide

• Advice:

  • turn baby on to the side and re-aspirate

  • turn baby on to the other side and try again to re-aspirate

  • inject 1 ml of air into tube and re-aspirate

  • give a sucking feed, wait 10 minutes then re-aspirate

  • try inserting or withdrawing the tube 1-2 cm then re-aspirate

If all of these have been tried, then advise DO NOT TUBE FEED and assess whether baby can safely wait until the morning to have the tube replaced:

• Ask about:

  • baby’s usual feeding pattern

  • baby’s current sucking

• Assess:

  • how dependent is the baby on the NGT?

• Advice:

  • baby to continue with sucking feeds only overnight and have a new NGT cited in the morning (Please leave a message on the home team mobile)
    OR

  • baby to be brought to neonatal unit to have new NGT inserted

Baby is not sucking as well as he / she was

• Ask:

  • does baby seem well or unwell?

• Assess:

  • does the baby need to be reviewed by a doctor?

  • can the baby safely continue with tube feeds only overnight?

• Advice:

  • if well:

    • continue with tube feeds overnight

    • ask Home Team to review at next opportunity

  • if unwell:

    • do they have symptoms of infectious illness? e.g., temperature, cough, runny nose, fast breathing, diarrhoea

      • if yes: advise to see GP / attend A&E

      • if no: review by Neonatal Unit medical team

ANY ADVICE GIVEN SHOULD BE DOCUMENTED IN EPIC AS A TELEPHONE CALL ENCOUNTER

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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