1. Lyman, Beth MSN, RN, CNSC, FASPEN
  2. Guenter, Peggi PhD, RN, FAAN, FASPEN

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Dear Drs Brandon and McGrath,


We would like to comment on a recently published article in the August 2018 issue of Advances in Neonatal Care, "Comparison of Neonatal Nursing Practices for Determining Feeding Tube Insertion Length and Verifying Gastric Placement With Current Best Evidence" by Leslie A. Parker et al.1 We agree with the authors that further research is needed to determine the best method for nasogastric tube (NGT) insertion length. We also agree that further research is needed for NGT placement verification in this population as our study showed that 61% of the pediatric patients requiring an NGT in our prevalence study were in a neonatal intensive care unit (NICU).2 However, until that research is completed and publishes, the use of the nose-ear-mid-umbilicus (NEMU) method for estimating insertion length and the use of pH to verify NGT placement are the best answers we have.


We want to recognize that the United Kingdom, Canada, and Australia have used pH for many years as their standard for NGT placement verification.3 While we do not have RCTs validating that this practice in the NICU is effective, we also do not have case reports indicating that the use of pH has been ineffective. While we wait for a large, multicenter RCT to be done, nurses need to stop using methods known to be unreliable-auscultation and/or aspiration with visualization of gastric contents.


We acknowledge that in the NICU population, data are lacking in this practice area, which prevents strong practice recommendations but given the serious/horrific outcome of an infant who is inadvertently fed into the lung,4 is it now wise to standardize care toward the use of the NEMU method for estimating insertion length and to pH to verify placement?5,6






Chair, NOVEL Project


Children's Mercy Kansas City, Kansas City, Missouri


Peggi Guenter, PhD, RN, FAAN, FASPEN


American Society for Parenteral and Enteral Nutrition


Silver Spring, Maryland




1. Parker LA, Withers JH, Talaga E. Comparison of neonatal nursing practices for determining feeding tube insertion length and verifying gastric placement with current best evidence. Adv Neonatal Care. 2018;18(4):307-317. [Context Link]


2. Lyman B, Kemper C, Northington L, et al Use of temporary enteral access devices in hospitalized neonatal and pediatric patients in the United States. JPEN J Parenter Enteral Nutr. 2016;40(4):574-580. [Context Link]


3. National Health Service. Resource set: Initial Placement Checks for Nasogastric and Orogastric Tubes. London, England: National Health Service; July 2016.[Context Link]


4. Visscher D. The story of a nasogastric tube gone wrong. Neonatol Today. 2018;13(7):12-15. [Context Link]


5. Lyman B, Peyton C, Lane B. Many hospitals still employ non-evidence based practices, including auscultation, creating serious patient safety risk in nasogastric tube placement and verification. Neonatol Today. 2018;13(7):3-11. [Context Link]


6. Irving SY, Rempel G, Lyman B, Sevilla WMA, Northington L, Guenter P; American Society for Parenteral and Enteral Nutrition. Pediatric nasogastric tube placement and verification: best practice recommendations from the NOVEL Project. Nutr Clin Pract. 2018;33(6):921-927. doi:10.1002/ncp.10189 [Context Link]