Feeding Tubes
From Holoprosencephaly
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A feeding tube is a medical device used to provide nutrition to patients who cannot obtain nutrition by swallowing or maintain an adequate nutritional state from oral intake.
Liquids administered through NG, gastric or j-tubes are named enteral feedings. Enteral means "within or by way of the intestines".
Types of Feeding Tubes
A variety of feeding tubes are used in medical practice. They are usually made of polyurethane or silicone. The diameter of a feeding tube is measured in French units (each French unit equals 0.33 millimeters). They are classified by site of insertion and intended use.
These include: Nasogastric tubes Gastrojejunal or G-J tubes Jejunostomy or J-tubes Gastric or G-tubes
Nasogastric tubes
A nasogastric tube (NG tube) is a tube, inserted into a nostril of the nose, into the throat, down the esophagus and into the stomach. It is suitable only for relatively short-term use, as it is uncomfortable and tends to be removed by the patient. It may also be used for nasogastric suction (for intestinal decompression), and for administration of medications to those unable to swallow.
G-J Tubes
G-J tubes or gastrojejunal tubes have a G port and a J port. The jejunal portion has to be placed either endoscopically or radiologically. The tube cannot be changed by the parent. If a G-J tube comes out at home, pop in a regular spare G-Tube, rather than letting the stoma close up. G-J tubes are useful when a child has severe gastroesophageal reflux (GER) and someone is trying to avoid a fundoplication (Nissen or other). Feeding jejunally generally needs to be done as a continous feed rather than bolus, because you are feeding directly into the small intestine (the jejunum) rather than the stomach. The problem with G-J tubes is they often come out and are really just a temporary measure if you think there is chance the child may outgrow the problem.
J-Tubes
A jejunostomy tube is similar to a gastric tube, though generally has a finer bore and smaller diameter, and is surgically inserted into the jejunum rather than the stomach. They are used when the upper gastrointestinal tract must be bypassed completely, and can be used as soon as 12 hours after surgery. This type of tube is usually used for people who have stomach ulcers.
These small bore tubes are prone to clogging, particularly with some medications and if not flushed as directed. Feeding through these tubes are generally commercially prepared to provide adequate nutrition and to not result in clogging when used with a pump or with drip feedings.
Gastric tubes
A gastric feeding tube, or "G-tube", is a tube inserted through a small incision in the abdomen into the stomach and is used for long-term enteral nutrition. The initial tubes that are placed endoscopically or by PEG (percutaneous endoscopic gastrostomy) have a bolster. When changing the PEG tube for the first time, usually the person removing the tube will attempt to pull the tube through the stoma. The PEG tube is then replaced with a standard gastrostomy tube.
Often a Nissen fundoplication, is completed at the same time as surgical g-tube placement to treat existing GERD or reduce the long-term risk of GERD and aspiration after surgery. The upper part of the stomach is wrapped around the LES to strengthen the sphincter and prevent acid reflux.
This fundoplication procedure may be done using a laparoscope and requires only tiny incisions in the abdomen.
Types of G-tubes
Balloon type tubes- These are inserted into the stomach and a balloon on the end is inflated with water to prevent the tube from coming out. Examples: Foley catheter, Mic tubes and Flow-thru tubes.
A skin level device or “button” –These lie flat on the abdomen and a mushroom-like tip or balloon is inflated inside the stomach to keep it in place. Examples: Mic-Key button, Bard button and Gastroport
G-Tubes can have different numbers of ports. Some only have one port and some have a bolus port, a medication port, and the balloon port.
Post-op
Although it is obviously more complex, think of the g-button hole as a new piercing, like one for an earring. Instead of an earring and back, you have a round button on the outside, narrow middle and balloon on the end.
Initially there will be a small amount of bleeding and irritation. It is important not to jerk on the button. After a week post-op, a scab should be formed around the base of the button. While this area heals, be sure to wash gently with a small amount of mild soap and water, and pat dry. A small amount of diluted alcohol solution may be used for cleaning, only if it is absolutely necessary.
Different MD's will prescribe different protocols post-op. Unless you've been told to do so, there should not be any peroxide used on the area, for a couple of reasons.
First, once the scab forms, it will be protecting the area underneath it to allow granulation tissue to "fill in" the area of skin that has been disturbed (like a band-aid). If you disturb that scab, like washing with a peroxide solution, it has to keep reforming and the area underneath isn't able to heal as well. When healing does eventually occur, there will be more scarring and the button will not fit as snug as it should.
Another reason there shouldn’t be heavy use of peroxide in this area is the potential for growth of pseudomonas infection. It is a nasty bacteria that loves to grow in warm, dark places, feeding off the oxygen molecules in the peroxide.
Feeding with a G-tube
Some children are fed at intervals, called bolus feedings. These may be delivered with syringes or with a pump over a short period of time, like an hour.
Others may need to be fed over a longer period of time or overnight, called continuous feeding. This type feeding requires use of a pump to deliver just the right amount of formula at a rate that is best for the child.
The child will begin on a schedule for tube feedings while he or she is in the hospital.
Caregivers will be taught how to feed their child through the tube or button, care for the tube/button insertion site, and troubleshoot any problems that may occur.
Initial set-up supplies in the hospital are provided by the hospital. After discharge, the child’s primary care physician can manage tube feedings and a home health company will provide feeding supplies and formula, usually on a monthly basis. Although general rules apply for most children in regards to feeding, caregivers should follow the instructions of their physician/nurse as to how feeding should be carried out, for how long, what type of formula should be used and any other special directions specific to the child.
Formula
Enteral formula differs from regular formula because certain molecules are already broken down and ready for absorption. Food/liquid begins breaking down in saliva and even further in gastric juices. By the time it reaches the small intestines, some of it's molecules are ready or almost ready for absorption. All of that is bypassed in tube feeding when the formula is placed directly into the stomach or small intestines. The ingredients are the same but in different form. There may be a small difference in the ratio of carbohydrates, protein and fat, but not much.
Caloric Intake
It is important for children with neurological problems to consume only what they need and maintain a normal weight otherwise they may be too heavy to move muscles that they are already having difficulty moving.
The primary focus should be on efficiency. The child should be getting enough nutrition to maintain normal electrolyte values, normal blood count ranges, normal protein balance and normal fluid balance while growing at a steady rate (in length and height). As long as the child does those things, it may not be important that they consume the amount of a "typical" baby their age. There are many other factors that are characteristic to each child that affect/change how much they need in comparison to others. One example in the different caloric needs may be that another infant their age may move around more than they do, consuming more energy and requiring more calories.
If caloric intake becomes a problem because the child is unable to consume a large quantity at once or more often, then a nutritionist may be able to assist with preparation of a more calorie-dense formula. Sometimes parents are tempted to add sugar or fat just to retrieve the caloric benefit but it's not good for babies to receive these in disproportionate amounts to other nutrients.
Giving medications
Caregivers should follow the instructions of their health care providers for safe medication administration.
Some medicines may react with the formula so careful timing is important.
Some pills may be crushed into fine powder and dissolved with water for administration. These may clot the tubing so it is important to flush with water prior to and after administration.
Reflux
If fundoplication isn’t completed along with g-tube placement, reflux may worsen after g-tube placement.
Often caregivers may notice extra secretions accumulating in the back of the child’s throat when they reflux.
Small infants (and older children with neurological problems) do not have the complete ability to manage those secretions. Often you will see them hold saliva in the back of their throat, causing the irritation to worsen or they will aspirate a small amount of that saliva and then cough it back out into the throat, again worsening the irritation. When they finally do swallow, it often refluxes back into the throat and the cycle repeats. With this occurrence, caregivers seek the advice of a pediatrician or GI specialist for treatment of esophageal reflux or GERD.
For more information about reflux symptoms/treatment see section labeled: GERD.
Gas and Decompression
Most kids who have a fundoplication deal with gas and bloating because their ability to release air through burping has been compromised. It is important to use a decompression tube to release air prior to feedings and when the child appears to have discomfort related to gas pressure (bloated abdomen, gagging or wretching, hiccups; etc).
The g-tube manufacturer will supply decompression tubes along with the device. It is very important for caregivers to read and follow instructions for specific use. In addition, the physician or nurse may be able to provide helpful suggestions. Initially it takes many attempts with trial and error until caregivers learn how to do this effectively.
For bolus fed children, it may be helpful to flush the tube with 5cc of warm water prior to attaching the decompression tube then allow ventilation for 5 minutes (or so) prior to each feeding. It is important to return any juices that escape during ventilation because they are essential to effective digestion.
A Farrell Valve Bag may also be ordered. This device allows simultaneous decompression (release of air) from the stomach during feeding.
If serious difficulties persist professional guidance should be sought to ensure that electrolytes are in balance and no otherphysiological/physical problems exist (like some anatomical problems in the digestive system, thyroid problems, growth hormone problems;etc)
If the device comes out
If the device comes out in the first 2 months after placement, it should be replaced by the surgeon. During this period, a catheter plug may be kept on hand to insert into the hole to keep it from closing too much.
After the hole has healed, parents may be taught how to change the g-button themselves. An extra device should always be kept on hand in case of emergencies.
Bard buttons must always be changed by a surgeon.
Sources: http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/ Eric Levey, M.D. Carter Center for HPE Kennedy Krieger Institute: http://home.att.net/~hpe/levey.htm http://en.wikipedia.org/wiki/Feeding_tube
Resources: Mic-Key by Kimberly Clark Bard Buttons Ross Abbot Laboratories Mead Johnson Farrell Valve Bags
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