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hesbon rasiene

medical personnel

Normal user

19 Sep 2018, 17:15

For how long should an n-g tube be in use before it is replaced? and can we make it recommendable for caregivers to be able to be feeding the children at home using it so long as insertion and removal is done by a health provider? The meal quantities can be prescribed. This will help bring more caregivers to seek nutrition interventions in hospital, because most shun away because they fear admission due to lack of funds to pay for bed and other hospital bills

Chantal Autotte Bouchard

AAH

Normal user

20 Sep 2018, 08:30

Hello, a nasogastric tube is generally not left in place at home including occcident because there is too much risk that it moves, is obstructed or it moves, the positioning of the tube must be checked before any passage of liquid in this one (listening with a stetoscope to make sure it is in the stomach and not the lungs and sending a small amount of water) if I understand the procedure, I honestly believe that it is too much complicated for families, without taking into account the risks of hygiene.

Paul

Frequent user

20 Sep 2018, 09:51

Hi Hesbon,
It is technically feasible to leave a short term NG tube in place for up to 4 weeks (except for neonates and ventilated children). The decision to replace would also need be based on an assessment that includes, among other things, whether the tube is causing any sores in the nasal / pharyngeal passages in which case replacement would be done sooner or is causing other medical problems requiring removal. Much will depend on the type and bore of the NG tube used, continued use beyond 10 days generally increases the risks for the patient.

It is also technically feasible for the family to give NG feeds at home but there are a lot of caveats and the mother needs to be well prepared in order to manage this safely.

Checking tube placement is a primary concern for home based treatment. Before discharge the placement of the tube should be marked with tape / indelible ink (the placement mark) and the carer advised that if the tape or mark moves then the tube should not be used and to seek medical care.

The carer can also be shown how to aspirate the tube and expect to see fluids of various colours (in the hospital setting we would potentially also test the fluids using pH paper - e.g. litmus test) so as to confirm placement before feeding.

Another way of confirming placement is to listen to the stomach with the ear when a small amount of air is flushed down the NG tube - a stethoscope is not strictly necessary - however these measures can only confirm placement (in the home setting) if the placement mark has not moved.

Under no circumstances should fluid be put down the tube to check placement. This may cause aspiration and lead to chest infections / respiratory compromise. If the tube is blocked then the heath care provider should be called, however part of the teaching for home management of the NGT would necessarily be for the tube to be flushed with a small amount of water after each feed.

I understand the concern over the carers' inability to pay medical bills and how this may affect admission. Although you don't mention the context of the question, introducing a protocol for home management of NG tubes for a SAM treatment programme raises some serious questions.

For a child with SAM we would only use an NG tube in phase 1 of inpatient care and as a rule we advise never to discharge the child to the home setting with therapeutic milk. If a child requires phase 1 care then it suggests that the necessity of the NG tube is a result of serious infection, that the child has no appetite and is need of 24 hr (and at least daily) attention, in which case discharge home carries a very high risk of mortality.

If fear of the cost is leading to carers, whose children require hospital care, to refuse admission then there is a bigger question. Why are so many SAM children being identified so late that they require admission to hospital for an NG tube to be placed?

You may need to review the SAM treatment programme and strengthen the community outreach component. In the first instance this should aim to recruit children to the programme early so that they can be treated as an outpatient with RUTF (before an nGT is required) and secondly to inform the community that (in the context of a CMAM programme) hospital admission for the small number that need it will usually be short term and treatment can continue as an outpatient once discharged.

Is it possible to look for funding so as to provide free treatment or link the carers with social protection programmes?

Below are some links to various organisations recommendations on NG tube placement and care in the hospital setting and home. However if this is a SAM treatment programme I would strongly advise that you reconsider your approach before introducing these as (potentially very unsafe) programme protocols.

Paul
https://rcni.com/sites/rcn_nspace/files/ns2005.09.20.3.59.c3967.pdf
https://patient.info/doctor/nasogastric-ryles-tubes
https://www.gosh.nhs.uk/health-professionals/clinical-guidelines/nasogastric-and-orogastric-tube-management

https://www.thh.nhs.uk/documents/_Patients/PatientLeaflets/paediatrics/PIID186-Nasogastric_%20tube_Oct12.pdf
https://www.uwhealth.org/healthfacts/parenting/7223.pdf

Jessica Bourdaire

Normal user

21 Sep 2018, 08:19

Hi Hesbon,

If you are referring to the use of NGT in acutely malnourished infants and young children not able to feed orally, NGT should only be used for a very short period, if the condition of the child requires it for longer, it should be replaced every 72h. NGT as well as therapeutic milks are only for inpatient care, under very close monitoring because of the risk of aspiration. If you estimate the child still requires NGT means that inpatient care is still needed for this child. The positioning of a NGT should be systematically checked before each feed, introducing air with a syringe is a simple way to do so but never liquids. I hope this helps.

Jess

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