A guide to the management of common gastrostomy and gastrojejunostomy tube problems

Gastrostomy (G) and gastrojejunostomy (GJ) tubes are commonly used to enhance nutrition and hydration, and facilitate the administration of medications to children with medically complex conditions. They are considered to be safe and effective interventions for the medical management of these patients; however, they are not without risks. There are common complications associated with G and GJ tubes. Health care providers play an active role in preventing, managing and supporting the patient and parents/caregivers in dealing with these complications. The present article reviews G and GJ tube devices, basic care principles, and how to prevent and manage common complications. Recommendations for how to support and share information with parents/caregivers is provided.     

滴服喂养和胃管喂养在极低出生体重儿中的应用

目的探讨喂养方式对极低出生体重(VLBW)婴儿生长发育及疾病康复的影响。方法将48例VLBW婴儿随机分成观察组和对照组。观察组23例,滴服喂养;对照组25例,胃管喂养。观察开始经奶头喂养时间、达全口喂养时间、胎粪排出时间、不良反应、并发症、光疗情况、奶量增加、体重增长和住院天数。结果与对照组比较,观察组开始经奶头喂养时间、达全口喂养时间、胎粪排出时间、累计光疗时间和住院日短,并发症发生率低,不良反应没有增加,奶量增加和体重增长快。结论滴管喂养适用于有吞咽功能的VLBW婴儿,能够充分满足生长发育所需能量,增强机体抗病力,缩短平均住院日,减少住院并发症,从而减轻患儿家属经济负担。     

滴服喂养和胃管喂养在极低出生体重儿中的应用

目的探讨喂养方式对极低出生体重（VLBW）婴儿生长发育及疾病康复的影响。方法将48例VLBW婴儿随机分成观察组和对照组。观察组23例，滴服喂养；对照组25例，胃管喂养。观察开始经奶头喂养时间、达全口喂养时间、胎粪排出时间、不良反应、并发症、光疗情况、奶量增加、体重增长和住院天数。结果与对照组比较，观察组开始经奶头喂养时间、达全口喂养时间、胎粪排出时间、累计光疗时间和住院日短，并发症发生率低，不良反应没有增加，奶量增加和体重增长快。结论滴管喂养适用于有吞咽功能的VLBW婴儿，能够充分满足生长发育所需能量，增强机体抗病力，缩短平均住院日，减少住院并发症，从而减轻患儿家属经济负担。     

The parental experience and perceptions of blenderized tube feeding for children with medical complexity

ObjectivesParents of children with medical complexity are often expected to implement complicated plans of care, such as enteral tube feeding, to support the health of their child. Enteral feeding can have psychosocial implications for the parent, child, and family. Blenderized tube feeding (BTF) refers to the administration of pureed food and drinks through a feeding tube. Little is known regarding parents’ experiences with BTF. Therefore, the purpose of this qualitative study was to understand the lived experience of BTF from the parent’s perspective.MethodsThis qualitative study was a grounded theory analysis utilizing semi-structured interviews of parents who provided at least 50% of their child’s diet through BTF. Participants were recruited using purposive sampling from the Complex Care Program at a tertiary care paediatric centre. Interviews were conducted until thematic saturation was achieved. Themes were identified using constant comparative analysis of transcribed interviews.ResultsParents (n=10) felt that BTF positively affected the experience of tube feeding and enhanced their child’s health and wellbeing. Parents described BTF as a means of self-empowerment and a mechanism to normalize feeding and care for the entire family. Despite reporting BTF as more time consuming than formula feeding, all parents were satisfied with having made the change, and planned on continuing the diet.ConclusionBTFs can improve the experience of tube feeding and positively address some of the negative psychosocial implications of enteral tube feeding, providing a sense of normalcy and control for parents caring for a child with medical complexity.     

Aseptic sialadenitis in preterm infants associated with long-term oro-gastric tube feeding

Sialadenitis is a rare disease in the newborn and the pathogenesis in this age group is not fully understood. We report five cases of neonatal sialadenitis in stable preterm, gavage-fed infants at 2 to 6 weeks postnatal age. The occurrence of sialadenitis was observed in temporal relation to changes in enteral feeding routines in the unit which were initiated with the objective of promoting full breast feeding at discharge. Clinical presentation consisted of a tender palpable mass over one of the salivary glands, low-grade (37.5–38.3°C) fever in conjunction with clinical malaise. C-reactive protein and white blood cell count were only moderately elevated. No suppuration from salivary ducts was present. Bacterial cultures were invariably negative. Viral investigations were not carried out. Aseptic sialadenitis was suggested as the cause of the symptoms. The clinical course was benign and the local tender mass over the salivary gland vanished shortly after intravenous fluids and antibiotics were started. Conclusion Long-term exclusive oro-gastric feeding may result in reduced reflex salivary gland stimulation, saliva production and hence ductal clearance of mucoid saliva, leading to functional ductal obstruction and local inflammation.     

Current trends in paediatric enteral tube feeding

The demand for enteral tube feeding in children is increasing globally. As our ability to manage complex medical conditions improves, so too does our understanding of the benefits of good enteral nutrition on health outcomes for these children. If oral feeding is not possible, an enteral tube can provide a viable alternative by delivering nutrition directly into the stomach or jejunum. The decision to recommend a child for long term tube feeding is complex and needs to be balanced against the potential risks. It is therefore essential that healthcare professionals keep up to date with the indications for referral, understand the current options available to children, and are able to identify common and serious problems that can arise following tube insertion. Healthcare professionals should also be aware of the debate surrounding the administration of blended feeds via the enteral tube. While some children may benefit from this practice, there are important considerations to be made for children receiving home blended feeds versus enteral formula. In this article, we review the indications for enteral tube insertion, device selection, complications and subsequent management. In addition, we review the logistics and implications for families and healthcare teams aiming to start blended tube feeding.     

Small-bowel intussusception around a gastrojejunostomy tube resulting in ischemic necrosis of the intestine

Gastrojejunostomy (GJ) tube feeding has made a significant difference in the lives of children with oropharyngeal motor problems and severe gastroesophageal reflux disease. It may, however, also lead to small-bowel intussusception. Previously, these intussusceptions have been reported as intermittent, self limiting, and innocuous. We report a case of a GJ-tube-related small-bowel intussusception that resulted in ischemic necrosis of the bowel. This case suggests that close monitoring and confirmation of successful reduction is necessary in the treatment of GJ-tube-related small-bowel intussusception.     

Feeding problems,growth and nutritional status in children with cerebral palsy

Aim: The aim was to estimate the prevalence of feeding and nutritional problems in children with cerebral palsy (CP) in Norway. Methods: Data were abstracted from the Norwegian CP Register for 661 (368 boys) children born 1996–2003 (mean age 6 years 7 months; SD: 1.5). For children born from 1999 to 2003, weight and height were available. Body mass index (BMI) (kg/m²) was used to assess nutritional status. Results: One hundred and thirty‐two (21%) children with CP were completely dependent on assistance during feeding. The prevalence of gastrostomy tube feeding was 14%. Longer duration of gastrostomy tube feeding was associated with higher weight and BMI, but not with height. Only 63% of the children with CP had normal BMI, 7% had grade 3 thinness, while the prevalence of overweight and obesity in our study was 16%. In all, 20% of the children had mean z‐scores for weight and/or height below – 2 SD. Conclusion: Feeding problems in children with CP were common and associated with poor linear growth. A high proportion of the children were undernourished. Moreover, our results suggest that gastrostomy tube feeding may have been introduced too late in some children.     

Continent feeding jejunostomy in children

Chronically ill and neurologically impaired children may require enteric tube feedings indefinitely to maintain adequate nutrition. When transgastric feedings are not feasible, a permanent feeding jejunostomy may be required. Since 1979, we have constructed a continent feeding jejunostomy in 16 children using a shortened Maydl Roux-en-Y limb with an intussuscepted nipple-valve mechanism. The jejunostomy is matured as a stoma through the abdominal wall, while the nipple valve is stabilized in the abdominal cavity anchored to the posterior fascia and peritoneum. Bolus or drip feedings can be initiated when gastrointestinal function resumes. Between feedings, the tube is removed as the jejunostomy is continent and can be covered with a gauze pad. No deaths were attributed to the operation, although more than 50% of these children died within 2 years from complications of their primary disease. The jejunostomy functioned well and was completely continent in 14 patients. The creation of a feeding jejunostomy with an intussuscepted nipple valve assures continence, avoids the complications of chronic indwelling tubes, and decreases the risk of regurgitation. Furthermore, the continent jejunostomy permits bolus feedings and requires minimal care. The use of this procedure is advocated whenever permanent feeding jejunostomy is anticipated.     

Conservative management of infantile pyloric stenosis by nasoduodenal feeding

Fifty cases of infantile plyoric stenosis were treated conservatively by transpyloric nasoduodenal tube feeding.The mean age on admission was 38.2 days. Transpyloric intubation was carried out in all patients and 45 (90%) with infantile pyloric stenosis were cured by nasoduodenal feeding. Among 5 (10%) requiring surgical intervention, abandonment of nasoduodenal feeding was the cause in only 3, and the parents chose an operation in the remaining 2 a few days after nasoduodenal feeding had been started. In non-surgically cured cases (45), mean body weights on admission and at discharge were 3,750 g and 5,177 g respectively; the duration of nasoduodenal feeding was 8 to 37 days (mean 17.2 days), mean weight gain during nasoduodenal feeding was 42.7 g/day and mean hospital stay was 39.7 days (38.0 days in 43 cases without any associated disorder).This experience suggests that nasoduodenal feeding in this report is a more effective treatment for infantile pyloric stenosis than any traditional medical treatment and it could be the preferred management in the small group of patients for whom an operation could carry a high risk, or whose parents refuse operation.     

Cardiovascular effects of nasogastric tube feeding in the healthy preterm infant

Th systemic blood pressure (BP) and heart rate were estimated by the neonatal Dinamap 847 in 16 healthy preterm neonates in active sleep (AS) before, during and after milk feed by indwelling nasogastric tube. The mean arterial blood pressure (MAP) rose by 10.2% (P less than 0.01) and the diastolic pressure by 8.3% (P less than 0.05) during feeding. The systolic and pulse pressures also rose but individual variation rendered these changes insignificant. The heart rate increased by 6.3% (P less than 0.05) 10 min after the end of the feed. The degree of change in BP and heart rate was unrelated to body weight, gestational age, postnatal age, rate of feeding, volume or duration of the feed.     

Pericardial sac perforation: a rare complication of neonatal nasogastric tube feeding

The insertion of a nasogastric tube for feeding and gastric aspiration is a common practice in the care of newborns, especially if they are preterm and unwell. Esophageal perforation is a rare but serious complication of this procedure. Associated perforation of the pericardial sac is an unusual, severe, and previously unreported complication of nasogastric tube feeding in a neonate. We present an illustrative case.     

儿童急性胰腺炎鼻空肠营养置管及肠内营养时机的探讨

目的 探讨儿童急性胰腺炎鼻空肠营养管置管及肠内营养的时机对临床预后的影响.方法 回顾性分析2008 年1 月至2013 年7 月31 例行鼻空肠营养的急性胰腺炎患儿的临床资料,探讨患儿腹部症状、体征是否缓解及血清淀粉酶水平是否正常与鼻空肠营养置管耐受性、肠内营养成功率的关系;比较早期肠内营养组(肠内营养距发病时间≤ 7 d)和晚期肠内营养组(肠内营养距发病时间>7 d)的治疗有效性及不良反应和并发症发生率.结果 患儿腹部症状、体征是否缓解及血清淀粉酶是否正常与鼻空肠营养置管耐受率、肠内营养成功率无关.早期肠内营养组较晚期肠内营养组血清淀粉酶降至正常时间缩短,系统并发症发生率、住院天数、住院费用明显减少,但体重增加低于晚期组(均P<0.05).两组置管耐受率及肠内营养成功率差异无统计学意义;肠内营养前后白蛋白增加量、肠内营养持续时间及不良反应发生率、局部并发症发生率差异亦无统计学意义.结论 腹部症状、体征及血清淀粉酶水平不能作为衡量能否鼻空肠置管及肠内营养的指标;早期肠内营养能更好地改善儿童急性胰腺炎的临床预后,且具有可行性.