• Contraindications to oral feeding, or baby unable to take full requirements orally
• Nasogastric or orogastric tube in place

• Enteral syringes (see https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiv9OmUjpv4AhVFkFwKHTs-C68QFnoECAsQAQ&url=http%3A%2F%2Fwww.premiersafetyinstitute.org%2Fwp-content%2Fuploads%2FOral-medicines-alert.pdf&usg=AOvVaw3PSI2MSRu2c0MpD7lx8Z)
• pH testing strips
• Gravity/bolus feeding set
• Feed/fluids/medication according to prescription
• Prescription chart (for medication)

Preparation

• See (see Nasogastric tube insertion guideline)
• Discuss procedure with parents/carer 
• Wash hands and prepare equipment
• Bring milk to room temperature by removing from fridge and warming in a waterless warmer or in hot water. Never deliver fridge-cold milk directly via nasogastric or orogastric tube (see Nutrition and enteral feeding guideline)

Position of baby for feeding

• Baby need not be lying down. It is preferable to feed baby whilst receiving kangaroo care 
• An awake and stable baby can be held for tube feed
  • preferably skin-to-skin with parents holding baby in an upright position
  • baby can also be placed in elevated side lying feeding position (ESLP) if skin-to-skin not possible at time of feed
• If lying flat in a cot:
  • elevate mattress to 30° before feeding and return to flat position within 1 hr 

Checking pH

• Check pH before every feed/use of tube according to NPSA guidelines (see Nasogastric tube insertion guideline)
  • if pH 0–5.5, commence feed and document pH
  • if pH 5.0–5.5 confirm pH interpretation with a second person before commencing feed 
  • if pH ≥6, do not commence feed. Repeat aspiration and retest
• If repeated test ≥6, seek advice from senior clinician and undertake risk assessment following NPSA algorithm (see Nasogastric tube insertion guideline). Document decision made and rationale
• If no aspirate obtained, do not feed. Follow procedure outlined in NPSA guideline

Feeding

• Avoid rigid feeding patterns (e.g. 1 bottle/2 tube, alternate bottle/tube etc.) (see Bottle feeding guideline)
• When handling tubes, ensure clean technique. Pay careful attention to feed preparation and administration
• Administer feed by gravity 
• Remove plunger, connect to tube, pour small volume of feed into barrel, raise level of barrel above baby’s stomach. Control speed of administration by raising or lowering barrel
• Do not plunge feed 
• Ensure tube feed takes approximately the same time as a suckling feed e.g.:
  • 20 min for 3-hrly full feed volume requirement
  • 10 min for 50% volume
  • 5 min for 25% volume

Monitoring

• Observe baby throughout feed for signs of deterioration or distress (change in colour, cyanosis, apnoea, bradycardia, vomiting, straining, squirming, grimacing and other avoidance behaviour)
• Observe for abdominal distension following a feed 
• If appropriate developmental stage/capabilities, offer small drops of milk to mouth to taste, but avoid in babies with no swallow mechanism
• Consider offering baby mother’s breast for nuzzling or non-nutritive sucking during tube feed [see Non-nutritive sucking (NNS) guideline]
• On completion of feed, instil small amount of air into tube (0.5–1 mL) 

• Document feed details: 
  • pH of aspirate
  • type of feed
  • volume of feed
  • time of feed
  • behaviour/response during feed
  • adverse reactions (vomiting etc.)
• Ensure feed chart is signed 

• For administration of medication, remember to check baby identity and prescription. Follow Trust policy for administration of medicines and British Association of Parenteral and Enteral Nutrition (BAPEN) guidance 
  • document administration of medication on prescription chart
• Flushing of NGT is not routine in preterm babies. To avoid medication remaining in NGT try to give medications pre-feed. Where this is not possible 1 mL of feed can be used to flush tube after inserting medication

• Nasogastric tube insertion guideline