Evolution and Expansion of the UPMC Newborn Medicine Program's NG Tube Home Feeding Protocol

In late 2020, the UPMC Newborn Medicine Program introduced a new feeding initiative: discharging neonatal intensive care unit (NICU) patients home with nasogastric (NG) tubes. This program was a shift from the traditional requirement that infants must achieve full oral feeding before being discharged. Past protocols for NICU patients needing a nasogastric tube (NG tube) to facilitate feedings or act as a bridge to self-feeding dictated that they could not be discharged home until they could feed normally without the supplemental support of the NG tube. Sending patients home with an NG tube was viewed as too complex and fraught with the potential for complications, such as aspiration or misplacement of the tube during changes.

The rationale behind the new program was to enable medically stable infants, whose only holdup for discharge was a delay in full oral feeding, to continue their recovery in the comfort of their homes with their family and the support of home health care services and pre-discharge education and training.

The benefits to the infant and family of transitioning to recovery at home are multiple. They are in a more developmentally appropriate environment at home, an environment where they can experience greater consistency in care, often with only one or two caregivers. This consistency can facilitate improved oral feeding, as the infants receive more stable and familiar interactions away from the more disruptive climate that is inherently part of the NICU and its care operations.

Directing the program are Arcangela Lattari Balest, MD, assistant professor of Pediatrics and director of the Multidisciplinary Feeding Program within the UPMC Newborn Medicine Program, and John Ibrahim, MD, FAAP, assistant professor of Pediatrics, who is also the chair of the Golden Hour program and director of the POCUS program in the division.

Early Program Implementation and Successes

Initially launched in December 2020, the NG tube discharge protocol aimed to identify and support families who could safely manage NG tube feedings at home. 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.

Dr. Balest highlights the safety and readiness of both the infant and the family as the primary considerations for enrollment in the program.

"We are highly selective in determining which patients and families are most likely to succeed with this protocol and do so while meeting our rigorous safety requirements," says Dr. Balest. “NG tube feeding is and can be successfully accomplished at home, under the right circumstances and with well-selected and motivated participants.”

The initial implementation of the program saw promising results. The first four infants were discharged successfully without complications or adverse events related to the NG tube while at home. Three of the four infants transitioned to full oral feeding within an average of 25 days post-discharge. This early success laid the groundwork for the program's continued use, evolution and now expansion.

Programmatic Evolution and Early Metrics

Over the past three years, the program has significantly evolved, driven by continuous learning and adaptation. By mid-2024, 24 infants had been discharged through the NG tube home feeding protocol, with only one requiring a subsequent gastrostomy tube (G-tube) placement due to the complex nature of the child’s underlying condition and not because of difficulties with NG tube feeds at home.

"Since the program's inception, we have saved approximately 900 total days in the NICU for these patients,” says Dr. Balest. “The average time to full oral feeding for these infants has been approximately 34 days, with a range from two days to 172 days. We’ve also likely abrogated the need to surgically place G tubes for a significant number of these patients.”

Dr. Balest and colleagues are continuing to collect data on the program and are in process of data analysis for what will ultimately be a published study on the program and its outcomes.

Program Expansion and Adaptation

The program's success has spurred interest from other institutions and has led to plans for expansion. In the near future, the NG tube discharge protocol will be implemented in the NICU at UPMC Magee-Womens Hospital.

“We are anticipating a higher volume of eligible patients at UPMC Magee due to its patient population and its focus on premature infants without other significant complications,” says Dr. Balest.

One significant adaptation or evolution in the program has been the inclusion of infants as young as 40 weeks post-menstrual age.

“We are actively working to further reduce this threshold to 38 weeks,” says Dr. Balest. “This change is based on our growing confidence in the protocol's safety and the ability of families to manage NG tube feedings effectively at home.”

Working Through Program Challenges and Solutions

One of the initial challenges was ensuring adequate home health support for patients and families in rural areas or distant geographies where pediatric home care services are either limited or nonexistent. Dr. Balest and colleagues addressed this by leveraging remote visits and involving local pediatricians in routine weight checks and other assessments of the infant’s progress.

"Our comfort level with the program has grown, and we've found innovative ways to include more patients," says Dr. Balest.

Digital Health Care Tools Lead to a Transformation of Neonatal Care

Telemedicine and digital health care tools and strategies have been increasingly implemented to support families and enhance the program's reach. Given the large geographic region that the UPMC Newborn Medicine Program receives patients from, telemedicine provides a critical link to follow-up care for the families in the NG tube Home Feeding Program, and numerous other initiatives within the division.

"Leveraging telemedicine has facilitated ongoing communication between families and the medical team for infants discharged home with NG feeds," says Abeer Azzuqa, MD, associate professor of Pediatrics and who is the clinical director of the Neonatal Intensive Care Unit, UPMC Children's Hospital of Pittsburgh, associate vice chair of Clinical Affairs/Telehealth in the Department of Pediatrics, and medical director of Neonatal Telemedicine in UPMC Newborn Medicine Program. "It allows for remote monitoring of their progress. Families can communicate with the physicians and advanced practice providers from the Pediatric Gastroenterology division through the patient portal and have their follow-ups virtually via video visits. This innovative support enables infants to receive care at home while maintaining access to our subspecialists."

In June 2024, the program received a grant from the Magee-Womens Medical Staff Research and Education Funding Committee to purchase scales to give to families enrolled in the program discharged into areas without home health care services. This grant will further facilitate the ability to conduct telemedicine follow-up appointments with families.

“This grant will help us assist families with digital follow-up appointments so they can accurately measure their infant’s weight changes,” says Dr. Balest.

An Innovative Approach to Neonatal Care

The UPMC Newborn Medicine Program's NG tube home feeding protocol represents a significant advancement in neonatal care. By safely discharging infants with NG tubes to recover at home and progress to full oral feeding, the program has improved developmental outcomes, reduced health care costs, and set a new standard for neonatal care practices. As the program continues to evolve and expand, it holds promise for even greater impact on the care and development of fragile NICU patients.

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.

Meet the Multidisciplinary Feeding Program Team

Arcangela Lattari Balest, MD, 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, along with Abeer Azzuqa, MD, and John Ibrahim, MD. The team also includes occupational therapy colleagues Jamie Scheller, OTR/L, and Nicole Klasmier, CScD, OTR/L, speech pathologist Lynn Golightly, MSCCC-SLP, all of whom have been instrumental in championing the transition to infant-driven feeding approaches within the program. Victoria Powell, CRNP, a nurse practitioner in the Division of Pediatric Gastroenterology, conducts telemedicine and in-person follow-up visits to monitor infant weight gain and adjust feeding volumes as needed.

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.