Nasoduodenal or naso‐jejunal tube feeding is commonly used as a short‐term option in children with risk of pulmonary regurgitation due to severe gastroesophageal reflux, gastroparesis, acute pancreatitis or as a bridge to nutritional therapy before surgery or nutritional support for critically ill children with various conditions in intensive care units.

An enteral tube may be placed endoscopically if other options such as spontaneous passage or installation under fluoroscopy with the use of a radiopaque guidewire have failed.

After the appropriate tube is chosen, a small loop at the tip of the tube should be created using a silk suture. The tube is inserted into the stomach via the nose, followed by the endoscope. The tube may be found either conveniently positioned along the greater curvature of the stomach oriented toward the antrum or coiled in the gastric body. In the second scenario, it is pulled back until the tip becomes visible.

The next step is grasping of the silk loop by the single‐use preloaded rotatable two‐pronged hemostatic clip device and pulling the loop back into the biopsy channel until the end of the tube gets close to the tip of the endoscope. Then, the endoscope is maneuvered through the pylorus into the distal duodenum or proximal jejunum in a standard fashion. The hemostatic clip is advanced forward a few centimeters and attached to the mucosa, preventing accidental ejection of the tube during the withdrawal phase of the procedure (Figure 36.1). Finally, the endoscope is pulled back to the stomach in a twisting fashion to decrease friction between the shaft and the feeding tube. The excess portion of the feeding tube is slowly retracted, leaving a small loop within the stomach. A postprocedure flat abdominal film confirms the appropriate position of the feeding tube.

A similar technique can be used for placement of a gastroduodenal or gastro‐jejunal feeding tube in children with an established gastrostomy. The only difference is the introduction of the feeding tube into the stomach through the existing gastrostomy.

Alternatively, naso‐jejunal intubation can be performed with an over‐the‐wire method. First, the distal duodenum or proximal jejunum is intubated during an upper endoscopy. Then, a lubricated Teflon®‐coated guidewire is fed through the biopsy channel and advanced under direct visualization beyond the tip of the scope until it meets resistance. Using a pull‐push or “exchange” technique, the endoscope is slowly withdrawn while the guidewire is simultaneously threaded through, so that it stays in a fixed position in the intestine. A soft lubricated tube is advanced into the oropharynx through the nose and blindly removed from the mouth using the index finger or a plastic grasper. A guidewire is fed into the tube and advanced until it becomes visible. The protective tube is removed. Before insertion of the enteral tube, then the course of the wire is studied under fluoroscopy and adjusted to ensure that there are no coils or loops within the gastric body. A lubricated naso‐jejunal tube is advanced along the guidewire into the distal duodenum or proximal jejunum. Once the position of the tube within the distal duodenum or proximal jejunum is confirmed, the guidewire is removed.

For some school‐age children and teenagers, a transpyloric insertion of the guidewire can be achieved during transnasal endoscopy with an ultra‐slim endoscope.