Abstract
INTRODUCTION: Nasogastric (NG) tubes are commonly used in hospitalized infants and children to provide nutrition and medications. Although clinical protocols emphasize the importance of confirming placement and tube patency, they pay less attention to the mechanical limits of NG tubes and the risks of fracture or rupture. Inconsistent guidance regarding tube care may contribute to preventable harm, particularly in the techniques used to clear obstructions. METHODS: We presented a case of a newborn who experienced irreversible harm following an NG tube fracture or rupture. This event prompted a multidisciplinary review and simulated evaluation of NG tube performance using varying syringe sizes to mirror common bedside practices. RESULTS: Simulation testing demonstrated that small-volume syringes, particularly 1-3 mL, can generate pressures high enough to balloon or rupture NG tubes. In contrast, larger syringes (≥30 mL) did not cause damage, even under maximum force. At the time of these events, manufacturer instructions did not provide pediatric-specific guidance regarding syringe selection, and local protocols additionally lacked specific recommendations. The size of the syringe selected may have contributed to tube fracture, esophageal rupture, and subsequent patient death. CONCLUSIONS: This case highlighted a safety gap in pediatric NG tube care, stemming from device performance and inconsistent instructional guidance. Improved alignment between manufacturer instructions and clinical resources, as well as pediatric-specific safety protocols, is essential to prevent similar events.