CE ARTICLE

Everything the nurse practitioner should know about pediatric feeding tubes Erin Hannah, MS, CPNP (Certified Pediatric Nurse Practitioner)1 & Rita Marie John, EdD, DNP, CPNP, CMHS (Associate Professor)2 1 2

Ola Pediatrics, Bronx, New York Columbia University, New York, New York

Keywords Pediatric; gastroenterology; primary care; children. Correspondence Erin Hannah, MS, CPNP, Ola Pediatrics 3032 Corlear Avenue Bronx, NY 10463. Tel: 617-791-2619; E-mail: [email protected], [email protected] Received: February 2013; accepted: July 2013 doi: 10.1002/2327-6924.12075 To obtain CE credit for this activity, go to www.aanp.org and click on the CE Center. Locate the listing for this article and complete the post-test. Follow the instructions to print your CE certificate. Disclosure The authors report no competing interests.

Abstract Purpose: To provide an overview of the current feeding tubes in use in the pediatric population including feeding tube complications, and specific guidance for patients at the initiation, throughout the use of, and at the discontinuation of tube feeding. Data sources: A review of the literature was performed using multiple databases including PubMed, CINAHL, Ovid Medline, and Cochrane Library. Key words used included pediatric gastrostomy (G) tubes, nasogastric (NG) tubes, gastrojejunostomy (GJ) tubes, enteral access, and nurse practitioner (NP). Conclusions: Any child who cannot obtain nutrition orally is a candidate for enteral feeding tube access. Tube feeding is the recommended care guideline for children that are undernourished or unable to safely take-in oral nutrition. Tube feeding has been known to improve health-related quality of life. There are a number of different forms of feeding tubes that can be used in children, including NG, orogastric, G, and GJ tubes. Implications for practice: Children are being sent home regularly with enteral feeding tube access and NPs will encounter these patients in everyday practice. It is important that NPs know the risks and benefits of tube feeding as well as the types of tubes currently in use and their indications, advantages, disadvantages, and complications.

Introduction Without a properly functioning gastrointestinal (GI) tract, a child needs an alternative way to obtain nutrition. For children and infants in particular, lack of a functioning GI tract can mean poor growth, failure to thrive, and sometimes even death without proper intervention. Feeding tube placement is an effective way to provide nutrition and is the recommended care guideline for obtaining adequate nutritional status in children who are unable to do so orally (Bankhead et al., 2009; Mahant, Friedman, Connolly, Goia, & Macarthur, 2009). Today nasogastric (NG), orogastric (OG), gastrostomy (G), jejunostomy (J), and gastrojejunostomy (GJ) tubes are all frequently used in children (Bankhead et al., 2009; Fortunato, Darberi, Mitchell, Thompson, & Cuffari, 2005). In the past most children requiring enteral nutrition were managed in an inpatient setting. Currently, most chil-

dren go home with enteral access (Bankhead et al., 2009; Daveluy et al., 2005). Nurse practitioners (NPs) are more likely to encounter a patient with a feeding tube in the outpatient setting. It is important that the NP knows how to properly treat and manage this patient population (Bankhead et al., 2009; Daveluy et al., 2005). The goal of this article is to present the current enteral tube options and research surrounding enteral tube feeds to NPs so that they are equipped to care for these patients in practice.

Indications for a feeding tube There are a number of chronic conditions that make oral feeding difficult, unsafe, or impossible for pediatric patients making them candidates for enteral nutrition (Friedman, 2004; Gassas et al., 2006; Shin & Park,

C 2013 The Author(s) Journal of the American Association of Nurse Practitioners 25 (2013) 567–577 

 C 2013 American Association of Nurse Practitioners

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Table 1 Indications for enteral feeding tube access Motor dysfunction Neurological impairment Cerebral palsy Traumatic brain injury Nutritional deficiencies Short bowel syndrome Greater than average nutritional requirements Cystic fibrosis Hypertonicity associated with cerebral palsy Failure to thrive Caused by malignancy Prematurity

Oral feeding difficulties Feeding aversion Birth defects of the mouth, esophagus, or stomach Postpyloric feeding requirements Severe GERD Pancreatitis Severe gastroparesis

Other Chronic lung disease Complex congenital heart disease Renal failure

Note. The data in this table are from Conway et al. (2010); El-Matary (2011); Farber (2007); Fortunato et al. (2005); Gassas et al. (2006); Gharpure et al. (2000); Goldberg et al. (2010); Mahant et al. (2009); Puntis (2009); Sullivan et al. (2006).

2010). These conditions range from failure to thrive and oral feeding difficulties to neurological problems, musculoskeletal abnormalities, and diseases that increase metabolic demands. Table 1 provides a summary of conditions that are more commonly associated with the need for additional enteral access.

Types of feeding tubes There are a number of different types of feeding tubes available to accommodate individual needs. Table 2 summarizes the different tubes available and their indications, methods of insertion, and associated complications. NG, OG G, J, and GJ tubes are all potential options for enteral access in a child. NG, OG, G, and GJ tubes will be discussed in this article. NG tubes are generally indicated for short-term access while G and GJ tubes are better equipped for a patient with long-term nutritional needs (Farber, 2007; Goldberg, Barton, Xanthopoulos, Stettler, & Liacouras, 2010; Puntis, 2009). OG tubes are most commonly used in premature infants and rarely used in older populations. Specific tube placement in the GI tract depends on the individual and their diagnosis. For example, a child with severe gastroparesis will do better with a tube that ends in the jejunum rather than a tube that ends in the stomach as this enhances gastric emptying and prevents gastric stasis (Farber, 2007).

Nasal and oral gastric tubes With nasal and oral tubes, access to the stomach, duodenum, or jejunum is possible (Farber, 2007; Westhus, 568

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2004). A tube is inserted through the nose/mouth and is fed down past the pharynx, through the esophagus and into the stomach (Beckstrand, Ellet, & McDaniel, 2007; Farber, 2007; Westhus, 2004). The tubes can be placed and removed at the bedside so they are ideal for shorter enteral access needs. This is a less-invasive placement procedure than surgical methods so it remains a good option when a family objects to surgical placement of a gastric tube (Beckstrand et al., 2007). External measuring methods are used to determine the internal distance to the body of the stomach. Current standard placement procedures involve measuring from the nose to the ear to the xiphoid process for gastric placement and to the umbilicus for duodenal placement (Beckstrand et al., 2007; Farber, 2007). Recent research has shown that using this method of measurement in a child often miscalculates the proper distance to the stomach (Beckstrand et al., 2007). In a study of 494 pediatric patients ranging in age from 2 weeks to 19 years, Beckstrand et al. (2007) developed age-specific formulas that were a more accurate measurement tool than standard external measurement alone. These formulas take into consideration the difference in length found between the measurements of mouth/nose to the stomach internally and the distance found with external measurement processes. While these formulas were more accurate in this particular study, whenever age-specific formulas cannot be used, standard external measurement is the next most appropriate option (Beckstrand et al., 2007). Once the tube has been inserted, correct placement must be verified before feedings can begin. Bedside methods like checking gastric pH and listening at the stomach for a “swish” of air are still in use. The standard of care for determining correct placement of NG tubes in children remains confirmatory x-ray, however radiation exposure needs to be considered (Bankhead et al., 2009; Beckstrand et al., 2007; Johnstone, Leung, & Friedman, 2011; Westhus, 2004). Different size NG/OG tubes are necessary for children of different ages and different weights. In general, smaller French sizes (5–8 French) should be used in infants and larger French sizes (10–12 French) should be used in adolescents (Farber, 2007). Depending on a patient’s weight, smaller French sizes may be more appropriate.

G tubes Laparoscopic, radiological, surgical, and percutaneous endoscopic gastrostomy (PEG) placement are acceptable G tube insertion methods used in pediatric patients (Arellano, 2011; El-Matary, 2011; Farber, 2007; Jones, La Hei, & Shun, 2007; Ponsky, Guaderer, Stellato, & Aszodi,

Everything the NP should know about pediatric feeding tubes

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Table 2 Summary of feeding tube options Tube Nasal/orogastric

Indication  Short-term enteral feeding

access (Farber, 2007; Goldberg et al., 2010; Puntis, 2009)

Gastrostomy

 Enteral feeding access

greater than 4–8 weeks (El-Matary, 2011)

Insertion method  Bedside insertion with radiographic

confirmation of placement (Beckstrand et al., 2007)

 Surgical  Laparoscopic  Radiologic  Percutaneous endoscopic gastrostomy

(PEG; Arellano, 2011; El-Matary, 2011; Farber, 2007; Jones et al., 2007; Ponsky et al., 1985; Sjovie et al., 2010) Gastrojejunostomy

 Postpyloric enteral feeding

access greater than 4–8 weeks (El-Matary, 2011)

 Insertion of a jejunal tube after previously

created gastrostomy is mature and healed (El-Matary, 2011)

Complications  Misplacement into the respiratory tract and

brain—younger patient age, abdominal distention at the time of insertion, vomiting, and OG placement are all risk factors for a misplaced tube (Creel & Winkler, 2007; Johnstone et al., 2011; Westhus, 2004)  Migration out of original position (Beckstrand et al., 2007)  Irritation at the insertion site (Conway et al., 2010)  Migration from the original site  Leaking around the tube  Skin infection  Granulation tissue formation  Carcinoma from repeated granuloma—rare but reported  Peritonitis  Fistula formation  Obstruction  Migration from the jejunum  Leaking around the tube  Intussusception  Diarrhea  Large gastric biliary aspirates  Need for frequent tube replacement

Note. Data in cells D2 and D3 are from Beres et al. (2009); Catto-Smith & Jimenez (2006); Doede et al. (2002); El-Matary (2011); Fortunato et al. (2005); Friedman, Ahmed, Connolly, Chait, and Mahant (2004); Goldberg et al. (2010); Lantz et al. (2010); Oh, Gill, Lynch, and Cowles (2011); Puntis (2009); Sjovie et al. (2010).

1985; Sjovie, Larsson, & Arnbjornsson, 2010). The laparoscopic method is reported as the preferred method for G placement in children; however, the PEG method is becoming both popular and more readily accessible (Beres, Bratu, & Laberge, 2009; El-Matary, 2011; Farber, 2007; Jones et al., 2007; Sjovie et al., 2010). Table 3 provides a comparison of the advantages and disadvantages of each method of insertion encountered in the pediatric population. Complications associated with G tube placement depend on the method of insertion used. Different G tube devices are available that can be used for enteral feeding once a stoma is well established. These devices are shown in Table 4 and include simple G catheter with bumper and skin-level button devices (Michaud et al., 2004; Novotny, Vegeler, Breckler, & Rescorla, 2009). G tube buttons that sit on the skin include balloon style tubes and mushroom style tubes or tubes with an internal silicone dome (Farber, 2007). The size of these devices, including French size and stem length, is determined based on the child’s weight and size. Sjovie et al. (2010) studied 164 children requiring G tubes and reported that choosing a smaller tube (12 French vs. 14 French) from the first insertion prevents leakage around the insertion site in the future. Because

these are more permanent devices, it is important to increase the stem length as the child grows (Michaud et al., 2004). Table 5 provides a comparison of different available devices.

GJ tubes GJ tubes are an option for patients who require post pyloric feeding without undergoing a full surgical J tube placement (Fortunato et al., 2005; Gharpure, Meert, Sarnaik, & Metheny, 2000). Patients who already have a G tube in place, but have severe gastroesophageal reflux disease (GERD) with aspiration may benefit from an additional jejunal tube insertion through the PEG stoma already in place (El-Matary, 2011; Ponsky et al., 1985). The original insertion of GJ tubes involved placing a PEG and a jejunal tube during the same procedure. The jejunal tube was inserted 6–8 inches past the pylorus after the establishment of the PEG (Doede, Faiss, & Schier, 2002; El-Matary, 2011; Ponsky et al., 1985). Current GJ tube insertion involves prior placement of a PEG followed by the insertion of a GJ tube 6–12 weeks later, allowing development and maturation of the tract previously created (El-Matary, 2011). This method is also useful in patients 569

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Table 3 Methods for gastrostomy insertion Method Surgical

Advantages

Disadvantages

 A well-established method that was used for the majority

of the 20th century—falling out of favor (Farber, 2007)  Safe when transillumination of the stomach is impossible (George & Dokler, 2002) Laparoscopic

Radiologic

PEG

 Shown to be a safe method of insertion (Farber, 2007)  May be associated with less mortality than PEG placement

(Jones et al., 2007)  Better visibility of tube site during placement therefore more favorable in patients with anatomic abnormalities (Farber, 2007)  Least invasive of all the methods described (Arellano, 2011)  Associated with less morbidity and mortality than the other methods described (Arellano, 2011)  Associated with lower cost (Arellano, 2011)  Major complications are less frequently reported (Shin & Park, 2010)  Can be performed by an interventional radiologist (Arellano, 2011; Shin & Park, 2010)  Most readily available technique used (Shin & Park, 2010)  Decreased percentages of morbidity and mortality in children (Ponsky et al., 1985)  Lower cost than surgical and laparoscopic methods (Jones et al., 2007; Ponsky et al., 1985)  Can be performed by a gastroenterologist, interventional radiologist, or surgeon (Arellano, 2011; Farber, 2007; Ponsky et al., 1985)

where it is unclear whether they will require further intervention with jejunal access. The simple G tube can be trialed and a J tube can be placed in the future if it is determined that the patient would benefit. GJ tubes can be used to either feed via the jejunal port or the gastric port. Feedings given through the jejunal port must be run at a slow and continuous rate to prevent dumping syndrome (Farber, 2007).

Considerations when choosing a tube Selecting the most appropriate tube for a child is a very individualized process, taking into consideration the child’s medical needs and psychological needs as well as the family’s preferences. If the duration of need is unknown at the time of enteral nutrition initiation, an NG tube can always be placed and a child can be transitioned to G or GJ tube at a later time. The nutritional and anatomic needs of the child are also important to consider. A child who has a well functioning lower esophageal sphincter, stomach, and pylorus can tolerate feedings gastrically (Gharpure et al., 2000). Jejunal ports are necessary for children who cannot tolerate significant volume in the stomach to help prevent delayed gastric 570

 Requires general anesthesia (Farber, 2007)  Invasive procedure (Ponsky et al., 1985)  Costly compared to other available methods (Farber, 2007;

Jones et al., 2007)  Surgeon must perform this method (Farber, 2007)  Requires general anesthesia (Farber, 2007; Jones et al.,

2007)  May take longer to perform than PEG or radiologic

methods (Jones et al., 2007)  May be associated with higher cost (Jones et al., 2007)  Surgeon must perform this method (Farber, 2007)  Contraindicated in patients with unfavorable anatomy,

inability to access the stomach safely, and coagulopathy that cannot be corrected (Arellano, 2011; Shin & Park, 2010)

 Associated with higher rate of minor complications

(Ponsky et al., 1985)  Contraindicated in patients with a prior gastric resection,

gastric varices, coagulopathy, inability to transilluminate the stomach, and inability to juxtapose the gastric wall against the abdominal wall (George & Dokler, 2002)

emptying and possible reflux (Srivastava et al., 2009). The formulation of prescribed medication to be administered through the tube should also be considered (Clarke, 2008; Williams, 2008).

Formula options Once it has been determined that enteral access will be initiated in a patient, feeding schedules and formula should be selected. Jejunal feedings cannot be given in bolus fashion; they must be run at low rates continuously over at least 12–14 h of the day with water flushes every 4–6 h to prevent clogging (Farber, 2007). Higher calorie formulas are indicated for children with greater than average nutritional requirements. The fat content in formulas is increased for these patients, but this can lead to vomiting and feeding intolerance (Levine et al., 2006). Alternatives to increased fat content are more frequent feedings throughout the day and increasing calories from protein and carbohydrates instead of just fat (Levine et al., 2006). There are a number of prepared formulas currently on the market suitable for tube feeding. The types of formulas are summarized in Table 6. Infants can use infant formula or breast milk. Formula preparations

Everything the NP should know about pediatric feeding tubes

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Table 4 Gastrostomy and gastrojejunostomy tubes Name of device

Picture

Information

Gastrostomy catheter with bumper and internal balloon

This device is a standard gastrostomy tube with bumper and internal balloon. The tube is inserted while the internal balloon is deflated. Once the tube is inside the stomach, the balloon is inflated with water using a syringe. The bumper is then adjusted to sit just above skin level so that the internal balloon and tube do not migrate from their original site. This device is a skin level button device with internal balloon. Like a standard gastrostomy tube, the skin level device is inserted into the stoma while the balloon is deflated. Once the button is in place, the balloon is inflated with water using a syringe. The button then sits level with the skin. Extension tubing comes with the device and should be attached to the button whenever feeds or medication are administered and detached otherwise.

Skin level device—button with internal balloon

Skin level device—button with internal silicone dome (mushroom style)

This device is another skin level device with internal silicone dome. These tubes must be changed in the clinic by the surgeon or NP using an obturator device seen to the right of the tube. The obturator is inserted into the dome to stretch the dome allowing it to become thin enough to fit through the stoma. Extension tubing is also attached to the device during feeds and medication administration and detached otherwise.

Note. Images courtesy of Erin Hannah, CPNP, RN. Table 5 Gastrostomy devices available and associated advantages and disadvantages Device Button with balloon

Mushroom/silicone dome button

Advantages

Disadvantages

 More cosmetically acceptable  Eliminates need to switch to button at a later time  Reduces early dislodgement of the tube  Can be placed with initial gastrostomy insertion  Less pain associated with changes of the button  More cosmetically acceptable  Reduces early dislodgement of the tube  May have more longevity than balloon button devices  Can be placed with initial gastrostomy insertion  Fewer reports of snag on clothing than balloon button

device Simple tube with bumper on skin

 Does not require a separate extension set  Can be placed with initial gastrostomy  Potentially more durable than a skin level device  Potentially associated with lower risk of infection than

skin level devices

 High reported frequency of inner balloon rupture  Originally designed for replacement in a mature tract

so oftentimes the original tube placed must be removed under surgical procedure to place a button with balloon  Difficult and painful to replace  Limited size availability  Extension tubing does not lock in place  Originally designed for replacement in a mature tract so oftentimes the original tube placed must be removed under surgical procedure to place a button with balloon  Usually requires second surgical procedure to transition to a low profile skin level device  Higher potential for dislodgement  Less cosmetically acceptable  Decreased patient and family satisfaction reported

Note. Data in table from Farber (2007); Michaud et al. (2004); Nishiwaki et al. (2011); Novotny et al. (2009); Srinivasan, Irvine, and Dalzell (2009).

made specifically for certain disease processes are also available to meet specific nutrition needs (Bankhead et al., 2009). NPs should prescribe formula by calculating the caloric needs of the patient in 24 h, and using the calories per ounce in the selected formula to determine how much formula a child will need per day. Some families prefer to make their own formula preparations for their children with feeding tubes. There are many benefits to using blenderized tube feeds (BTFs) but

families who choose to take on this responsibility must be aware of the time and effort needed to prepare food capable of passing through a tube without clogging. A family must have a heavy-duty blender at home that can process food well (Novak, Wilson, Ausderau, & Cullinane, 2009). The guidance of a Registered Dietician is needed to prevent any potential nutritional deficiencies. Families must undergo extensive nutritional education in order to prepare foods with adequate nutritional value and calories.

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Table 6 Prepared formulas for tube feeding Type of formula

Composition

Action

Hydrolyzed (monomeric)

 Predigested proteins and simple

 Predigested and therefore minimal

carbohydrates such as glucose polymers  Fat source can be from oil or medium chain triglycerides

Semielemental (oligomeric)

 Varying length proteins  Peptides

digestive function is needed  Less stimulation of exocrine pancreatic function  Gives the GI tract a rest  Good for tubes placed in the jejunum  Tend to be the most hyperosmotic and can lead to diarrhea, cramping, nausea, and vomiting  Can be used for patients with malabsorptive, maldigestive processes  Dipeptides and tripeptide can be absorbed more efficiently than amino acids/whole proteins  Contains casein and lactalbumin hydrolysates stimulating jejunal absorption of electrolytes and water  Can be used for patients with maldigestive, malabsorptive processes  Complex to put together if a complete diet is desired.  Can be used as a supplement for a missing macronutrient

 Simple sugars  Glucose polymers or starch  Fat components are medium chain

triglycerides

Modular formula

Polymeric

Disease specific

 Contains only one of the

macronutrients (carbohydrates, fats, or protein)  Can be grouped together to form a complete diet  Contain unaltered proteins, carbohydrates, and fat

 Content of formula varies

depending on nutritional requirements of the disease process, for example, renal disease formulas are lower in protein, potassium, magnesium, and phosphorous compared to regular formulas

 Contains intact proteins, which

theoretically may be less well absorbed  Can include blenderized whole food and may clog the tube  It can be used in patient with a normal GI tract  Designed to meet the specific nutritional needs of a patient with a particular disease process

Examples of formula  Elecare (Abbott)  Peptamen Junior (Nestle)  PediaSure Peptide  Vivonex Pediatric (Novartis)

 Pediatric Peptinex DT (Novartis)  Vital Junior—for kids 1–13 years

(Abbott)

 Medium chain triglycerides (MCT

oil) is an example  Benefiber (Novartis)

 Resource Just for Kids (Novartis)  Osmolite 1.0, 1.2 (Ross)  Pediasure (Ross)

 Resource Diabetic (Novartis)  Nutri-Renal (Nestle)

Note. Data in this table from Makola (2005); Malone (2005).

There is always a risk with beginning BTF of a child losing weight from lack of calories and nutritional intake. Families must have a backup formula at home that is appropriate for their child if they are unable to prepare food or if BTF become too challenging to prepare on a daily basis (Novak et al., 2009). While using BTF is time consuming, there are also numerous benefits both nutritionally and psychologically for patients and their families. Children with feeding tubes are often inadvertently left out of meal preparation and mealtimes with their families. Using BTF provides a way for a child with a feeding tube to participate in meal preparation along with the rest of the family. This restores some normalcy around food, nutrition, and meals 572

(Dunitz-Scheer et al., 2011; Novak et al., 2009). Children transitioning from a feeding tube to oral nutrition benefit from BTF. They are more familiar with regular oral nutrition habits and often have an easier time transitioning to oral feedings with less risk of tube dependency (DunitzScheer et al., 2011; Novak et al., 2009).

Medication considerations When NPs prescribe medications for patients who are feeding tube dependent, they need to consider the medication formulations. Timing of nutrition and medication administration must be considered because medications should never be directly added to formula preparations

Everything the NP should know about pediatric feeding tubes

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Table 7 Supplies needed for patients with tubes Nasogastric tube

Gastrostomy or gastrojejunostomy tube

Portable feeding pump Tubing Feeding bags Stethoscope Syringes Tegaderm DuoDERM Water Bowl Appropriate formula

Portable feeding pump Tubing Feeding bags Syringes Gauze Water Bowl Appropriate formula

Note. Data in this table is from personal communication with Joanne Carroll, RD, RN, CPNP.

(Williams, 2008). If a child has a continuous tube feed cycled over 12–24 h, it is necessary to stop the feeding for administration of any medication. Liquids are often the preferred formulation for medication administration via a feeding tube (Williams, 2008). If a patient is transitioning to a tube and the medications are being converted to liquid preparations, caution must be taken to ensure correct dosage as not all formulation dosages translate (Williams, 2008). Extended release medications cannot be crushed and inserted through a tube similarly to enteric-coated tablets. Patients who previously used extended release medications may need to be transitioned to a regular release liquid formula that is administered several times throughout the day (Williams, 2008). Capsules that contain microencapsulated pellets should not be opened and inserted through the tube unless absolutely necessary. The microencapsulated pellets pose a risk of clogging because they are not always fine enough to fit easily through an enteral tube (Williams, 2008). The location of the distal tip of the tube must always be considered when choosing medication formulations. Medications that can only be absorbed in the stomach should never be administered through a jejunal port (Williams, 2008).

Tube feeding at home A new enteral tube is overwhelming for the child with the tube, their parents, and their family. Extensive education and preparation is important for families planning to take their child home with enteral access. Parents must have demonstrated adequate care of the tube site, proper administration of feedings and medication, and proper use of any feeding pump the child requires before the child can go home with an enteral access device (Bankhead et al., 2009). Table 7 lists the supplies needed at home for a child with both NG and G/GJ tubes. For

a child with an NG tube, the parents or caregivers must know how to check for proper position of the tube and know to stop feedings and call or seek medical care if they feel the tube has migrated out of place (Johnstone et al., 2011). Parents can change NG tubes at home while the provider should change G/GJ tubes. Parents should coordinate with the provider to order new tubes and develop a tube-changing schedule. NG tubes are usually changed every 7 days and G/GJ tubes are usually changed every 6 months to a year after the initial tube is changed depending on the device (Bankhead et al., 2009; Farber, 2007). Parents should understand what to do if a tube falls out and how to properly care for a stoma site to prevent skin breakdown (Puntis, 2009). Any parent or caregiver who does not feel comfortable caring for an NG or G/GJ tube at home should not be expected to take their child home with an enteral feeding device. If additional support is needed such as a visiting nurse or home health aid, the NP can help the patient and family coordinate additional home services. It is also important to make sure that the school nurse is comfortable with the care of a child with a feeding tube.

Care of the tube For NG and OG tubes, care at the insertion site includes providing buffers between the tube and mucous membranes or skin to prevent irritation (Conway, Morton, & Wolfe, 2010; Farber, 2007). The stoma site of a G or GJ tube should be assessed everyday to look for signs of infection, redness, swelling, discharge, leakage, and the presence of granulation tissue. A clean, dry, and wellhealed stoma site can often be left to air without a dressing or gauze around the tube (Farber, 2007). After the stoma is initially created, the site should be cleaned every day for the first 1–2 weeks with a 1/2 hydrogen peroxide, 1/2 normal saline or water solution to help remove any drainage or crusts. Thereafter, the tube site can be cleaned with warm water and a gentle soap and dried thoroughly each day. Tubes should be rotated at least 180◦ once a day to prevent adherence of the internal balloon to the stomach wall (Farber, 2007). Tube complications and solutions to common tube problems can be found in Table 8.

Role of the NP The role of the NP is to offer support and guidance to the patient and family at the initiation, discontinuation, and throughout the course of tube feeding. An NP needs to educate about tube feeding risks, benefits, proper care of the tube, treat common tube complications, alleviate parental concerns, and offer advice at the initiation, continuation, and/or discontinuation of the tube feeding 573

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Table 8 Common tube complications Complication

Solution

Tube clog

 Flush the tube with 5–10 mL of either carbonated water, soda, cranberry juice, or a mixture of pancreatic enzymes,

Leaking at stoma site

 Contact specialist who placed the tube

baking soda, and water  Check the tube for leaks or damage  Apply a barrier cream to the skin surrounding the stoma site to prevent skin breakdown from stomach contents  Check the balloon of the tube to ensure that it is fully inflated, if the stoma is extremely large then remove the tube

for a short period of time (1–2 h) and allow stoma to close slightly on its own Tube falls out

 Contact specialist who placed the tube, insert a Foley catheter or NG tube to prevent closure of the stoma site if the

tube falls out within 4 weeks of initial insertion  If it falls out after 4 weeks of initial insertion, clean the tube that fell out, reinsert and tape in place

Tube migration

 Follow-up with specialist who placed the tube  Always mark the tube so migration can be identified  If migration occurs, contact specialist who placed the tube, stop feeds until proper placement has been confirmed

Presence of hypergranulation tissue Deflated internal balloon

 Apply mid-potency topical steroid cream to the granulation tissue as a first line treatment  If this does not work, use silver nitrate  Use syringe to empty balloon completely and remove from stoma, check the balloon for damage or leaks  If balloon is not damaged, reinsert tube and add correct volume of fluid to the balloon using the syringe  If balloon is damaged, contact the specialist who placed the tube and keep stoma open until replacement device is

ordered Note. Stop feeds and medications when correcting complication, do not restart feeds or medications until it is confirmed that the tube is functioning properly and in the correct place. The data in this table are from Farber (2007); Goldberg et al. (2010); Mukherjee et al. (2010); Puntis (2009).

process (Campbell, 1988; Craig & Schambler, 2006; Dunitz-Scheer et al., 2009, 2011). Families who are aware of risks and complications before a tube is inserted are less likely to be distressed if complications occur in the future.

The benefits of tube feeding While tube feedings can be overwhelming for patients and their families, there are benefits of enteral tube feeds, which include weight gain, improved nutritional status, less complications in certain chronic illness, and improved quality of life. Weight gain and nutritional status is often the primary indication for initial placement of a tube. There is evidence throughout the literature that placement of a feeding tube can greatly increase weight gain in pediatric patients. A qualitative study of 50 severely neurologically impaired children done by Mahant et al. (2009) showed that after 6 and 12 months with a G or GJ feeding tube, weight for age significantly increased. Conway et al.’s (2010) systematic review of the literature on cystic fibrosis (CF) patients showed enteral tube feeding increased total energy intake, body weight, height, height velocity, and total body fat in patients with CF. Feeding tubes have also been shown to improve healthrelated quality of life. Mahant et al.’s (2009) study also showed that parents saw a statistically significant increase in their child’s health-related quality of life 12 months after initial G tube insertion. While it may be ideal for a pa574

tient to live successfully without a feeding tube, improved health-related quality of life can make dealing with all other aspects of a chronic condition more bearable. Enteral feeding access has also shown improvement in quality of life for caregivers of patients with severe neurological impairment (Srivastava et al., 2009; Vernon-Roberts et al., 2010).

The risks of tube feeding There are risks associated with tube placement and long-term tube presence including skin problems such as infection, irritations, and hypergranulation tissue (HGT); leaking around the tube; aspiration pneumonia (AP); and tube dependency. Infection and skin breakdown around the site of the feeding tube may occur. G and GJ tube sites can become infected shortly after placement or after the tube has been there for an extended period of time (El-Matary, 2011; Goldberg et al., 2010; Sjovie et al., 2010). Adequate education for patients and families and high-quality care of tube sites can help reduce the risk of infection. If gastric contents leak around the stoma site, the skin is more susceptible to breakdown because of the presence of gastric acid. Proper tube size prevents the leaking of gastric contents initially. If leaking occurs, the tube should be removed for a period of time to allow partial closing of the stoma site before a tube is reinserted. The appearance of HGT is also a potential risk with these tubes (Lantz, Larsson, & Arnbjornsson, 2010; Sjovie et al., 2010). Figure 1 shows HGT around a GJ tube.

E. Hannah & R. M. John

Figure 1 Peristomal hypergranulation tissue around a gastrojejunostomy tube.

It is important to differentiate HGT from infection as antibiotics are not used for HGT (Mukherjee, Coha, & Torres, 2010). Triamcinolone cream, silver nitrate, and surgical revision are treatments for HGT. Triamcinolone cream is applied with a cotton tip applicator two to three times a day to the HGT. Silver nitrate can be used but it does cause pain (Mukherjee et al., 2010). There is no current treatment option that is known to prevent regrowth of HGT and it is important not to use triamcinolone cream for 3–4 days after the application of silver nitrate. Patients can also have internal gastric irritation because of the presence of the balloon inside the stomach or intestine (Fortunato et al., 2005). Adjusting fit and ensuring proper placement of the tube can reduce the chance of irritation inside the gut. Despite GERD being an indication for tube placement, GERD has also been a reported complication of the presence of a tube and balloon inside the gut (Fortunato et al., 2005). AP is a complication associated with motor dysfunction of the GI tract and neurologic impairment. While arguments have been made that insertion of a G tube can increase reflux and AP, research that compares rates of AP before and after tube insertion has shown otherwise. A study done in 93 adult patients with G tubes showed a

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decreased incidence of AP during the first year after patients received their G tubes (Gray & Kimmel, 2006). A similar study done in 57 neurologically impaired children comparing respiratory morbidity before and 6–12 months after insertion of the G tubes reported that insertion of the tube decreased the number of bacterial infections in the first year after insertion (Sullivan et al., 2006). Long-term placement of a feeding tube without any oral intake can result in dependency on a tube. Tube dependency occurs when a patient no longer requires nutritional support from a feeding tube, but continues to use the feeding tube and has significant difficulty transitioning to oral nutritional intake (Dunitz-Scheer et al., 2009, 2011). This poses a particular problem for patients who may be candidates for tube weaning after their health status has improved. Tube dependency often presents with retching, vomiting, and aversion to all oral forms of nutrition (Dunitz-Scheer et al., 2009). Dunitz-Scheer et al. (2009) set out to define tube dependency and provide guidance to providers on how to help their patients wean off of feeding tubes. They suggest a 3-week program of slowly decreasing tube feed volume to induce hunger. Once a child demonstrates oral activity, feedings should be stopped during the day to allow for oral nutrition. Patients need to be closely monitored during weaning to prevent weight loss of greater than 10% and medical care must be available at any time should a child become unstable (Dunitz-Scheer et al., 2009). In order to prevent tube dependency from occurring at the time of weaning, activities such as oral stimulation throughout tube feeding and child participation during meal preparation are suggested. If it is safe for a tube-fed child, feedings can also be scheduled to run solely at night to allow for oral feeding during the day (Dunitz-Scheer et al., 2009).

Anticipatory guidance and support for patients With all of the physical, emotional, and psychosocial implications of tube feeding, providing support for both patient and family is important. Feeding a child is one way that parents bond with their children. There may be a stigma associated with tube feeding that causes a parent to feel that they failed to care for their child adequately (Craig & Schambler, 2006; Goldberg et al., 2010). As NPs, offering education about the benefits of tube feeding and informing parents of the improved weight and health-related quality of life can enhance acceptance. Parents need to be educated about restoring normalcy to eating, feeding, and meal preparation by involving their child in mealtimes (Novak et al., 2009). Tube feeding requires a team approach that largely involves cooperation and commitment from the patient’s family (Novak et al., 2009). Using shared decision making in providing care 575

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allows families to remain in control and can ultimately benefit the care that the child receives from both provider and family.

Recommendations for providers It is recommended that NPs get involved in patient and family education early and collaborate with other physicians and healthcare personnel who are involved to prevent oversights from occurring (Novak et al., 2009). NPs should consider family financial situations and available community resources such as WIC that may be able to help with costs of formula. The NP should also be familiar with the patient’s health insurance as costs of feeding pumps and tubing may be covered. Being empathetic toward financial constraints helps to build rapport with the family and provide the most practical care to the patient. NPs should reassure the parents throughout the course of tube feeding that providing nutrition for their child, even if through a tube, is benefiting the growth, health, and well-being of their child (Mahant et al., 2009). Being present as a resource for parent and child questions and concerns is imperative when caring for a tube-fed child.

Summary Feeding tubes are indicated as standard practice for pediatric patients who are unable to safely obtain oral nutrition. More tube-fed patients are living at home and NPs must be equipped to care for and provide education to this patient population (Bankhead et al., 2009; Daveluy et al., 2005). It is important for NPs to understand the risks, benefits, and complications associated with enteral feeding and some basic methods of care for feeding tubes. With the immense psychological implications for both patient and family, it is imperative that all NPs are able to provide support and guidance to their patients with tubes throughout the course of their care.

Acknowledgments I would like to thank Dr. Rita Marie John, EdD, DNP, CPNP, CMHS, for her unending guidance and support throughout the writing process and beyond. Without her advice, clinical expertise, and editing, this article would not be possible. I would also like to thank Joanne Carroll, RD, CPNP, for providing her own clinical experiences and advice regarding care of patients with feeding tubes. Her assistance, guidance, and opinions are highly valued and add great substance and clinical information to this article.

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