The oesophagus, stomach and small bowel in newborns and young children is much thinner and more fragile making it more susceptible to damage from NG tube insertion. A delicate, careful technique with a high index of suspicion for malposition and upper gastrointestinal perforation is essential. 

Top tips for avoiding harm include: 

o   Appropriate length by determining the expected length prior to insertion 

         (NEX - measure tip of Nose to the Earlobe, then nose to Xiphisternum) 

o   pH of aspirate is less than 5.5 immediately after insertion 

o   Confirm position with x-ray if in doubt 

Key complications include: 

Ultrasound guidance has been shown to reduce morbidity, with landmark-guided attempts carrying higher complication rates and longer operative time (5). Utilise ultrasound to select appropriate vessel and guide insertion. Communication with anaesthetics throughout the procedure is vital in order to confirm cardio-respiratory stability. If any acute changes occur - reassess line position with imaging. If there are any concerns – escalate. Things can change quickly. 

Ensure fastidious asepsis is employed by using a maximum sterile barrier – mask and sterile gloves, gown, drapes. Follow your local protocols for handling of the line during insertion, fixation and dressings. Placing a loop on the external aspect of the line can reduce the risk of it becoming displaced if it is pulled on! 

 Multiple magnets can trap bowel between them causing rapid pressure necrosis and perforation – management is time critical. A rise in presentations following magnet ingestion in children led to release of national guidance in 2021 (6). 

Neonatal and infant skin is fragile and much more susceptible to burns from alcohol-based skin preparation fluid and diathermy plate burns in the event alcohol-based fluid makes contact with the diathermy during the operation. Appropriate selection of prep solution is essential, as is ensuring time for prep to dry and making sure it is not pooling or in contact with the plate. Adhesive diathermy pads can also damage fragile paediatric skin if not handled carefully. Careful placement and removal of the adhesive diathermy plate helps to avoid skin damage and the use of a diathermy gel where possible can further reduce this risk as the adhesive pad is not required.  

A diligent NIPE by a trained healthcare practitioner is essential in avoiding missed congenital anomalies. The national NIPE programme is specifically intended to screen for congenital heart disease, congenital cataracts, developmental dysplasia of the hips and cryptorchidism. In addition, a full and thorough examination of every newborn is vital in order to identify other anomalies such as cleft palate, hypospadias and anorectal malformations. Missing such diagnoses in the newborn can have a significant impact on both the child and their family (9). 

Anorectal malformations are an important example of this in paediatric surgical practice. A recent population-based cohort study of patients with anorectal malformations found 22% of neonates had a late diagnosis and 7% received a diagnosis after 30 days of age in the UK and Ireland (7). Key factors contributing to late diagnosis were female gender and presence of a perineal fistula.  

Top Tips: 

In general, when performing a NIPE, if there are any concerns about an abnormality - escalate to the appropriate speciality early. 

Normal observations vary according to age. For clinicians in paediatric practice, reference to the age-appropriate PEWS is vital in clinical assessment and can aid early identification of the deteriorating child. If a raised PEWS is highlighted – don’t ignore the numbers. Action is required. 

Of note, the updated PEWS includes parent/carer concern in the scoring system – a valuable aspect of patient assessment which must be considered alongside a child’s clinical observations (8). It is vital to also consider scenarios when clinical observations are normal on paper but there is still concern ie. we must not rely on the numbers alone. 

The format of the World Health Organisation (WHO) surgical safety checklist varies between centres, so it is important to be familiar with your local guidance. These are some important factors to consider in Paediatric practice: 

Small children are vulnerable to dehydration and hypoglycemia with prolonged nil-by-mouth (NBM) time. Newborns are particularly at risk and children with complex comorbidities may also have more limited metabolic reserves. There can, in addition, be psychological consequences to prolonged fasting as children are less able to rationalise being NBM and become distressed by hunger and thirst (10). Points to consider: 

This is an inherent ethical issue in healthcare for children and represents a key patient safety concern when appropriate moral and legal processes are not followed. There is not only the potential harm of undergoing a procedure/treatment, but also the psychological harm of undergoing an intervention the child may not agree to and the possibility of later regretting decisions made on their behalf. 

Additionally, some children may wish to speak to health professionals without their parent/guardian being present and may be able to make their own decisions about their care. Each case requires an individual approach and an appreciation of the available guidance and legislation. If there are uncertainties regarding the correct processes to follow, escalation to the child’s consultant should occur. 

Important considerations: 

 References