Crash course in feeding tubes

Cite this article as:
Georgina Bough, Ana Waddington, Rachel Radley and Rebecca McConnell. Crash course in feeding tubes, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32900

Flatter tubes

Gastrostomy button (Low profile balloon gastrostomy e.g. MIC-KEY button®, MiniONE button®)

Gastro-jejunostomy button (G-J button e.g. MIC-KEY gastro-jejunal feeding tube®)

Dangly tubes:

PEG tube (e.g. Freka® PEG, CorFlo® PEG)

PEG-J tube: (e.g. Freka® PEG-J, CorFlo® PEG-J)

Balloon gastrostomy (e.g. MIC gastrostomy®):

Ok, got that … Troubleshooting

Complications often depend on the type of tube – balloon or PEG, gastrostomy or gastrojejunostomy.

Tube has fallen out

This is probably the most common ED problem. They tend to be a balloon tube (the balloon bursts) and then it’s an urgent problem. If the tract is left empty it will close up in hours and may need a laparotomy to replace the tube.

Replace the tube if you can (family will often have a spare and many will do this at home). Otherwise put a foley catheter in the tract, tape it to the skin and call the relevant surgical team if you can’t replace the tube.

Lie the child down on the bed, bring a selection of catheters (6Fr, 8Fr, 10Fr, 12Fr) and lots of lube, aim to gently place the largest catheter that will go in, insert about 5cm in a larger child, 3cm in a smaller child. Tape the tube securely to the tummy.

DO NOT do this if this is a primary balloon gastrostomy.  See below.

The jejunal part has fallen out / flipped up

Again this is an urgent problem. The family may report milk coming back through the gastric port/ milky vomiting, a PEG-J that is strangely easy to flush, a tube that looks different to normal or a jejunal tube in the nappy or stoma bag!

PEG-J’s are made from different parts.  The jejunal tube is fed through the gastric part and can fall off (into the patient).  This can be confirmed on x-ray and a radiologist will need to re-thread a new jejunal tube. The old tube will usually pass out per rectum or via a stoma. Don’t use the jejunal part of the tube until it has been replaced.

Balloon gastro-jejunostomies are made as one piece but the jejunal end can flip back into the stomach (can be confirmed on x-ray). A radiologist will need to re-site the tube. Don’t use the jejunal part of the tube until it has been re-sited.

The tube is leaking / split

Leaking from skin level

This can happen if the child is unwell and the gastric motility is reduced (higher than normal pressure in the stomach). 

Is the PEG/PEG-J loose? If the tube moves in and out a lot, pulling it snug and securing the flange may stop the leak.  

Balloon tubes may have too little water so changing the water and adding 1ml may help. Padding the tube with a thick dressing or using a shorter tube may also help.

The family should have contact with a CNS who can help.

Leaking from further down the tube

This is often due to a split tube or connector on a PEG / PEG-J. It can be fixed without an anaesthetic as long as the split isn’t close to the skin. You need to find the parts that are specific to the tube, then cut the damaged part off and put a new end on – like DIY or Lego. Usually a nurse specialist or paediatric surgeon does this but knowing which tube the child has is essential.

The tube is blocked

This usually happens with longer tubes. Hospitals often have a protocol for unblocking, and there are a lot of hospital guidelines on the web. If simple measures don’t work change the tube (see below).

Skin problems

These can occur when a tube leaks, is infected or a granuloma forms. The family should have a CNS or enteral feeding nurse who should be able to help

  • Infection: swab the site for bacteria and fungi and treat. Use a dressing to stop the tube rubbing
  • Leaking: See leaking tube.  
  • Granuloma: Usually not an ED problem. More common in clinic or on the ward.

Summary

Tube typeDangly?Number of ends?How is it held in?Who changes it?
Gastrostomy buttonNo1BalloonAnyone trained (unless it is a primary gastrostomy button placed within 6 weeks, see below)
Gastro-jejunostomy buttonNo2BalloonPaediatric radiologist
PEGYes1 (varies by brand)Plastic discSurgeon/gastroenterologist
PEG-JYes2Plastic discIf jejunal part has fallen out - radiologist, if the whole thing is broken - surgeon/ gastroenterologist
MIC-G tubeYes1BalloonAnyone trained

** unless this is a primary gastrostomy button and was placed for the first time within 6 weeks. If a primary button falls out within 6 weeks call the surgical team who did the operation urgently.

a The PEG ends vary between brand. Here’s a couple of pictures of PEG tube ends and PEG-J ends for reference

Special cases

There are always exceptions! 

Primary gastrostomy buttons

Some surgeons create a new gastrostomy and use a button as the first tube (primary button). Many place a PEG first and then change the PEG for a button once the tract has healed. If a primary button falls out before the tract has healed (in the first 6 weeks) placing a new tube roughly could push the stomach away from the abdominal wall and leave the end of the tube in the peritoneum. After 6 weeks, the gastrostomy tract has healed and is like an ear piercing – you can change the tube without worrying where it will go. Ask the surgical history. The tract starts to form when it is first made, a general anaesthetic is required and they won’t have had a gastrostomy before then.  

Other uses for balloon gastrostomies

These are brilliant devices, they can be used in other ostomies e.g. vesicostomies, jejunostomies. Changing them is the same but they usually sit somewhere else in the abdomen (rather than in the left upper quadrant or epigastrium as gastrostomies do).

Other tubes

There are lots of other tube types out there and other brands including malecot tubes, Cor-flo PEGs. If in doubt ask a senior or your local friendly surgical registrar, if you can take a photo of the tube (with consent) this will help the conversation.

Combination tubes

As the PEG tubes can be assembled/disassembled like Lego® occasionally people will have odd-looking tubes.  This lass has a Corflo PEG end with a Freka securing device (external flange). Combination tubes should be the minority.

Gastrostomy Week – Complications

Cite this article as:
Camille Wu. Gastrostomy Week – Complications, Don't Forget the Bubbles, 2015. Available at:
https://doi.org/10.31440/DFTB.6390

You review a patient on the ward for abdo pain and pyrexia, and they have some sort of tube with feeds going into their stomach. You need to call the surgeons for a consult for their abdo pain. But what you call it? Do you know the difference between your PEGs and gastrostomies? Do you understand about tube calibres and lengths? In this four-part series, Camille Wu covers everything the general paediatrician needs to know about enteral feeding via gastrostomies….

Gastrostomy Week – Devices

Cite this article as:
Camille Wu. Gastrostomy Week – Devices, Don't Forget the Bubbles, 2015. Available at:
https://doi.org/10.31440/DFTB.6355

You review a patient on the ward for abdo pain and pyrexia, and they have some sort of tube with feeds going into their stomach. You need to call the surgeons for a consult for their abdo pain. But what you call it? Do you know the difference between your PEGs and gastrostomies? Do you understand about tube calibres and lengths? In this four-part series, Camille Wu covers everything the general paediatrician needs to know about enteral feeding via gastrostomies….

Gastrostomy Week – types

Cite this article as:
Camille Wu. Gastrostomy Week – types, Don't Forget the Bubbles, 2015. Available at:
https://doi.org/10.31440/DFTB.6353

You review a patient on the ward for abdo pain and pyrexia, and they have some sort of tube with feeds going into their stomach. You need to call the surgeons for a consult for their abdo pain. But what you call it? Do you know the difference between your PEGs and gastrostomies? Do you understand about tube calibres and lengths? In this four-part series, Camille Wu covers everything the general paediatrician needs to know about enteral feeding via gastrostomies….

Gastrostomy Week – why and when?

Cite this article as:
Camille Wu. Gastrostomy Week – why and when?, Don't Forget the Bubbles, 2015. Available at:
https://doi.org/10.31440/DFTB.6351

You review a patient on the ward for abdo pain and pyrexia, and they have some sort of tube with feeds going into their stomach. You need to call the surgeons for a consult for their abdo pain. But what you call it? Do you know the difference between your PEGs and gastrostomies? Do you understand about tube calibres and lengths? In this four-part series, Camille Wu covers everything the general paediatrician needs to know about enteral feeding via gastrostomies….

Constipation week – Day 4: Evidence on Tough Topics

Cite this article as:
Angela Clarke. Constipation week – Day 4: Evidence on Tough Topics, Don't Forget the Bubbles, 2014. Available at:
https://doi.org/10.31440/DFTB.5638

Bottom line: (pun definitely intended!)

  • A PR examination should only be undertaken by a doctor competent to interpret features of anatomical abnormalities or Hirschsprung’s disease e.g. paediatric surgeons
  • TFTs and coeliac screen should only be ordered by specialists in patients with intractable constipation
  • Abdominal xrays and abdominal ultrasounds are not recommended to aid diagnosis of constipation
  • Dietary interventions alone are not recommended but should be used in conjunction with a laxative
  • According to evidence, PEG 3350 (Movicol) should be the oral laxative of choice
  • Maintenance regimes should be continued for several weeks to months
  • Routine use of enemas is not recommended

See our other Constipation Week posts

Do I order TFTs and coeliac screen?


Thyroid function testing and coeliac screening should only be ordered by a specialist service as part of the investigation of intractable constipation when atypical presentations of these diseases are considered. There are no published studies stating the prevalence of coeliac disease and hypothyroidism in children with idiopathic constipation (Reuchlin-Vroklage et al, 2005).

Should I get an abdominal x-ray to confirm my diagnosis?

Evidence shows that abdominal x-rays play little role in confirming or refuting the diagnosis of constipation as there is poor diagnostic accuracy and reproducibility (Reuchlin-Vroklage et al, 2005). It is important to remember that the average radiation dose of an abdominal x-ray is 0.7mSv, that’s 7 times higher than a chest x-ray. That is relatively high compared to the background yearly exposure of approximately 3mSv (Mettler et al, 2008).

What about an abdominal ultrasound?

Abdominal ultrasounds have shown that children with idiopathic constipation have a larger rectal diameter than those without constipation. However, they don’t give any extra information than what is obtained through thorough history taking and examination and are therefore not routinely recommended.

Which laxative do I choose?

There are a series of case series and randomized control trials that show treatment with PEG 3350 was effective in causing disimpaction of children with constipation.  The studies show that higher doses are more effective than smaller doses and that PEG 3350 is more effective than stool softeners and enemas (Youssef et al, Tolia et al, Guest et al ). There is currently no evidence of the effectiveness of stimulant laxatives in treating disimpaction.

The NICE ‘Constipation in children and young people’ guidelines suggest the following management for children over 1 year of age:

  1. Rule out ‘Red flags’.
  2. Assess for impaction – i.e. overflow soiling and/or faecal mass palpable abdominally. Start maintenance therapy for those not faecally impacted, treat for disimpaction if faecally impacted.
  3. Treat for disimpaction or commence maintenance therapy:
    • 1st line – Macrogol PEG 3350  – escalating dose regime for disimpaction or adjusted according to response in maintenance regime.
    • 2nd line – (2 weeks later) Add a stimulant laxative (e.g. sodium picosulfate,  bisacodyl, senna,)
    • 3rd line – Substitute a stimulant laxative singly or in combination with an osmotic laxative (lactulose) if Macrogol PEG 3350 not tolerated.
    • 4th line – Enema (stimulant laxative: Microlax or Bisacodyl)
    • 5th line – Manual evacuation under anaesthetic.
  4. Continue maintenance regime for several weeks to months.
  5. Medications not to be stopped abruptly but to be weaned over a period of months.

Dosage guides are provided in the guideline – https://guidance.nice.org.uk/CG99.

 

References

Reuchlin-Vroklage LM, et al. Diagnostic value of abdominal radiography in constipated children: a systematic review. Archives of Pediatrics and Adolescent Medicine. 2005;159(7):671-8.

Mettler FA, et al.  Effective Doses in radiology and Diagnostic Nuclear Medicine: A Catalog. Radiology. 2008 Jul ;248(1):254-63.

Youssef NN, et al. Dose response of PEG 3350 for the treatment of childhood fecal impaction. Journal of Pediatrics. 2002;141(3):410-4.

Tolia V, et al. A prospective randomized study with mineral oil and oral lavage solution for treatment of faecal impaction in children.  Alimentary Pharmacology and Therapeutics. 1993;7(5):523-9.

Guest JF, et al. Clinical and economic impact of using macrogol 3350 plus electrolytes in an outpatient setting compared to enemas and suppositories and manual evacuation to treat paediatric faecal impaction based on actual clinical practice in England and Wales. Current Medical Research and Opinion. 2007;23(9):2213-25.

Candy DC, Edwards D, Geraint M. Treatment of faecal impaction with polyethelene glycol plus electrolytes (PGE + E) followed by a double-blind comparison of PEG + E versus lactulose as maintenance therapy. Journal of Pediatric Gastroenterology and Nutrition. 2006;43(1):65-70.

Pashankar DS and Bishop WP. Efficacy and optimal dose of daily polyethylene glycol 3350 for treatment of constipation and encopresis in children. Journal of Pediatrics. 2001;139(3):428-32.