Long-term enteral indwelling feeding tubes are placed by a healthcare prescriber.
All long-term enteral indwelling feeding tubes must have an internal stabilizer to keep the tube from falling out. They must also have an external stabilizer to keep the tube in the correct position and prevent tube migration into the gastrointestinal (GI) tract (Figure 38-1 and Table 38-1). The shapes of these stabilizers differ; care of the tube may need to be adjusted accordingly.
Gastrostomy tubes (G-tubes) are placed either surgically (called a Stamm procedure), endoscopically, or, in some cases, by interventional radiology. G-tubes are placed directly into the stomach by either open surgery or laparoscopic surgery. Percutaneous endoscopic gastrostomy (PEG) tubes are placed endoscopically. After an established G-tube tract is formed (about 12 weeks), a skin-level G-tube device can be placed. There are numerous devices available. The internal stabilizer for skin-level devices is either a balloon type or a mushroom type. A balloon-type skin-level device may also be placed with minimally invasive surgery at the time of an antireflux surgical procedure or considered for special indications, such as when a caregiver gives a history the child may pull out the PEG due to behavioral patterns.
Figure 38-1 PEG gastrostomy tube. The internal, dome-shaped tip anchors tube in body and prevents tube from falling out. The crossbar at skin level prevents internal tube migration.
Jejunostomy tubes (J-tubes) can be placed through similar procedures. The distal tip rests in the jejunum but may originate through the stomach (G-J or PEG-J) or directly into the jejunum. Skin-level devices are available. These tubes may also be referred to as a transgastric jejunal (TJ) or transpyloric feeding tubes. They are referred to as J-tubes in this chapter unless specific care is dictated by a certain device.
Tubes that originate in the oral cavity, oral gastric (OG) nares, nasogastric (NG), or nasojejunal (NJ) are discussed in Chapter 39.
Indwelling enteral tube site care should be performed every day (during the bath is a convenient time) and as needed to maintain skin integrity.
If dislodgment of a newly placed tube occurs (usually less than 10 to 12 weeks after initial placement), or if it is the first tube change, reinsertion of the tube is performed by the healthcare prescriber. If there is difficulty with the insertion of the tube, a tube study should be performed by radiology to confirm correct placement.
Per institutional policy, a registered nurse (RN), primary caregiver/family member, or child trained in the balloon-type gastrostomy tube replacement can perform a tube replacement once the gastric tunnel and stoma are well established and the initial change has been done (usually 10 to 12 weeks after initial placement of tube). These tubes include balloon-type G-tubes, skinlevel devices, and/or a balloon catheter device.
If dislodgment of a jejunostomy tube occurs, a trained RN or primary caregiver/family member may insert a balloon-type replacement G-tube or catheter into the stoma for the sole purpose of splinting open the stoma until the healthcare prescriber can replace it. Instructions must be given to not feed through the device until the tube is replaced and position of the new tube is confirmed.
TABLE 38-1 Comparative Chart of Gastrostomy Tubes in Children
Topic
Skin-Level G-Tubes (Low-Profile Tubes)
Type
Traditional G-Tubes: de Pezzer, Malecot (Mushroom-Tipped) Catheter
Percutaneous Endoscopic Gastrostomy (PEG)
Balloon-Type G-Tubes/Balloon Catheter
Button (Bard)
Balloon Type (e.g., MIC-KEY®, Mini®)
Indications
Postsurgical decompression of stomach for select congenital anomalies or surgical emergencies of the newborn
Antireflux surgical procedure for hiatal hernia or GERD when unresponsive to medical management
Supplemental/total nutrition
Supplemental/total nutrition
Contraindications: Prior abdominal surgery, hepatomegaly, ascites, gastric varices, abdominal mass, morbid obesity
Supplemental/total nutrition
Replacement G-tube
Balloon-type G-tube may be placed surgically or after PEG
Foley may be used for transition G-tube for dilatation of tract before skinlevel G-tube placement
Supplemental/total nutrition
Body image/personal preference/developmental
May transition after 6-8 weeks from PEG/traditional G-tube
Supplemental/total nutrition
Laparoscopic antireflux surgical procedure
Body image/personal preference/developmental
May transition after 6-8 weeks from PEG/traditional G-tube
Sedation
Recommend
child-life
specialist to prepare all children with developmentally appropriate strategies.
General anesthesia
In OR with general anesthesia or deep sedation with EGD
For removal of PEG and replacement with balloon type, sedation per patient need
For routine change of balloon-type tube, bedside placement or outpatient
For removal of PEG and routine change sedation per patient need
For removal of PEG and initial insertion done with EGD under sedation per patient need. For routine change outpatient/bedside placement
For laparoscopic antireflux procedure, in OR with general anesthesia
Device description
Rubber latex
Internal stabilizer: “mushroom tip”
External stabilizer: placed by caregiver
No feeding port closure; use rubber band for closure
No medication port
Avoid use of clamps on tube
Silicone
Internal stabilizer: dome shape
External stabilizer: crossbar, round ring, or disc
Has feeding port and medication port and closures
Tract may need to be dilated with Foley to prep for skin-level G-tube
Centimeter calibrations on external segment of tube
Silicone; Foley: available as rubber latex, prefer silicone
Internal stabilizer: 5-mL balloon requires external stabilizer
No feeding port closure; use rubber band for closure
Silicone
Device is at skin level
One-way valve at base of device
Feeding attachments: bolus/continuous must match the FR size of the device
Internal stabilizer: mushroom tip
Requires a special tubing for venting decompression
Silicone
Device is at skin level
One-way valve at top of device
Feeding attachments lock in place for bolus and continuous
Universal-size feeding attachments
Internal stabilizer: balloon: volume of H2O: MIC-KEY® maximum is 10 mL; Mini® maximum varies by size of device. Always check manufacture’s recommendations.
Balloon-type G-tubes:
Have an external stabilizer (e.g., disk shape)
Have feeding and medication port closures
Avoid use of clamps on tubes
General information
Sutures at stoma removed per surgeon
After sutures removed, tube can move in/out of stoma freely
Vent stomach:
After antireflux surgical procedure
Before and after feeds
Abdominal discomfort/distention
Retching/gagging (must vent to maintain intact operative site)
No sutures
During first 24 hours do not change dressing
Minimal manipulation until well healed (about 3 days)
No ongoing dressing needed
Can vent stomach
The cm markings on external segment of tube help identify tube has maintained correct position.
Keep external segment securely taped to abdomen for at least 3 days after initial placement to avoid traction on site
No sutures
No dressing
Tube can move freely in/out of stoma
Caregiver can learn to replace
Balloon volume can be adjusted for peristomal leakage
Balloon-type G-tube has cm markings on external segment to identify correct tube position is maintained
Foley catheter used as a replacement tube
Requires a well-established G-tube tract
No dressing needed
One-way valve allows gastric contents to remain in stomach when device is unplugged
Venting requires special decompression tubing
Requires a well-established G-tube tract
No dressing needed
One-way valve allows gastric contents to remain in stomach when device is unplugged
Can vent stomach by attaching the feeding tubing
Caregiver can learn to replace when stoma is well-healed
Postlaparoscopic antireflux surgical procedure: device is secured with surgical adhesive or sutures to avoid accidental dislodgement
Consider keeping the feeding tubing attached to the device post antireflux surgical procedure for comfort and to vent frequently
Skin care
Initial: use normal saline
Stoma well healed: use soap and water
Apply external stabilizer: use “gauze bolster” or tape wrap to stabilize and correctly position
Initial: use normal saline for 3 days
Stoma well healed: use soap and water
Check tension of external stabilizer: comfortably fit cotton-tipped applicator under external stabilizer or a U.S. dime-sized space between skin and external stabilizer
Rotate device during skin care
Soap and water
• For gauze external stabilizer:
Change daily with skin care
Rotate in a 3-6-9 o’clock fashion
For tape wrap:
Increases the circumference of the tube at the skin level to avoid tube migration
Pull tube back against stomach wall before wrapping tape around tube at skin level
Replace it as needed
Soap and water
Rotate device during skin care
Soap and water
Rotate device during skin care
Postlaparoscopic surgery: skin care may be ordered by surgeon. Can use sterile normal saline until sutures are removed
Flusha
Routine flush with warm water, Flush after medications and feeds with water (3-5 mL)
Activity
Bathe after stoma healed and sutures out
Secure tube to avoid dangling and tube dislodgment
May position prone as tolerates
Bathe after stoma healed (2-3 days)
Secure tube to avoid dangling and tube dislodgment
May position prone as tolerates
Can bathe
Secure tube to avoid dangling and tube dislodgement
May position prone as tolerates
Can bathe as usual
Better accepted for body image and increased activity
May position prone as tolerates
Can bathe as usual; check with surgeon for postlaparoscopic surgery care
Better accepted for body image and increased activity
May position prone as tolerates
a a For children at risk for fluid balance disturbance, adjust flush volumes individually.
G-tube, gastrostomy tube; GERD, gastroesophageal reflux disease; OR, operating room; EGD, esophagogastroduodenoscopy.
Indwelling enteral tubes are made of biocompatible medical grade silicone material and should not require routine change unless they become accidentally dislodged or the integrity of the tube itself is breaking down. Follow manufacturer’s instructions for routine time periods to replace enteral tubes in children receiving long-term enteral therapy.
Gauze or soft washcloth
2 × 2 split gauze
Water
Cleansing solution (e.g., for newly placed tubes: sterile normal saline; for well-healed stomas: soap and water)
Three cotton-tipped applicators
Two small medicine cups
Paper tape (1 inch)
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