Received: 29 July 2020 Revised: 19 November 2020 Accepted: 23 November 2020

DOI: 10.1002/jcu.22958

TECHNICAL NOTE

Ultrasound-guided nasogastric tube placement in a pediatric

emergency department

Takaaki Mori MD, MRCPCH, MSc1 | Hirokazu Takei MD1 | Takateru Ihara MD1 |
Yusuke Hagiwara MD, MPH1 | Osamu Nomura MD, MA, PhD1,2

1
Division of Pediatric Emergency Medicine,
Department of Pediatric Emergency and Abstract
Critical Care Medicine, Tokyo Metropolitan Nasogastric tube (NGT) insertion is commonly performed in pediatric emergency
Children's Medical Center, Tokyo, Japan
2 care. Point-of-care ultrasound is used for confirming NGT insertion, but reports of its
Department of Emergency and Disaster
Medicine, Hirosaki University, Hirosaki-shi use in the pediatric emergency department (ED) are scarce. We describe our experi-
Aomori, Japan
ence of ultrasound-guided NGT placement in a pediatric ED. The study pool con-
Correspondence sisted of twelve patients and the NGT tip was successfully visualized in the
Takaaki Mori, MD, MRCPCH, MSc, Division of
esophagus and gastric cardia in all cases, demonstrating that ultrasound has the
Pediatric Emergency Medicine, Department of
Pediatric Emergency and Critical Care potential to be a useful alternative to conventional methods of NGT insertion in
Medicine, Tokyo Metropolitan Children's
the pediatric ED.
Medical Center, 2-8-29 Musashidai, Fuchu,
Tokyo 183-8561, Japan.
Email: takaakimori001019@gmail.com KEYWORDS

Ultrasound-guided procedure, nasogastric tube placement, pediatrics, esophagus

1 | I N T RO DU CT I O N series aimed to describe the use of US-guided NGT placement in

Nasogastric tube placement (NGT) is commonly performed in
pediatric emergency care for gastric decompression, enteral feed-
ing, and drug administration.1 Nonetheless, it can be associated
with serious complications. 2 A study showed that the rate of
NGT misplacement was around 2% in more than 2000 cases.3
Another study conducted in a neonatal intensive care unit (NICU)
showed that the feeding tubes were wrongly placed in over half
the cases.4 Radiography is currently the reference standard for
confirming NGT insertion5 despite the availability of several other
methods, including auscultation, capnography, observation of gas-
tric aspiration, and gastric pH monitoring. The American Society
for Parental and Enteral Nutrition (ASPEN) proposed a consensus
recommendation on a method of confirming of NGT placement
using a combination of these techniques.6 However, the uncer-
tainty of the techniques, possible misinterpretation of radio-
graphic findings, and concern about radiation exposure continue
to make the usefulness of this recommendation in routine clinical
practice controversial.6 While point-of-care ultrasound (POCUS)
7
is currently used to confirm NGT insertion, especially in adults
and pre-hospital patients,8 reports of its use in the pediatric
emergency department (ED) are still scarce.9-12 The present case
a pediatric ED setting.
2 | METHODS
2.1 | Study design and patient enrollment
The present retrospective case-series study enrolled patients who
underwent POCUS for NGT placement at Tokyo Metropolitan
Children's Medical Center between January 2018 and March 2020.
The medical records of patients younger than 16 years who under-
went POCUS for confirmation of NGT placement were reviewed
using the search terms, “ultrasonography,” “point-of-care ultrasound,”
and “nasogastric tube placement.”
2.2 | Setting
Tokyo Metropolitan Children's Medical Center has a pediatric popula-
tion of almost half a million and each year, about 38,000 children visit
our ED. All patients are initially evaluated by pediatric residents under
the supervision of board-certified pediatricians or emergency

J Clin Ultrasound. 2020;1–4. wileyonlinelibrary.com/journal/jcu © 2020 Wiley Periodicals LLC 1

2 MORI ET AL.

physicians. Patients in critical condition are evaluated by emergency

physicians.

2.3 | Ultrasound-guided nasogastric tube

placement

The procedure was performed by three pediatric emergency physi-

cians (MT, TH, and NO) who completed the pediatric emergency US
course certified by the World Interactive Network Focused on Criti-
cal Ultrasound (WINFOCUS) and had several years of experience F I G U R E 2 Transverse sonogram of the anterior neck shows the
using pediatric emergency US. US was performed using a M-Turbo 10-Fr NGT as a hyperechoic structure (yellow circle) with a
reverberation artifact in the esophagus located to the left of the
scanner (FUJIFILM, SonoSite Inc, Japan) with a 6 to 13 MHz linear
trachea. CCA, common carotid artery; IJV, internal jugular vein
transducer and a 2 to 5 MHz convex transducer or a LOGIQ e scan-
ner (GE Healthcare, Wauwatosa, WI) with a 8 to 13 MHz linear and
a 1.5 to 4 MHz convex transducer. The patients were placed in a
supine position, and the transducer was placed transversely on the
anterior neck just below the cricothyroid membrane (Figure 1). Nor-
mally, the trachea is visible in the center of the field while the esoph-
agus is usually visible in the left paratracheal space.13 The trachea
forms a semi-circular, hypoechoic structure with a reverberation
artifact from the air-mucosa interface. The esophagus appears as a
round structure with several concentric layers. If the NGT is present
in the esophagus, a hyperechoic structure is visible in the esophagus
(Figure 2).
The transducer was then placed longitudinally in the subxiphoid
region slightly left of the midline (Figure 1). Normally, the gastric car-
F I G U R E 3 Sagittal sonogram of the subxiphoid region shows the
dia is visible between the liver and the abdominal aorta as a round
NGT tip as a hyperechoic structure (arrows) entering the gastric cardia
shape with multiple, concentric layers. When the NGT passes through posterior to the liver and anterior to the abdominal aorta (see also
the gastric cardia, a hyperechoic structure appears in the region, Video S1)

(Figure 3) and the movement of the NGT entering the cardia can be
dynamically observed (Video S1). The two operators evaluated the
patient outcome after the procedure. The presence of the NGT tip
was confirmed by radiography in accordance with the consensus
guidelines of our hospital.

2.4 | Data collection

An abstractor (MT) collected data on age, gender, body weight, under-

lying diseases, diagnosis, indications for NGT placement, size and
insertion length of the NGT, and patient outcomes from the medical
records.

2.5 | Ethical considerations

This study was conducted in accordance with the Declaration of Hel-

F I G U R E 1 POCUS protocol. The anterior neck (1) was first sinki (2013) and the Institutional Review Board of our hospital
scanned, then the subxiphoid region (2) was examined (2019-b74), which allowed us to waive informed consent.
MORI ET AL. 3

T A B L E 1 Patient characteristics of the 12 cases of US-guided nasogastric tube placement. The esophagus was located to the left of the
trachea in all cases, and all NGT placements were done for gastric decompression

Age Weight Underlying NGT Insertion

Patients (years) Gender (kg) diseases Diagnosis size (Fr) length (cm) Complications
1 0 Female 4 None Bronchiolitis 8 34 None
2 0 Female 4 None Bronchiolitis 8 28 None
3 0 Female 5 None Subdural 8 20 None
hematoma
4 0 Female 6 None Bronchiolitis 8 20 None
5 0 Male 6 Intestinal atresia Pneumonia 8 30 None
6 0 Male 7 None Status epilepticus 8 30 None
7 1 Male 8 West syndrome Status epilepticus 8 34 None
8 0 Male 9 None Status epilepticus 10 35 None
9 1 Male 11 None Status epilepticus 8 37 None
10 1 Male 12 None Status epilepticus 10 40 None
11 5 Female 20 None Status epilepticus 12 45 None
12 11 Male 30 None Traumatic neck 12 55 None
injury

2.6 | Statistical analysis
Statistical analyses were performed using SPSS statistical software,
version 18.0 (SPSS Inc, Chicago, Illinois). Summary statistics were
presented as the median with interquartile range (IQR).
3 | RESULTS
The study pool consisted of twelve patients with the median age of
9.5 months (IQR; 2–18 months), with males representing 58.3% of the
total (Table 1). The median body weight was 7.5 kg (IQR;
5.3–11.8 kg). One patient had West syndrome and another patient
had intestinal atresia as an underlying disease. The most prevalent
diagnosis was status epilepticus (six cases) followed by bronchiolitis
(two cases). An 8-Fr NGT was inserted in eight patients, and a 10-Fr
and 12-Fr NGT were used in two patients each. In all the patients, the
esophagus was situated to the left of the trachea. The procedure was
performed by TH in ten patients and by TM and NO in one patient
each. In all the cases, a hyperechoic structure suggesting an NGT was
visible in the upper esophagus and the gastric cardia although
the reflux of gastric contents in the proximal NGT was not visible. All
the procedures were successful and there were no complications. The
outcome measures of the patients were assessed by the operators
until the patients were discharged.
4 | DISCUSSION
14
The introduction of US into acute care procedures has led to its use
in confirming NGT placement in adult patients7 as well as in the pre-
hospital setting.8 A Cochrane review demonstrated that the sensitivity
and specificity of US for confirming NGT placement in adults was
91%–98% and 56%–100%, respectively.15 Previous studies used a US
scan of the neck or epigastrium or a combination of both.15 In the cur-
rent study, the combination method was used to enhance the accu-
racy of the procedure.
Reports of US use in pediatric patients are scarce; only a few
articles and two case reports have been published on this topic.9-12
A study conducted in a pediatric intensive care unit showed a sensi-
tivity of 100% for NGT placement confirmation, but the procedure
was performed by radiologists.9 One study suggested that US was
unsafe for confirming NGT placement in neonates11 whereas
another prospective study conducted in a neonatal intensive care
unit demonstrated a sensitivity of 92.2% for US performed by criti-
cal care physicians.10
To the best of our knowledge, the present study is the first case-
series study demonstrating the experience of ultrasound-guided NGT
placement by a pediatric emergency physician in a pediatric
ED. Hitherto the effectiveness of this procedure had not been evalu-
ated in a pediatric emergency setting. Furthermore, the quality of the
procedure is often operator-dependent, and a certain amount of train-
ing is required to obtain an adequate image.16 As the ASPEN currently
recommends a mixed approach for NGT confirmation, including aspi-
ration, pH monitoring, and radiography,6 in the present case-series
radiography was used in accordance with the consensus guidelines of
our hospital although this was not required.
US is a real-time, non-invasive, non-ionizing procedure which can
lower children's lifetime risk of malignancies due to radiation expo-
sure.17 The procedure is also highly effective due to its rapidity espe-
cially in cases where other confirmation methods are not immediately
available, such as in patients requiring resuscitation or those in a pre-
hospital setting. Although further investigation is needed to determine
the optimal manner and length of training needed to perform the
4 MORI ET AL.
procedure, the current study demonstrated that a pediatric emer-
gency physician was able to perform US to confirm NGT placement.
There are several limitations to this study. First, the present case
series was a non-blind chart review; the procedure was performed by
three emergency physicians (MT, HT, and NO), one of whom
(MT) reviewed the data. Thus, information bias in data abstraction cannot
be excluded. Second, the similarity in the demographic data of almost all
the patients may limit the generalizability of our findings. The patients
were chosen to undergo US-guided NGT placement by the physicians
who performed the US; thus, selection bias may have occurred in
selecting patients, who were able to be treated easily or were more ame-
nable to the procedure. Third, follow-up and monitoring for long-term
complications were not performed. However, none of the study patients
returned to our ED due to any complications of the procedure. A larger,
prospective study is required to overcome these limitations.
DATA AVAI LAB ILITY S TATEMENT
The data that support the findings of this study are available on
request from the corresponding author. The data are not publicly
available due to privacy or ethical restrictions.
ORCID
Takaaki Mori https://orcid.org/0000-0003-0824-3632
Osamu Nomura https://orcid.org/0000-0003-1296-1768
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SUPPORTING INF ORMATION
Additional supporting information may be found online in the
Supporting Information section at the end of this article.
How to cite this article: Mori T, Takei H, Ihara T, Hagiwara Y,
Nomura O. Ultrasound-guided nasogastric tube placement in a
pediatric emergency department. J Clin Ultrasound. 2020;1–4.
https://doi.org/10.1002/jcu.22958