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Nutritional support at home: Accessing the gut
Current Paediatrics (1997) 7, 213-217 © 1997 Harcourt Brace & Co Ltd
Mini-symposium: Gastroenterology
Nutritional support at home: accessing the gut
G. Sharpe, J. W. L. Puntis
INTRODUCTION
Box
1 Tube feeding is used in the followinggroups of conditions
Impaired suck, chew and swallow • prematurity • cerebral palsy • neurodegenerativediseases • orofacialmalformations • paediatric intensive care
Delivery of nutrients by tube is now used in a wide range of paediatric disorders ~ reflecting growing awareness of the importance of good nutrition in severe illness. 2 Enteral tube feeding is indicated in the child who, despite a functional gastrointestinal tract, is unable to ingest sufficient food to maintain or restore normal nutritional status. This definition includes premature infants with immature suck and swallow, as well as older children in w h o m these mechanisms are either temporarily or permanently impaired. There are a number of additional indications listed in Box 1. The need for reliable and safe enteral nutritional support continues to stimulate innovation both in the field of tube design and the methods for establishing gastrointestinal access. For long-term enteral nutritional support a gastrostomy tube, inserted using a percutaneous endoscopic technique, is increasingly preferred over a nasogastric (NG) tube. The management of complex nutritional problems, including planning, implementation and supervision of tube feeding, is best coordinated by a multi-disciplinary nutritional care team? This brings together the particular expertise of a paediatric surgeon, a paediatric gastroenterologist, a dietitian, a pharmacist and a nutrition nurse specialist. Joint decisions are made about the most suitable approach and type of tube to be used for each patient. Whilst life threatening complications of tube feeding are relatively unusual,
Breathlessness on feeding • congenital heart disease • respiratory disease Disordered appetite • cachexiaassociated with chronic disease/malignancy • anorexianervosa • primary appetite disorder Increased energy requirements • cysticfibrosis • liverdisease • acquired immunodeficiencysyndrome (AIDS) Continuous supply of nutrients required • short bowel syndrome • protracted diarrhoea • glycogenstorage disease Unpalatable liquid feeds used as primary therapy • Crohn'sdisease • multiple food intolerance
minor problems are common. Continuing support and education for carers and patients in hospital or at home is therefore a key role for the nutrition nurse specialist.
PSYCHOLOGICAL PREPARATION When long-term tube feeding is envisaged it is important for children and families to receive adequate psychological preparation. Parents may feel that tube feeding is an indictment of their ability to provide a fundamental aspect of childcare. For those who have been spending many fruitless hours trying to encourage an
GiftSharpe, The Children's Centre, Department of Paediatrics and Child Health, The University of Leeds, Leeds, UK. John W. L. Puntis, Neonatal Unit, Clarendon Wing, The General Infirmary at Leeds, Belmont Grove, Leeds LS2 9NS, UK. Correspondence and requests for offprints to JWLR
213
214
Current Paediatrics
Box 2 Accessroutes for enteral feeding Short-termfeeding: Fine-bore nasoenteraltubes • nasogastric • nasoduodenal • nasojejunal Double lumennasoenteraltubes • gastricaspiration/jejunalfeeding Longer-termfeeding: Gastrostomies • surgicalgastrostomy • percutaneousendoscopicgastrostomy(PEG) • fluoroscopicpercutaneousgastrostomy • laparoscopicgastrostomy Duodenostomy • percutaneousendoscopic Jejunostomy • surgicaljejunostomy • percutaneousendoscopic • jejunal tubes throughPEG • needlecatheterjejunostomy • cuffedtubejejunostomy • subcutaneousjejunostomy underweight and ill child to eat more, reassurance can be given that tube feeding will not only lead to weight gain but also free time for more rewarding parent~zhild interaction. Useful teaching aids include photographs and video recordings depicting previous patients with feeding tubes. A doll can be used to explain basic anatomy as well as demonstrate tube care. Children old enough to understand should be offered an explanation of why they need tube feeding, and given the opportunity to become familiar with enteral feeding equipment. There are some helpful booklets written specifically for younger children, and also a support group for home enteral tube feeding families (Appendix 1).
malnutrition resulting from inadequate intake, as well as providing supplementary nutrition. Technically, it is the most simple and safe route of delivery but may not be appropriate if there is severe gastro-oesophageal reflux or impaired stomach emptying leading to an increased risk of aspiration. Prolonged use may cause nasopharyngeal discomfort, mucosal erosion, middle ear problems and reluctance to take food by mouth. The increase in upper airway resistance exacerbates breathing difficulties in some children. One of the main objections to long-term use of N G tubes is the social and psychological difficulties which result from visibility of the tube? Some older children receiving nocturnal feeds prefer to remove their N G tube each morning and replace it at bed time. Nasogastric tube position can be confirmed by syringe aspiration of gastric contents (acid pH). Auscultation of the epigastrium while a small volume of air is injected is an unreliable technique and should no longer be used. If aspiration is inconclusive, or the patient has a depressed conscious level, altered cough ~or gag reflex, or is undergoing mechanical ventilation, X-ray confirmation of the tube position is mandatory. Many tubes are removed accidentally and good fixation to the nose and face with surgical tape (such as Tegaderm or Meflx) is essential. Stomahesive can be applied first in order to protect the skin.
Transpyloric feeding
The choice of feeding tube (Appendix 2) and route of insertion (Box 2) depends upon a number of different considerations. For short-term feeding, fine-bore N G tubes are most frequently used. These are usually 12 mm internal diameter and 2-3 mm (6-9 F; 1 French = 1/3 mm) external diameter. Polyurethane and silicone tubes, which are resistant to hardening by stomach acid are associated with fewer complications than polyvinyl chloride (PVC) tubes (which rapidly harden), can be left in place for 6 weeks and may be repassed in the same patient if pulled out. Polyurethane allows the production of a tube with a larger internal diameter than is possible with PVC. This type of tube is prelubricated with a water activated polymer, thus aiding passage and being more comfortable for patients.
In critically ill children gastroparesis and risk of aspiration mean that a transpyloric tube is the preferred method for short-term enteral feeding in many units, although a trial of nasogastric feeding is reasonable in the first instance. Once the tube is in the stomach a prokinetic agent such as metoclopramide, cisapride or erythromycin can be given to aid transpyloric passage. Weighted tubes do not appear to offer advantages either in terms of success with placement or maintaining tube position in the small bowel. Placement under X-ray control or using endoscopy both achieve high success rates, but the necessary equipment and expertise is often not available on the intensive care unit. Recently, pH-assisted placement has been developed to give a continual pH reading during tube placement. As the tube passes from oesophagus to stomach to small intestine, pH changes from alkaline to acid and back to alkaline. In a randomized study this method was shown to be much more reliable than a standard insertion technique, and was associated with decreased radiation exposure and lower costs?
FORMS OF FEEDING
Gastrostomy feeding
FEEDING TUBES
Nasogastric feeding Nasogastric tube feeding is the most common form of tube feeding and can overcome most causes of
Although gastrostomy placement in the past was always a surgical procedure, a percutaneous endoscopic technique, first described in 1980, has since become widely practised. 6 It is contraindicated when
Accessing the gut
//
Fig. 1 The stomachis inflatedvia the endoscopeand the placement wire insertedthroughthe abdominalwallvia a Seldingerneedle.
the liver or transverse colon directly overlie the proposed gastrostomy site, however. Gastrostomy should be considered if nutritional support is likely to be required for longer than 8 weeks. An operative approach is still employed for those children who require anti-reflux surgery in addition to gastrostomy. Percutaneous endoscopic gastrostomy can be performed under intravenous sedation or general anaesthesia; a broad spectrum antibiotic is usually given during the procedure. Inflation of the stomach brings it close to the abdominal wall and pushes the colon down. The point of brightest transillumination from the gastroscope on the anterior abdominal wall identifies where the gastrostomy will be sited. A needle is inserted through the skin at this point and into the stomach under endoscopic vision (Fig. 1). A wire is then threaded through the needle, snared by the endoscopist and pulled out of the mouth with the gastroscope (Fig. 2). The gastrostomy tube can then be attached to the wire which is pulled back through the abdominal wall bringing the tube with it (Fig. 3). A disc or T-bar on the tube in the stomach stops it falling out, and one on the outside prevents it falling in. Once a good enterocutaneous track has formed, around 6 weeks, many children and parents prefer to have the gastrostomy tube replaced by a low profile device such as the MIC-KEY 7 so that there is no longer any tubing hanging from the abdominal wall (Fig. 4). Laparoscopic gastrostomy is an alternative
215
Fig. 2 The endoscopeis used to snare the wire and pull it out through the patient's mouth.
method of placement, but is time consuming and has to be performed under general anaesthesia. Although surgical gastrostomy may provoke or exacerbate gastro-oesophageal reflux, this appears less likely with a percutaneous endoscopic gastrostomy? Other complications include a small risk of gastrocolic fistula, leakage of gastric contents into the peritoneal cavity, wound infection and granulation tissue around the exit site. The latter can be treated by twice daily topical application of Sofradex ointment (dexamethasone with framycetin and gramicidin) or, if this fails, by silver nitrate. The method of removal of a gastrostomy device when it is no longer required depends on the individual design. Some require cutting externally so that the intragastric portion then passes on down the gastrointestinal tract and is passed per rectum. This is potentially hazardous in children who have had previous abdominal surgery with risk of adhesions, or in those who may have a narrowed segment of bowel as in Crohn's disease. In these cases endoscopic retrieval is advisable.
Jejunostomy feeding Jejunostomy feeding can be used when there is major risk of aspiration from intragastric feeds such as in
216
Current Paediatrics Box 3 Giving medicines via enteral feeding tube • givemedicines by mouth or other route if possible • use liquid preparation, or thoroughly crush tablets and mix with water • dissolve contents of gelatine capsules in warm water • do not give enteric coated and slow release tablets via the tube • flushtube with water before and after each medication • avoidadding medication directly to feed formula
children with persistent severe gastro-oesophageal reflux who are unsuitable for anti-reflux surgery. Surgical jejunostomy m a y be carried out either as a separate operative procedure, or during abdominal surgery. A jejunal feeding tube m a y also be inserted via a gastrostomy tube, 9 for example, in a child who develops significant gastro-oesophageal reflux following gastrostomy.
)
TUBE PROBLEMS
Fig. 3 The placement wire is attached to the lubricated PEG tube which can then be pulled through the patient's mouth, stomach and abdominal wall.
Balloon Inflation Valve
l T
1
Feeding Port
Silicone Retention Balloon
Feeding Port Cover
Fig. 4 A MIC-KEY skin level gastrostomy device.
Tubes m a y become blocked with feed and should be flushed regularly with water after each bolus feed and at least twice a day when the feed is being given continuously. Some blockages can be cleared by syringing with w a r m water, 'diet coke' or pineapple juice, but if this doesn't work a solution o f pancreatic enzymes (if a powdered preparation is available) m a y be successful. I° Use o f a guide-wire to unblock tubes is to be discouraged because o f the risk o f tube and bowel perforation. Medicines, often given via feeding tubes, are sometimes responsible for blockage. This can be averted by following some simple rules (Box 3). Accidental removal o f gastrostomy or j e j u n o s t o m y tubes occurs quite frequently. I f not replaced quickly there is a real risk o f the track closing completely within the matter o f a few hours. It is helpful for the parents or carers to be provided with written problem solving guidelines at home, together with a spare tube. ACKNOWLEDGEMENT We are grateful to Sister Gill Abel for reviewing this manuscript and providing her expert comments. APPENDIX 1 The following educational material is available for children beginning tube feeding. Feeding time with Roo and Joe. Sherwood, Davis and Geck, 154 Fareham Road, Gosport, Hampshire, UK. The story of Gizzy the gastrostomy tube. Fresenius Ltd, 6/8 Christleton Court, Manor Park, Runcorn, Cheshire WA7 1ST, UK. My 'secret' PEG. E. Merck Pharmaceuticals, Winchester Road, Four Marks, Alton, Hants GU34 5HB, UK. The children's section o f P I N N T (Patients on Intravenous and Nasogastric Nutrition Therapy), is H a l f - P I N N T , and can be contacted at 258 Wennington Road, R a i n h a m , Essex R M 1 3 9UU, U K .
Accessing the gut
217
APPENDIX 2
REFERENCES
There are a wide variety o f enteral feeding tubes available. These are some c o m m o n l y used in our practice.
1. Puntis J W L, Holden C E. Home enteral nutrition in paediatric practice. Brit J Hosp Med 1991; 45: 101-106. 2. Booth I W. Enteral nutrition in childhood. Brit J Hosp Med 1991; 46: 111-113. 3. Puntis J W L, Booth I W. The place of a nutritional care team in paediatric practice. Intensive Therapy and Clinical Monitoring 1990; 132-136. 4. Holden C E, Puntis J W L, Charlton C P L, Booth I W. Nasogastric feeding at home: acceptability and safety. Arch Dis Child 1991; 66: 148-151. 5. Krafte-Jacobs B, Persinger M, Carver J, Moore L, Brilli R. Rapid placement of transpyloric feeding tubes: a comparison of pH-assisted and standard insertion techniques in children. Pediatrics 1996; 98: 242-248. 6. Grunow J E, Chait P, Savoie S, Mullan C, Pencharz E Gastrostomy feeding. In: Recent Advances in Paediatrics, 12, David, T J (ed). Edinburgh: Churchill-Livingstone, 1994. 7. Faller N A, Ferraro C, Bagley E The MIC-KEY. An alternative to obturated low-profile gastrostomy devices. Ostomy/Wound Management 1992; 38: 50-53. 8. Launay V, Gottrand F, Turck D, Michaud L, Ategbo A, Farriaux J E Percutaneous endoscopic gastrostomy in children: influence on gastroesophageal reflux. Pediatrics 1996; 97: 726-728. 9. Albanese C T, Towbin R B, Ulman I, Lewis J, Smith S D. Percutaneous gastrojejunostomy versus Nissen fundoplication for enteral feeding in the neurologically impaired child with gastroesophageal reflux, J Pediatrics 1993; 123: 371-375. 10. Marcuard S P, Stegall K S. Unclogging feeding tubes with pancreatic enzyme. J Parent Ent Nutr 1990; 14: 198-200.
•
•
•
• •
'Silk' polyurethane (long-term) nasogastric feeding tubes. Larger internal lumen than P V C tube; recessed exit p o r t to facilitate aspiration; wateractivated lubricant; guidewire; 56 cm, 5, 6 and 8 Ft. 'Corsafe' polyurethane 'pill shaped' bolus tip for transpyloric feeding, otherwise like 'Silk' tube; 109 cm, 8 E B o t h types o f tube supplied with male/male luer fitting to ensure compatibility with all currently available enteral administration sets; m a n u f a c t u r e d by C o r p a k , U S A , further information f r o m E. M e r c k Pharmaceuticals (address as in A p p e n d i x 1). MIC-gastrostomy tube, M I C - P E G kit, M I C - K E Y skin level gastrostomy feeding kit, MIC-jejunostomy tube. Medical Innovations Corporation, a division o f Ballard Medical Products, 12050 South Lone Peak Parkway, Draper, U t a h 84020, USA. Freka-PEG-Systems. Fresenius L t d (address as in A p p e n d i x 1). Corflo P E G feeding tube. C o r p a k button, Merck Biomaterial, Lenten House, Lenten Street, Alton, H a m p s h i r e G U 3 4 1HG, U K .
Mini-symposium: Gastroenterology
Nutritional support at home: accessing the gut
G. Sharpe, J. W. L. Puntis
INTRODUCTION
Box
1 Tube feeding is used in the followinggroups of conditions
Impaired suck, chew and swallow • prematurity • cerebral palsy • neurodegenerativediseases • orofacialmalformations • paediatric intensive care
Delivery of nutrients by tube is now used in a wide range of paediatric disorders ~ reflecting growing awareness of the importance of good nutrition in severe illness. 2 Enteral tube feeding is indicated in the child who, despite a functional gastrointestinal tract, is unable to ingest sufficient food to maintain or restore normal nutritional status. This definition includes premature infants with immature suck and swallow, as well as older children in w h o m these mechanisms are either temporarily or permanently impaired. There are a number of additional indications listed in Box 1. The need for reliable and safe enteral nutritional support continues to stimulate innovation both in the field of tube design and the methods for establishing gastrointestinal access. For long-term enteral nutritional support a gastrostomy tube, inserted using a percutaneous endoscopic technique, is increasingly preferred over a nasogastric (NG) tube. The management of complex nutritional problems, including planning, implementation and supervision of tube feeding, is best coordinated by a multi-disciplinary nutritional care team? This brings together the particular expertise of a paediatric surgeon, a paediatric gastroenterologist, a dietitian, a pharmacist and a nutrition nurse specialist. Joint decisions are made about the most suitable approach and type of tube to be used for each patient. Whilst life threatening complications of tube feeding are relatively unusual,
Breathlessness on feeding • congenital heart disease • respiratory disease Disordered appetite • cachexiaassociated with chronic disease/malignancy • anorexianervosa • primary appetite disorder Increased energy requirements • cysticfibrosis • liverdisease • acquired immunodeficiencysyndrome (AIDS) Continuous supply of nutrients required • short bowel syndrome • protracted diarrhoea • glycogenstorage disease Unpalatable liquid feeds used as primary therapy • Crohn'sdisease • multiple food intolerance
minor problems are common. Continuing support and education for carers and patients in hospital or at home is therefore a key role for the nutrition nurse specialist.
PSYCHOLOGICAL PREPARATION When long-term tube feeding is envisaged it is important for children and families to receive adequate psychological preparation. Parents may feel that tube feeding is an indictment of their ability to provide a fundamental aspect of childcare. For those who have been spending many fruitless hours trying to encourage an
GiftSharpe, The Children's Centre, Department of Paediatrics and Child Health, The University of Leeds, Leeds, UK. John W. L. Puntis, Neonatal Unit, Clarendon Wing, The General Infirmary at Leeds, Belmont Grove, Leeds LS2 9NS, UK. Correspondence and requests for offprints to JWLR
213
214
Current Paediatrics
Box 2 Accessroutes for enteral feeding Short-termfeeding: Fine-bore nasoenteraltubes • nasogastric • nasoduodenal • nasojejunal Double lumennasoenteraltubes • gastricaspiration/jejunalfeeding Longer-termfeeding: Gastrostomies • surgicalgastrostomy • percutaneousendoscopicgastrostomy(PEG) • fluoroscopicpercutaneousgastrostomy • laparoscopicgastrostomy Duodenostomy • percutaneousendoscopic Jejunostomy • surgicaljejunostomy • percutaneousendoscopic • jejunal tubes throughPEG • needlecatheterjejunostomy • cuffedtubejejunostomy • subcutaneousjejunostomy underweight and ill child to eat more, reassurance can be given that tube feeding will not only lead to weight gain but also free time for more rewarding parent~zhild interaction. Useful teaching aids include photographs and video recordings depicting previous patients with feeding tubes. A doll can be used to explain basic anatomy as well as demonstrate tube care. Children old enough to understand should be offered an explanation of why they need tube feeding, and given the opportunity to become familiar with enteral feeding equipment. There are some helpful booklets written specifically for younger children, and also a support group for home enteral tube feeding families (Appendix 1).
malnutrition resulting from inadequate intake, as well as providing supplementary nutrition. Technically, it is the most simple and safe route of delivery but may not be appropriate if there is severe gastro-oesophageal reflux or impaired stomach emptying leading to an increased risk of aspiration. Prolonged use may cause nasopharyngeal discomfort, mucosal erosion, middle ear problems and reluctance to take food by mouth. The increase in upper airway resistance exacerbates breathing difficulties in some children. One of the main objections to long-term use of N G tubes is the social and psychological difficulties which result from visibility of the tube? Some older children receiving nocturnal feeds prefer to remove their N G tube each morning and replace it at bed time. Nasogastric tube position can be confirmed by syringe aspiration of gastric contents (acid pH). Auscultation of the epigastrium while a small volume of air is injected is an unreliable technique and should no longer be used. If aspiration is inconclusive, or the patient has a depressed conscious level, altered cough ~or gag reflex, or is undergoing mechanical ventilation, X-ray confirmation of the tube position is mandatory. Many tubes are removed accidentally and good fixation to the nose and face with surgical tape (such as Tegaderm or Meflx) is essential. Stomahesive can be applied first in order to protect the skin.
Transpyloric feeding
The choice of feeding tube (Appendix 2) and route of insertion (Box 2) depends upon a number of different considerations. For short-term feeding, fine-bore N G tubes are most frequently used. These are usually 12 mm internal diameter and 2-3 mm (6-9 F; 1 French = 1/3 mm) external diameter. Polyurethane and silicone tubes, which are resistant to hardening by stomach acid are associated with fewer complications than polyvinyl chloride (PVC) tubes (which rapidly harden), can be left in place for 6 weeks and may be repassed in the same patient if pulled out. Polyurethane allows the production of a tube with a larger internal diameter than is possible with PVC. This type of tube is prelubricated with a water activated polymer, thus aiding passage and being more comfortable for patients.
In critically ill children gastroparesis and risk of aspiration mean that a transpyloric tube is the preferred method for short-term enteral feeding in many units, although a trial of nasogastric feeding is reasonable in the first instance. Once the tube is in the stomach a prokinetic agent such as metoclopramide, cisapride or erythromycin can be given to aid transpyloric passage. Weighted tubes do not appear to offer advantages either in terms of success with placement or maintaining tube position in the small bowel. Placement under X-ray control or using endoscopy both achieve high success rates, but the necessary equipment and expertise is often not available on the intensive care unit. Recently, pH-assisted placement has been developed to give a continual pH reading during tube placement. As the tube passes from oesophagus to stomach to small intestine, pH changes from alkaline to acid and back to alkaline. In a randomized study this method was shown to be much more reliable than a standard insertion technique, and was associated with decreased radiation exposure and lower costs?
FORMS OF FEEDING
Gastrostomy feeding
FEEDING TUBES
Nasogastric feeding Nasogastric tube feeding is the most common form of tube feeding and can overcome most causes of
Although gastrostomy placement in the past was always a surgical procedure, a percutaneous endoscopic technique, first described in 1980, has since become widely practised. 6 It is contraindicated when
Accessing the gut
//
Fig. 1 The stomachis inflatedvia the endoscopeand the placement wire insertedthroughthe abdominalwallvia a Seldingerneedle.
the liver or transverse colon directly overlie the proposed gastrostomy site, however. Gastrostomy should be considered if nutritional support is likely to be required for longer than 8 weeks. An operative approach is still employed for those children who require anti-reflux surgery in addition to gastrostomy. Percutaneous endoscopic gastrostomy can be performed under intravenous sedation or general anaesthesia; a broad spectrum antibiotic is usually given during the procedure. Inflation of the stomach brings it close to the abdominal wall and pushes the colon down. The point of brightest transillumination from the gastroscope on the anterior abdominal wall identifies where the gastrostomy will be sited. A needle is inserted through the skin at this point and into the stomach under endoscopic vision (Fig. 1). A wire is then threaded through the needle, snared by the endoscopist and pulled out of the mouth with the gastroscope (Fig. 2). The gastrostomy tube can then be attached to the wire which is pulled back through the abdominal wall bringing the tube with it (Fig. 3). A disc or T-bar on the tube in the stomach stops it falling out, and one on the outside prevents it falling in. Once a good enterocutaneous track has formed, around 6 weeks, many children and parents prefer to have the gastrostomy tube replaced by a low profile device such as the MIC-KEY 7 so that there is no longer any tubing hanging from the abdominal wall (Fig. 4). Laparoscopic gastrostomy is an alternative
215
Fig. 2 The endoscopeis used to snare the wire and pull it out through the patient's mouth.
method of placement, but is time consuming and has to be performed under general anaesthesia. Although surgical gastrostomy may provoke or exacerbate gastro-oesophageal reflux, this appears less likely with a percutaneous endoscopic gastrostomy? Other complications include a small risk of gastrocolic fistula, leakage of gastric contents into the peritoneal cavity, wound infection and granulation tissue around the exit site. The latter can be treated by twice daily topical application of Sofradex ointment (dexamethasone with framycetin and gramicidin) or, if this fails, by silver nitrate. The method of removal of a gastrostomy device when it is no longer required depends on the individual design. Some require cutting externally so that the intragastric portion then passes on down the gastrointestinal tract and is passed per rectum. This is potentially hazardous in children who have had previous abdominal surgery with risk of adhesions, or in those who may have a narrowed segment of bowel as in Crohn's disease. In these cases endoscopic retrieval is advisable.
Jejunostomy feeding Jejunostomy feeding can be used when there is major risk of aspiration from intragastric feeds such as in
216
Current Paediatrics Box 3 Giving medicines via enteral feeding tube • givemedicines by mouth or other route if possible • use liquid preparation, or thoroughly crush tablets and mix with water • dissolve contents of gelatine capsules in warm water • do not give enteric coated and slow release tablets via the tube • flushtube with water before and after each medication • avoidadding medication directly to feed formula
children with persistent severe gastro-oesophageal reflux who are unsuitable for anti-reflux surgery. Surgical jejunostomy m a y be carried out either as a separate operative procedure, or during abdominal surgery. A jejunal feeding tube m a y also be inserted via a gastrostomy tube, 9 for example, in a child who develops significant gastro-oesophageal reflux following gastrostomy.
)
TUBE PROBLEMS
Fig. 3 The placement wire is attached to the lubricated PEG tube which can then be pulled through the patient's mouth, stomach and abdominal wall.
Balloon Inflation Valve
l T
1
Feeding Port
Silicone Retention Balloon
Feeding Port Cover
Fig. 4 A MIC-KEY skin level gastrostomy device.
Tubes m a y become blocked with feed and should be flushed regularly with water after each bolus feed and at least twice a day when the feed is being given continuously. Some blockages can be cleared by syringing with w a r m water, 'diet coke' or pineapple juice, but if this doesn't work a solution o f pancreatic enzymes (if a powdered preparation is available) m a y be successful. I° Use o f a guide-wire to unblock tubes is to be discouraged because o f the risk o f tube and bowel perforation. Medicines, often given via feeding tubes, are sometimes responsible for blockage. This can be averted by following some simple rules (Box 3). Accidental removal o f gastrostomy or j e j u n o s t o m y tubes occurs quite frequently. I f not replaced quickly there is a real risk o f the track closing completely within the matter o f a few hours. It is helpful for the parents or carers to be provided with written problem solving guidelines at home, together with a spare tube. ACKNOWLEDGEMENT We are grateful to Sister Gill Abel for reviewing this manuscript and providing her expert comments. APPENDIX 1 The following educational material is available for children beginning tube feeding. Feeding time with Roo and Joe. Sherwood, Davis and Geck, 154 Fareham Road, Gosport, Hampshire, UK. The story of Gizzy the gastrostomy tube. Fresenius Ltd, 6/8 Christleton Court, Manor Park, Runcorn, Cheshire WA7 1ST, UK. My 'secret' PEG. E. Merck Pharmaceuticals, Winchester Road, Four Marks, Alton, Hants GU34 5HB, UK. The children's section o f P I N N T (Patients on Intravenous and Nasogastric Nutrition Therapy), is H a l f - P I N N T , and can be contacted at 258 Wennington Road, R a i n h a m , Essex R M 1 3 9UU, U K .
Accessing the gut
217
APPENDIX 2
REFERENCES
There are a wide variety o f enteral feeding tubes available. These are some c o m m o n l y used in our practice.
1. Puntis J W L, Holden C E. Home enteral nutrition in paediatric practice. Brit J Hosp Med 1991; 45: 101-106. 2. Booth I W. Enteral nutrition in childhood. Brit J Hosp Med 1991; 46: 111-113. 3. Puntis J W L, Booth I W. The place of a nutritional care team in paediatric practice. Intensive Therapy and Clinical Monitoring 1990; 132-136. 4. Holden C E, Puntis J W L, Charlton C P L, Booth I W. Nasogastric feeding at home: acceptability and safety. Arch Dis Child 1991; 66: 148-151. 5. Krafte-Jacobs B, Persinger M, Carver J, Moore L, Brilli R. Rapid placement of transpyloric feeding tubes: a comparison of pH-assisted and standard insertion techniques in children. Pediatrics 1996; 98: 242-248. 6. Grunow J E, Chait P, Savoie S, Mullan C, Pencharz E Gastrostomy feeding. In: Recent Advances in Paediatrics, 12, David, T J (ed). Edinburgh: Churchill-Livingstone, 1994. 7. Faller N A, Ferraro C, Bagley E The MIC-KEY. An alternative to obturated low-profile gastrostomy devices. Ostomy/Wound Management 1992; 38: 50-53. 8. Launay V, Gottrand F, Turck D, Michaud L, Ategbo A, Farriaux J E Percutaneous endoscopic gastrostomy in children: influence on gastroesophageal reflux. Pediatrics 1996; 97: 726-728. 9. Albanese C T, Towbin R B, Ulman I, Lewis J, Smith S D. Percutaneous gastrojejunostomy versus Nissen fundoplication for enteral feeding in the neurologically impaired child with gastroesophageal reflux, J Pediatrics 1993; 123: 371-375. 10. Marcuard S P, Stegall K S. Unclogging feeding tubes with pancreatic enzyme. J Parent Ent Nutr 1990; 14: 198-200.
•
•
•
• •
'Silk' polyurethane (long-term) nasogastric feeding tubes. Larger internal lumen than P V C tube; recessed exit p o r t to facilitate aspiration; wateractivated lubricant; guidewire; 56 cm, 5, 6 and 8 Ft. 'Corsafe' polyurethane 'pill shaped' bolus tip for transpyloric feeding, otherwise like 'Silk' tube; 109 cm, 8 E B o t h types o f tube supplied with male/male luer fitting to ensure compatibility with all currently available enteral administration sets; m a n u f a c t u r e d by C o r p a k , U S A , further information f r o m E. M e r c k Pharmaceuticals (address as in A p p e n d i x 1). MIC-gastrostomy tube, M I C - P E G kit, M I C - K E Y skin level gastrostomy feeding kit, MIC-jejunostomy tube. Medical Innovations Corporation, a division o f Ballard Medical Products, 12050 South Lone Peak Parkway, Draper, U t a h 84020, USA. Freka-PEG-Systems. Fresenius L t d (address as in A p p e n d i x 1). Corflo P E G feeding tube. C o r p a k button, Merck Biomaterial, Lenten House, Lenten Street, Alton, H a m p s h i r e G U 3 4 1HG, U K .