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Nursing Intervention Study: Nasogastric Tube Feeding for Failure to Thrive

Introduction

This assignment describes the care of an infant in the Special Care Baby Unit (SCBU), exploring the implications of a nursing intervention. The chosen intervention is the use of a nasogastric tube for feeding to redress poor growth in Baby Simon (name changed to protect confidentiality). Simon was born at 35 weeks plus 3 days, less than two weeks pre-term, and was nursed in the special care nursery for two days following delivery. Following this, Simon was released to his mother's care on the postnatal ward, but returned to the SCBU on day five, with a history of poor feeding and weight loss. Although breastfeeding, and with a lot of support, Simon was not feeding effectively. Simon had lost more than 10% of his birthweight.

Blood sugars were recorded, and over an eight hour period, fluctuated between 2.1 and 3.9 mmols/l, but the majority of the readings were below 2.5 mmols/l. Simon's SA02 was 98% on air, but his temperature was difficult to maintain and he was hypothermic. The decision was made to return Simon to the SCBU nursery, for him to be cared for using a combination of a warmed cot and kangaroo mother care, and, most importantly, to supplement feeds using a nasogastric tube. Feeds were to be a combination of either expressed breast milk and formula milk, but the plan was that Simon would be put to the breast regularly as well, to ensure continuation of breastfeeding.

This essay will discuss the rationale and reasons for providing nasogastric tube supplementation, and explore some of the aspects of the role of the nurse within the SCBU setting. It will also look at the impact of such an intervention on the parents as well as the infant's health, taking a critical approach to analysing care.

Discussion

Forms of enteral tube feeding have existed for a very long time, and because of this, techniques for tube placement and nutritional support are well developed (Chernoff, 2006). Nasogastric tube feeding, particularly in the barely preterm neonate, is usually considered to be a relatively benign means of supplementing oral nutritional intake in cases of poor feeding or sub-optimal weight gain. Weight gain is particularly important in the maintenance of blood sugar, the maintenance of body temperature, and the maintenance of homeostasis in the preterm infant. Thermoregulatory mechanisms in particular are dependent on maintenance of blood sugar, and proper metabolic functioning is important in supporting brain function and neurological development.

Nasogastric tube feeding is a good option for a number of reasons. Firstly, it does not interfere with sucking and rooting reflexes, and does not cause nipple confusion when introduction of bottle feeds using an artificial teat might. Because Simon is breastfed, and because introduction of bottle feeds can undermine breastfeeding success, use of a nasogastric feed supplementation seems like the appropriate intervention. Secondly, it ensures that there is a clear record of the amount of feed that Simon has taken. If there were any underlying metabolic reasons for poor weight gain, at least the staff would be aware of the amount of feeds that Simon had been given, and could evaluate his ongoing growth and development in the light of this.

However, there are disadvantages to using nasogastric feeds in preterm neonates. One of the main issues is incorrect placement, because nasogastric tube placement is a blind technique, and misplacement is common (Metheny et al, 2007; Clarke, 2007). Most often, misplacement in the respiratory tract occurs, and if this is not diagnosed, this can lead to serious complications of aspiration of the feed, as well as traumatic damage to the respiratory tract (Metheny et al, 2007; Clarke, 2007). Such is the danger of misplacement that in February 2005 this resulted in the issuing of a high priority patient safety alert by the UK's National Patient Safety Agency (NPSA, 2005). There are particular means by which practitioners can assure that they have correct placement, and in particular, pH testing of nasogastric tube aspirate can indicate correct placement (NPSA, 2005). Gut secretions and contexts are primarily acidic, due to the presence of digestive enzymes and hyrochloric acid in the gut, and so a pH test can indicate correct placement, if the reagent strip turns pink. However, this is no one hundred percent foolproof. Other approaches, and a critical awareness of potential risks, can ensure that all those involved, not just the nurse placing the tube, are careful to assess for risk and any complications (Bain and Stevenson, 2005).

Visual inspection can also ensure the tube is placed in the gut, not coiled at the back of the oropharynx, and so the nurse would look inside the baby's mouth to determine this. The behaviour of Simon, and his breathing, colour and tone would also give some indication, but again, this is not conclusive. Certainly the nurse would have to be aware of what procedures to take should incorrect placement occur, especially if a feed has been attempted (NPSA, 2005).

Another issue is the developmental features of suckling activities, which help infants to establish normal swallowing and deglutition actions (physiologically) and also help infants with normal development of the chin and cheek and normal sucking patterns (Boiron et al, 2007). This is one of the reasons why, in Simon's case, he continued to be breast-fed regularly, and supplementation provided during the feed. This also helps to establish or maintain feeding routines, which are important for Simon and also for his parents during the time of transition to parenthood (Cherry and Thomas, 2008).

Although the rationale for tube feeding seems straightforward, there are issues around its efficacy in weight gain, because the relatively simple relationship between nutrient intake and growth is complicated with variations in feeding approaches and patterns (Blackwell et al, 2005). In their study, Blackwell et al (2005) found that "mean NICU growth velocity of healthy, moderately premature infants did not achieve in utero growth standards. There was significant inter-NICU variation in growth outcomes and feeding practices. Further study is needed to identify practices associated with better growth in this healthy moderately premature infant population" (p 478). This would suggest that while Simon may benefit from the supplementation, and the route of supplementation may avoid some complications of bottle feed supplementation, there is still a gray area in terms of how much this contributes to ongoing growth and development. Therefore, this would be another good reason to continue with breastfeeding and normal infant care practices provided by the parents.

The supplementation could, however, have been provided with cup feeds, rather than using the somewhat invasive nasogastric tube. Collins et al (2004), in a rancomised controlled trial, found that cup feeding was effective in supporting ongoing breastfeeding, and increasing the rates of breastfeeding at discharge for preterm babies. Therefore, in this case, Simon could have been cup fed, and may not have required to be kept on the SCBU. However, there are issues around this. Parents can be nervous about cup feeding, and the technique must be followed closely to avoid choking. It may also be that the dominant ideologies and ingrained practices of the SCBU predisposed the staff towards NG tube supplementation rather than cup feeding. Or on a more basic level, the availability of the sterile cups suitable for cup feeding might affect the decision.

Decision making in this case is an important element of the nurse's care, and her role. As Monteresso et al (2005) state "Neonatal intensive care unit (NICU) nurses are often faced with complex clinical and ethical problems." (p 108). While this may not seem to be one of the more significant issues that might face a nurse in this context, the role of the nurse is to look after the wellbeing of the baby, and also the wellbeing of the family who are caring for that baby. Thus, every decision is weighted with significance, because it could impact on how the parents cope with having their baby in the SCBU, and how they bond with and related to their baby. However, as Monteresso et al (2005) found in their study, "nurses saw their role in ethical decision-making primarily as advocating for the best interests of the infant and family, that they used clinical knowledge and experience to guide ethical decision-making, they were able to clearly articulate ethical problems and respond to them according to the clinical scenario" (p 108). Therefore, in this case, the nursing intervention was decided upon after full consideration of the baby's condition.

Making such decisions, however, cannot be done without the involvement of the parents. Having a baby on the SCBU or NICU can cause significant stress to parents (Franck et al, 2007). This stress comes not only from the psychological and emotional aspects of worrying over a child who is unwell, and coping with the stressful environment (Franck et al, 2007), but also from other factors, such as financial implications, social implications, impact on siblings and other family members, and feelings of guilt or other complex emotional responses. The way that the nurse interacts with the parents, involves them and supports them is key to reducing the impact of the stressors surrounding such a situation.

Conclusion

In the case of Baby Simon, the decision to use nasogastric tube feeding was made in terms of how best to support his growth, development and wellbeing, and the best place of care to provide the surveillance and monitoring needed at this early stage of his life. Safety issues around NG tube placement were taken into consideration, and staff followed the guidance in checking for placement through aspirate pH testing. The rationale and reasons for the placement were parent-supportive, and the parents were involved in the decision making throughout.

References

Bain, T. and Stevenson, E. (2005) Misplaced nasogastric tubes: reducing the harm by identifying and balancing the risks. Journal of Neonatal Nursing 11 48-50.

Blackwell, M.T., Eichenwald, E.C., McAlmon, K. et al (2005) Interneonatal Intensive Care Unit Variation in Growth Rates and Feeding Practices in Healthy Moderately Premature Infants Journal of Perinatology 25, 478–485.

Boiron, M., Da Nobrega, L., Roux, S. et al (2007) Effects of oral stimulation and oral support on non-nutritive sucking and feeding performance in preterm infants Developmental Medicine & Child Neurology 49 (6) 439-444

Chernoff, R. (2006) An Overview of Tube Feeding: From Ancient Times to the Future Nutrition in Clinical Practice, 21 (4) 408-410.

Cherry, R. and Thomas, D.W. (2008) Infant Feeding in Special Circumstances Pediatrics in Review. 29:274-280.

Clarke, S. (2007) A review of nasogastric tube management in children 2: position, placement error and hydration Journal of Children's and Young People's Nursing, 1 (3) 119 - 128

Collins, C.T., Ryan, P., Crowther, C.A. et al (2004) Effect of bottles, cups, and dummies on breast feeding in preterm infants: a randomised controlled trial BMJ329:193-198

Ebenezer, K., Bose, An., Carl, S. (2007) Neonatal gastric perforation following inadvertent connection of oxygen to the nasogastric feeding tube. Archives of Disease in Childhood Fetal & Neonatal Edition. 92(5):F407

Franck, L.S., Cox, S., Allen, A. and Winter, I. (2007) Measuring neonatal intensive care unit-related parental stress. Journal of Advanced Nursing 49 (6) 608-615

Linda S. Franck PhD RN RGN RSCN FRCPCH FAAN, Susanne Cox BA RGN RSCN, Alison Allen BSc RGN RSCN and Ira Winter MSc RGN RSCN

Metheny, N.A., Meert, K.L. and Clouse, R.E. (2007) Complications related to feeding tube placement. Current Opinion in Gastroenterology. 23(2):178-182, March 2007.

Monterosso, L., Kristjanson, L., Sly, P. et al (2005) The role of the neonatal intensive care nurse in decision-making: Advocacy, involvement in ethical decisions and communication.

International Journal of Nursing Practice. 11(3):108-117.

NPSA (2005) http://www.npsa.nhs.uk/nrls/alerts-and-directives/alerts/feedingtubes/

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