Neonatal Feeding Program Update: Early Successes Of NG Tube Discharge Protocol Shows Promise

Until recently in the UPMC Newborn Medicine Program, neonatal intensive care unit (NICU) patients requiring a nasogastric tube (NG tube) to facilitate feedings or act as a bridge to self-feeding could not be discharged home until they could feed normally without the supplemental support of enteral feedings via NG tube. 

In the past, sending patients home with an NG tube to be cared for and maintained by their parents or caregivers was seen as too complex and fraught with the potential for complications, such as aspiration, misplacement of the tube during changes, or suboptimal nutrition.

However, keeping some patients in the hospital when they could be discharged except for their temporarily requiring an NG tube was seen as detrimental for both the patient and family. Some of these patients are such that with close support, training provided for the family, and the added support of home nursing services, they may theoretically leave the hospital and continue their convalescence and development in the comforting surroundings of their home without adverse outcomes.

“For these patients, we know they will do better medically, developmentally, and in terms of comfort if they can be at home with their families. This was our rationale for developing our NG tube discharge protocol and it is what drives our work to find as many babies and families as possible that can benefit,” says Arcangela Lattari Balest, MD, who serves as the director of the Multidisciplinary Feeding Program within the UPMC Newborn Medicine Program.

The new NG tube discharge protocol went into effect in December 2020. 

Protocol Detail Highlights

Above all other concerns, the one factor that ultimately determines whether or not an individual patient and family can be discharged home with an NG tube is safety. 

“We are highly selective in determining which patients and families are most likely to succeed with this protocol, and do so while meeting our safety requirements,” says Dr. Balest.  “Parents and caregivers must be fully committed to the learning process and the work that will be required once they get home with their infant. Our screening procedures and assessments of patient and family readiness are extensive. We leave nothing to chance.”

Another key component of the program is that eligibility for the NG tube discharge protocol is independent of the underlying condition (e.g., neurological conditions, congenital heart disease) or the patient’s reason for being in the NICU. There are currently no exclusionary conditions that would preclude an infant from the protocol, except if there is some form of craniofacial anomaly that makes it impossible to place an NG tube. 

The majority of the reasons a case may not meet eligibility criteria fall into questions of commitment from the parents, their available resources for support, or their physical or emotional ability to care for their infant with an NG tube, and other requirements. 

For example, because home health visits from a visiting nurse are essential for patient monitoring and family support, individuals that live in a distant or isolated geography with minimal or no home health care services available to them are excluded from the protocol.

“Our protocol entails very close follow-up support from home nursing services, case management, and the patient’s NICU team working in collaboration with the family to ensure the safety, security, and well-being of the baby,” says Dr. Balest.

Infants must also pass an eight-point check list for inclusion in the protocol with criteria including tolerating bolus feedings, post-menstrual age greater than 42 weeks, and demonstration of adequate growth on enteral feeding.

Initial Case Examples and Successes

Since the beginning of the program, the Multidisciplinary Feeding Program has discharged four patients through the NG tube home feeding protocol with successful outcomes in all four cases and no discernible complications or adverse events.

The first case through the protocol was a premature infant delivered at 26-27 weeks gestational age and who also had an underlying genetic disorder. As Dr. Balest explains, this particular infant also had a history of necrotizing enterocolitis and struggled significantly with oral feeding. The family was highly motivated to avoid having to place a gastrostomy tube (G Tube), which would have required anesthesia and surgery. This made for an excellent candidate to take part in the NG tube home discharge protocol.

Another case through the protocol was a referral from an outside institution for a difficult feeding case in which a G Tube was being considered because of the infant’s feeding challenges that were hypothesized to be due to oral aversion.

Not only was the Multidisciplinary Feeding Program team able to avoid having to place a G Tube in this case and avoid its accompanying surgical intervention, they were able to assess the infant’s feeding needs, teach the family strategies to make feeding less stressful for this baby, and discharge them home in the new NG tube home feeding program after three weeks in the NICU.

With the first four cases through the program, all of the infants were able to transition to full oral feeding in less than 25 days post-discharge. None of the four infants had to be readmitted to the hospital for feeding concerns, nor were there any adverse events that required emergency medical care related to the NG tubes. Growth and food intake levels all progressed according to set plans by the medical teams caring for the infants. 

Upcoming Abstract Presentation

Dr. Balest and the team of collaborators responsible for developing and managing the new NG tube discharge protocol will be presenting an abstract about their developmental work and initial experiences with the first four cases at The Children’s Hospitals Neonatal Consortium annual symposium in November 2021. 

More About The Multidisciplinary Feeding Program of the UPMC Newborn Medicine Program

The Multidisciplinary Feeding Program has evolved its approach to one based largely on the concepts of infant-driven or cue-based feeding, moving away from more traditional quantity-based measures of feeding success. The evolution of the program began in earnest more than five years ago and has included numerous programmatic changes and quality improvement initiatives to improve infant feeding success, safety, and patient and family satisfaction. The multidisciplinary approach of the program combines the expertise of neonatal physicians and nurses, occupational and speech-language pathologists, gastroenterology specialists, and other disciplines to optimally manage the challenges associated with feeding difficulties in fragile NICU patients.

Arcangela Lattari Balest, MD, a neonatologist and feeding specialist in the Division of Newborn Medicine, and Sheryl Rosen, MA, CCC-SLP, dysphagia lead for the program, have helped to spearhead many of the changes and evolution of feeding practices for NICU babies at UPMC Children’s Hospital of Pittsburgh and UPMC Magee-Womens Hospital. Other members of the team, including occupational therapy colleagues Jamie Scheller OTR/L, and Nicole Klasmier, CScD, OTR/L, and speech pathologist Lynn Golightly, MS,CCC-SLP,  have been instrumental in championing the transition to infant-driven feeding approaches. The combined collaborative efforts of the team during the last several years has fundamentally reshaped and improved the approach to infant feeding in the UPMC Newborn Medicine Program.