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Providers' decisions largely depend on specific patient circumstance.

"If the patient is ill-appearing and intubated. I would want to decrease any risk of aspiration and go more transpyloric. If they seem to be more stable, then I would lean towards gastric."

"I feel like you kind of have to look at the patient individually. I know we have protocols in place that help us make that decision, but you have to look at the patient, what their history is, what predisposing conditions they have, were they feeding before, whatever incident brought them in. A lot of the heart babies weren't great feeders before. Look at what brought them to the hospital to see how safe it is to do gastric versus postpyloric."

"If they were stable and [in a] more "normal" state do gastric feeds, but if more critically ill would go more towards postpyloric."

Providers prefer to start patients on gastric feeds.

"I think there is a lot of concerns with gastric feeds that it will lead to aspiration, and I think those fears tend to be overstated. I think they're based on personal experience; I think the evidence is fairly clear that gastric feeding is best."

There are some reasons to start postpyloric feeds first.

"If it's CDH [congenital diaphragmatic hernia], then I expect the baby to have lots of issues with reflux and feeding, so then postpyloric. Any other patient-feed into stomach first."

"Patients with prolonged intubation or repeated intubation worry me a lot as well, these patients concern me to be fed gastric. I rather [the] safety margin of first feeding [a] kid postpyloric, and then switching to gastric if it is okay to do so."

Institutional culture plays a role in decision making.

"I feel like that's the way I was trained in the PICU. It becomes habit to lean toward postpyloric to decrease any risk of aspiration."

"If I practiced in Cardiac ICU, I would probably not gastric feed. Here [in the NICU] it seems gastric is default."

"I don't think it plays a role in mine; I do think it does for some people. In groups that always feed postpylorically first I think that's a cultural decision not based in evidence."

More research needs to be done on this topic and guidelines would be useful.

"The feeding decisions aren't consistent. It seems more provider-dependent and unit-dependent. It would be nice to have more evidence-based guidelines. We need more evidence-based medicine going into that decision."

"I think it's a good thought process. Just by doing this, I'm thinking about things I've never thought about before, but maybe I should. We have patients right now where it's a big deal trying to pick between one way or the other. [It] affects parents."

"I know the culture in all the units is very different in terms of feeding. Often can be strange for parents when they're used to one type of feed and then they go to another unit and it changes drastically. Some sort of consistency and consensus would be useful."

Variable viewpoints exist surrounding complication rates of each method.

"Neither results in more. Transpyloric feeds increase patients cost because you have to get imaging to make sure tube is in correct position, small risk of radiation."

"I don't think it makes a difference. We can theorize all day but no evidence."

"Transpyloric tubes need to be replaced a lot, could cause some discomfort for the patients. [There can be] delayed intro of oral feeds with transpyloric feeds due to fear of aspiration."

"I don't know if one causes more complication than the other. They both have their benefits and setbacks. In my experience it just depends on the situation."

"I don't think one causes more than the other. I have seen with postpyloric quite a bit of perforations and free air in abdomen. Have not seen any perforations with NG tubes."

"I think postpyloric. Makes your patient feel hungry, oftentimes patients tube fed are on respiratory support, so [when] not feeding in the stomach they feel hungry all the time. Have to use more sedatives and analgesics to make them comfortable. Main complication is that you're making your patients miserable."

Feeding with a gastric tube initially may result in a better feeding situation on discharge.

"[For] babies that have already had stuff in [their] stomach, it's easier to transition them to be able to tolerate bolus feeds directly into the stomach. Some of the babies we've had on transpyloric feeds for a really long time, aside from the weight issues, we sometimes struggle getting them to tolerate feeds by mouth. So, I think the initial gastric, typically from my experience, leads to better situation at discharge."

"I don't think initial method affects situation at discharge. You progress one way or the other. It may take longer to start with continuous postpyloric and get to oral, but ultimately you can get to the best for that patient either way."