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Pediatric Feeding Tubes

Jessica Mason, MD, Jason Woods, MD, and Rebecca Jacobson, NP
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24:31

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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03:23

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EM:RAP 2020 02 February Written Summary 257 KB - PDF

Pediatric Feeding Tubes

Jessica Mason MD, Jason Woods MD and Rebecca Jacobson NP

Print editor: Whitney Johnson MD MS

 

Take Home Points

  • G-tubes and J-tubes are the same device used in different locations.
  • It is important to determine when the G-tube was placed as six weeks are necessary for maturation of the tract and replacement of the tube in this time period is at risk of complication.
  • Progressive dilation of the stoma or use of the stylet in the kit can help with G-tube replacement.
  • Irrigation with warm water (not Coca-Cola) is recommended for flushing clogged tubes.

 

  • Jacobson is a pediatric nurse practitioner who has experience in gastrostomy tube (G-tube) What do you do if a child presents in the ED with complications of a G-tube?
  • A G-tube is a means for enteral access or to feed a child when they cannot take enough by mouth for a number of different reasons.
  • Are G-tubes and J-tubes (jejunostomy tube) the same thing? The same device can be used in multiple locations. The same type and brand of button are used in multiple locations in the gastrointestinal (GI) A G-tube is used to describe any device that goes through the abdominal wall directly into the stomach. A J-tube is the same type of device, but goes directly through the abdominal wall into the small intestine. A GJ-tube goes through the abdominal wall into the stomach and has a long limb that goes in the small intestine.
  • What is a button? A G-tube can be a long tube hanging outside the body for several inches. A button is a skin level or shorter device that is more easily concealed under clothing. The button tends to be a better device in children as it does not tend to get caught on things or
  • The terms MIC-KEY and MINI refer to bands. These are essentially the same thing.
  • Inside the skin on most G-tubes is a water-filled balloon that holds anywhere between 2.5-5 mL of water. It holds the tube in the child’s stomach. There are some G-tubes that do not have a balloon but have a mushroom cap to hold the G-tube in the stomach. These are less common. You can tell the difference as any G-tube that has a balloon will have a balloon port on the outside.
  • Button G-tubes have two measurements. One measurement refers to the width or the French size of the shaft. The length corresponds with the thickness of the abdominal wall thickness. This value may change over time as the child gains weight.
  • How do you know how much to fill the balloon? Many of the G-tubes tell you on the balloon port. Look there first. If you do not see it, you can ask the parents and they likely If not, it is probably safe to start with 4-5 mL.
  • A child just moved to town but had their G-tube placed at another hospital. The family is questioning whether or not the tube size is still appropriate or the balloon is underfilled. How do you assess whether the tube is the right fit?
    • Make sure the patient is far enough out from surgery to manipulate the tube. You want to wait a minimum of six weeks to allow the tract to form.
    • If the patient is at least six weeks out from surgery, check the volume of the balloon. Make sure the balloon is inflated to the proper volume because if it is under- or overinflated, it may seem to be inappropriately sized.
    • Check fit by gently lifting on the G-tube and rotating it. Make sure there is a little space between the outer flange and the skin. This allows air circulation and prevents pressure sores at the G-tube site. They should spin easily and it should not cause much discomfort.
    • What is the concern with replacing the G-tube prior to 6 weeks after placement? Most G-tubes are placed by a laparoscopic procedure that includes suturing the stomach to the abdominal wall. These sutures dissolve after a few days. Part of what holds the stomach to the abdominal wall is the G-tube. Eventually the stomach adheres to the abdominal wall but it takes time for that adhesion to develop. If the tract is not formed, the stomach can fall away from the abdominal wall and placing the G-tube can lead to placement in the peritoneal cavity. If feeds are administered through the tube, the child can develop sepsis or peritonitis.
  • The child is fed through the tract while it heals. The tube is usually used within the first 24 hours after surgery.
  • The internal valve is a V-shaped piece of silicone. When the extension set is connected, it pops the V open. When the extension set is removed, the V-valve should close on its own. Formula should not be leaking out. There is a specific extension set for each brand and type of G-tube so make sure a compatible extension set is used. There is usually a little black line on both the G-tube and extension set, line up the lines, push down and twist the extension set to lock on the device.
  • Can you vent with the extension set? You can usually use the same extension set to deliver food and medication or vent. You can connect an open syringe or pull back on the plunger to withdraw stomach contents. There are some G-tubes that need a specific venting set but this is uncommon and the parents will usually know if this is the case.
  • Once the tube is used, does it need to be flushed? Every time the G-tube is used for a feed or medication, it should be flushed with a small amount of water to clear the extension set line and lumen of the G-tube. If medication or formula sits in the tube, it will become clogged. The lumen is quite small and clogs easily.
  • How often are G-tubes changed? Typically, exchanging the G-tube is suggested every 3-6 months. You do not have to change the G-tube and can just wait until the balloon fails and the tube falls out, but this usually happens at inconvenient times.
  • Leaking tubes.
    • A patient with an established tube presents with complaints of tube leaking and subsequent irritation of the skin. It is important to determine if it is leaking around the tube or in the middle of the tube as this will affect the management.
    • For skin irritation, a thick barrier cream is recommended covered by a thin piece of gauze secured with tape in a tic-tac-toe pattern. The tic-tac-toe pattern involves two pieces of tape across the G-tube itself (the balloon port and open flap) and two pieces of tape across the gauze itself. This stabilizes the tube so it does not move or stretch out the hole.
    • Leakage of tube contents around the tube. A little bit of leaking around the tube is normal as the connection between the skin and stomach is not completely watertight. If the patient has any underlying illness such as cough, vomiting, constipation or pneumonia, it can cause increased leakage around the G-tube site. It is concerning if there is so much leakage that it is impacting the quality of life of the family or resulting in severe skin breakdown, weight loss or dehydration.
    • Leaking through the center of the G-tube. A few drops is normal but if it is oozing or pouring out, it means that the valve is broken. This is not an emergency, but the tube needs to be replaced if it has been present for at least six weeks after surgery. If it has not been six weeks after surgery, you just have to maintain it until six weeks has surpassed.
  • Dislodged tubes.
    • Tubes can be dislodged with the balloon inflated or deflated. There may be some trauma or bleeding from the tract. Families are taught to replace the G-tube at home after six weeks post-operatively. Families are also taught to use a Foley catheter if they do not have a replacement G-tube available or they cannot get the G-tube back in. The Foley catheter has a more tapered tip. The priority is placement of something in the tract before it closes. The tract can close significantly within 30-60 minutes after G-tube removal.
    • What size Foley is used? Generally, families are sent home with two Foley sizes; the same French size as the G-tube and one size smaller.
    • Does the family need to come to the ER if they are able to replace the G-tube at home? They are instructed to go to the ER if it has not been six weeks since surgery. Fluoro study or x-ray studies with contrast are recommended to make sure the surgery has not fallen apart from the inside and the balloon is inflated in the stomach and not the peritoneal cavity. At approximately 6 weeks post-operatively, they can use it as long as the child does not seem to be in pain and it seems to be flushing and withdrawing without difficulty. Fluoro studies may not be available at some sites or at some hours. A small amount of water soluble contrast can be instilled followed by an x-ray.
    • How do you replace a G-tube? The process is easy. Remove the Foley The new G-tube needs to be lubricated with a small amount of water soluble lubricant. If you do not have lubricant, there is generally enough leakage of stomach contents to lubricate the tube. Gently insert the G-tube into the hole. Draw up the proper amount of water in a slip-tip syringe. If you have the kit, the booklet says how much water is recommended. Attach the syringe to the balloon port, gently inflate the balloon, and remove the syringe. Spin the tube and make sure it rotates easily.
    • Most G-tube kits come with a blue stylet. This looks like a golf tee. This goes down the center of the G-tube itself to make the G-tube stiffer allowing you to use some pressure to get it in the stomach. If this does not work, go down a French size on a Foley catheter and try to place it. Leave it in for 5-10 minutes and then try to move up to the next size.
  • Granulation tissue. This can be distressing for family as they may think the stomach is coming out or the child has an infection. This is an overreaction by the body to a foreign body. If the tissue is small and not causing problems like leakage or pain, you do not have to do anything. We want to intervene when it is causing problems such as rapid growth, pain or bleeding. Granulation tissue is not an emergency and silver nitrate applications can go awry.
  • Clogged tubes.
    • Jacobson uses warm water. G-tubes do not clog very often unless they are not being flushed. If it is clogged, she tries warm water. Coca-Cola has not been well-studied and might make the clog worse. If you have the blue stylet, you can use it to try to dislodge the clog. If the tube has been in place for over six weeks, you could remove the tube and rinse it out in the sink with warm water. If that does not work, replace the tube.

 

Alfred S., M.D. -

Can you comment on the use of pH paper to confirm proper location of a replaced tube to avoid x-rays in these patients.

Jason Woods -

This piece is really focused on through the skin gastric tubes, so the confirmation is different. In general in a developed tract, neither radiographic or pH confirmation is used. If the tube enters easily, is able to spin in the skin without resistance, and does not cause pain when a small amount of fluid is flushed into it, we consider this confirmation of appropriate placement. For tracts that are not well developed or experience trauma, typically the use of contrast is required and neither plain X-rays or pH paper is adequate.

For an NG tube, local protocols dictate what you can do at your institution and that is outside of the scope of this piece. The generally accepted cutoff for using pH paper to confirm gastric placement of NG is 5. There are many reasons why pH paper may not be adequate (misinterpretation, medications that change the pH of the gastric content, inability to obtain an aspirate) but these generally are not false confirmations. Many institutions allow the use of pH paper with pH less than or equal to 5 as confirmation of NG placement.

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EM:RAP 2020 February Full episode audio for MD edition 198:29 min - 276 MB - M4AEM:RAP 2020 February German Edition Deutsche 98:04 min - 135 MB - MP3EM:RAP 2020 February Aussie Edition Australian 23:12 min - 32 MB - MP3EM:RAP 2020 February Canadian Edition Canadian 23:31 min - 32 MB - MP3EM:RAP 2020 February Farsi Edition Farsi 186:09 min - 256 MB - MP3EM:RAP 2020 February Spanish Edition Español 80:16 min - 110 MB - MP3EMRAP 2020 02 February Individual MP3 256 MB - ZIPEM:RAP 2020 02 February Written Summary 257 KB - PDFEM:RAP 2020 February Board Review Answers 147 KB - PDFEM:RAP 2020 February Board Review Questions 226 KB - PDF

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