Question: I have been searching through your publications and have not been able to find this answer and I am curious if you could help me. I have been getting questions regarding our swallow study process and the validity of a swallow study when a baby has an NGT. Our physicians are questioning if we need to complete a swallow study with and without an NGT. Is this necessary? Thank you for your support and all the great work you do!”
Catherine’s Answer:
I think the key considerations would include:
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Having the feeding “environment” for the VFSS the same as the typical feeding environment or you add an artifact to the data set. So if there is an indwelling NGT, that is the typical feeding environment for that infant. If the NGT is to be removed in a few days and “no NGT in situ” will be the typical feeding environment, then that would be a reason to objectify physiology without the NGT in situ. But that would be an unlikely plan if we are going to radiology.
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Observing under both conditions increases radiation exposure which we know the AAP advises against unless we expect new data
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Recognizing that most preterms are PO feeding with an NGT in situ for a period and they still progress to full PO. It in and of itself does not appear to be a variable adversely affecting progression. It’s not typically the indwelling NG tube that is the problem, it’s the impact of the infant’s unique comorbidities (based on research about co-morbidities) affecting the swallow-breathe interface.
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We have no data that I am aware of in an RCT regarding this question specific to the NICU. The only citations I know of are below. Edwards et al (7 DOL to 13 years) does not even look at the etiology for the aspiration events so we cannot conclude that the NGT being in situ was “causal” — only that it was a “co-occurring” variable in this cohort. I think the conclusions are not warranted. The distinction between what is “causal” and what is “co-occurring” is rooted deeply in medicine — and should be with our differentials as well.
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My clinical wisdom over almost 40 years in Level III and level IV NICUs suggests as a guideline we leave the NGT in during the VFSS. The pathophysiology witnessed has never appeared to me to be related to the effect of the NGT but rather to other factors, often related to infant’s unique history and comorbidities.
Relevant references~
- Alnassar, M., Oudjhane, K., & Davila, J. (2011). Nasogastric tubes and videofluoroscopic swallowing studies in children. Pediatric radiology, 41, 317-321. Quoted Summary: The presence of a nasogastric tube does not alter the findings of VFSS; however, it might increase the incidence of respiratory compromise when aspiration is present.
- Edwards, S. T., Ernst, L., Sherman, A. K., & Davis, A. M. (2020). Increased episodes of aspiration on videofluoroscopic swallow study in children with nasogastric tube placement. Plos one, 1 Quoted Results: Sixty-three children with NG tubes were identified, along with 63 age and sex matched children without NG tubes in place, at the time of VFSS. Ages ranged from 7 days to 13 years. The NG group had a significantly higher proportion demonstrating aspiration (46% vs. 23.8%, p = 0.0089). Quoted Conclusions: This study supports the need for further prospective evaluation of NG tubes and their effect on swallow, as well as more careful consideration of prolonged NG tube placement in patients with feeding problems. Consideration should be given to removal of the NG prior to VFSS to prevent the impact of NG placement on results of the swallow study which could lead to inappropriate modifications to the patient’s care plan.