Feeding tubes are alternative ways to enter the gastrointestinal system while bypassing the mouth. Feeding tubes are used for children who need additional help to gain weight or protect them from complications from oral feeding, and to ensure that the child receives enough fluids to stay adequately hydrated*. These tubes also provide options to give medications when a child can’t or won’t take them by mouth. Tubes also can help to vent (relieve gas) and remove or drain unwanted fluids from the gastrointestinal (GI) tract. This section explains the basic differences of the various feeding tubes and gastrointestinal ostomies, and addresses common questions and concerns. The resource links provide useful additional opportunities to learn more about these topics. Decisions about placing and removing any tube that goes in the body can be difficult. It is important for families and medical personnel to discuss benefits and possible risks associated with the various options before making a decision.
Parts of the Digestive Tract. This diagram is provided as a reference to help visualize where the various feeding tubes extend into the body. By Mariana Ruiz Villarreal (LadyofHats) (Own work) [Public domain], via Wikimedia Commons.
- Unsafe oral feeding. In some children, tube feeding may be necessary due to frequent coughing, choking, and aspiration. Even if maximum efforts are made to prevent aspiration of food and drink into the lungs (with gastrostomy tube feeding and Nissen fundoplication), oral secretions may still be aspirated;
- Severe reflux and the need for preventative surgery to prevent it (Nissen fundoplication) - a feeding tube will usually be inserted at the time of reflux surgery.
- Inefficient feeding due to oral motor dysfunction leading to prolonged labor-intensive feeding or poor weight gain. Families often don't realize how long they spend preparing food and feeding their child with a chronic condition - for children with CP and swallowing problems, estimates are 3.5 hours/day compared to 0.8 hours/day for typically developing children. Families who have opted for tube feeding often report an improved quality of life due to a reduction in feeding times, improved medication administration, and decreased worries about their child's nutrition. [Sullivan: 2004];
- Recurrent periods of dehydration or weight loss due to frequent illnesses; and
- The need for an alternate route to give medications, fluids, or an unpalatable diet (ketogenic diet formulas).
- If malnutrition is present, oral feeds, even with nutritional supplementation, are rarely enough to resolve it. Sometimes however, a period of tube feeding (nasogastric or gastrostomy tube) supplementation may allow the child to catch up to a normal weight and then continue with oral feeds alone.
- Percutaneous placement of a gastrostomy tube or gastrojejunal tube is recommended if the child will require tube feeding for more than about six weeks. These are readily removable when no longer necessary.
- The child with a temporary feeding tube can be fed by tube at night, allowing hunger and thirst to occur during the day so that oral feeding can continue. This may also be a time that oral-motor skills to improve oral feeds may be optimized, allowing a better transition back to oral feeding.
Phot courtesy of Nanoxyde
via Wikimedia Commons.
Photo courtesy of "The LeCrones" on Flickr,
Sept. 15, 2006, via Creative Commons.
Ostomies generally refer to surgically created pathways to enter or exit the body, such as a gastrostomy that is a pathway to the stomach, or a jejunostomy that is a pathway to the jejunum (part of the small intestine). The site where the gastrointestinal tract (stomach or intestine) is pulled up to meet the skin heals into an opening called a stoma. There are many other kinds of ostomies in the body not covered in this section, such as colostomies and ileostomies as exits for chime (digested food and fluid) or stool, tracheostomies for respiration, and urostomies for removal of urine. Stoma nurses (or enterostomal teams) have specialized experience in caring for common problems such as irritation or leaking.
- Stamm gastrostomy - open surgical procedure
- Janeway gastrostomy - laparoscopic procedure
- Percutaneous Endoscopic Gastrostomy (PEG) - endoscope or image-guided radiography to insure proper g-tube placement
Balloon-bolster low profile gastrostomy device
- Contains an internal, water filled balloon which holds the low-profile device in place and prohibits displacement
- The balloon is breakable, so g-tube changes may be required more frequently than non-balloon devices.
- The valve is located on the outside of the body
- Relatively easy and painless to change
- Has a feeding adapter locking mechanism
- Contains a mushroomed shaped tip which prevents displacement
- The mushroom tip is less likely to break than the balloon tip, and therefore needs to be changed less frequently (once per year)
- The valve is located inside the stomach, making the non-balloon button less noticeable than the balloon device
- More difficult to change
- Does not have a feeding adapter locking mechanism
- Care should be taken to select the appropriate formula – consultation with local nutrition experts or pediatric gastroenterology may be helpful.
- Formula, milk and water are the only fluids permissible to use through a G-tube.
- The child should always be held upright during a feeding.
- Oral stimulation (chewing, sucking on pacifier) is recommended during the feed to promote normal development.
- Participation at the dinner table, or routine family eating activities should be performed during a G-tube feed to promote socialization.
- The G-tube should be flushed with water after each feeding to avoid obstruction due to drying of residual formula or medications. Recommended flushes are 5-10cc of water for infants and 15-30cc of water for older children.
- Venting of gas may be needed for the child’s comfort, similar to burping a baby after a feeding. Venting can be done using an empty syringe, opening the extension catheter to drain air out, or with a specialized decompression tube for Bard buttons.
|Image courtesy of Feeding Raya (http://agirlandhertube.blogspot.com)|
To prevent medical errors and improve patient safety, it is important to think about which medications, formulas, and supplements are given, how they are formulated (liquid versus pill, immediate-release formulations versus time-release, etc.) and how they are metabolized (processed) in different parts of the body. All prescription medications, over-the-counter medications, supplements, and natural or holistic remedies need to be discussed with the medical provider and pharmacist to help prevent interactions. Medical errors can arise from crushing certain medications, mixing medications together for administration, or even mixing certain medications with nutritional formulas. Some medications, including some liquids, require diluting before administering through a tube. The tube may become clogged or deteriorate with exposure to certain chemicals and formulations. Co-administered liquid medications can alter the pH and cause denaturing of either or both medicines. Viscous liquid medications may adhere to the interior of the tube, despite flushing. Immediate-release products are more likely to be able to be crushed and given by tube, however the finer particle size caused by crushing can still change the drug’s metabolism in the body. Extended release or enteric coated pills, tablets, or capsules are not designed to be crushed and given through a feeding tube. Feeding tubes should be flushed between each medication.
- Parents should clamp the g-tube or close the valve prior to bathing the child.
- Avoid overtly hot water, which could irritate the surrounding skin.
- Use mild soaps and soft washcloths to avoid further irritation and abrasion.
- Granulation tissue represents a foreign body reaction in the skin surrounding the tube. It is red/pinkish inflamed epithelial tissue.
- Excess granulation tissue can be controlled or reduced by topical application of triamcinolone cream three times daily for
a week, or cauterized using silver nitrate sticks obtained through a physician.
- Major complications in a retrospective cohort of 208 patients with gastrostomy placement by interventional radiology included peritonitis (3%), and death (0.4%). [Friedman: 2004] Spearing or poking the transverse colon can occur, requiring surgery to fix.
- Minor complications in this cohort included tube dislodgement (37%), tube leakage (25%), and g-tube skin infection (25%).
- Children can pull-out their g-tube directly or inadvertently through contact or traction while playing.
- Dressing children in a "onesie," a one-piece undershirt with the tube tucked inside, or placing the end of the tubing under the tabs of a disposable diaper can help avoid the tube being pulled out.
- Using an abdominal binder can also help protect the tube from being pulled out.
- A dislodged GJ tube typically requires fluoroscopy to replace.
- Leaking is a common problem with feeding ostomies. Ensuring that the tube is properly placed and, if there is a balloon, that the balloon is properly inflated, can reduce leaking.
- Balloon style buttons for children vary in the volume contained in the balloon. Typically this is 3 mL (cc) for infants up to 1 year and 5 mL (cc) for older children. If unsure, contact the physician who placed the button.
- Other factors such as granulation tissue, damaged or displaced tubes, or weight changes can affect the fit of the tube. Leaking may also occur if the stomach is too full, which can happen with poor gastric motility (slow emptying) or with rapid bolus feeds.
- Facilitating family coping strategies
- Adjusting the child's diet for optimal growth and nutrition (and prevention of obesity)
- Adjusting the child's feeding schedule for optimal family/child functioning
- Monitoring the feeding tube for complications (feeding intolerance, reflux with aspiration, stoma leakage etc.)
- Ensuring that the family has adequate equipment for using and caring for the feeding tube
- Ensuring that the family is aware of what to do if the tube dislodges
- Working with the family to ensure adequate and safe feeding at school, childcare and respite settings
- Helping the child and family continue to focus on advancing oral feeding by monitoring safety, prescribing oral motor therapy (if indicated), and optimizing the feeding schedule to enhance hunger during meal times
Nonoral Feeding for Children and Youth With Developmental or Acquired Disabilities (AAP)
This clinical report provides (1) an overview of clinical issues in children who have developmental or acquired disabilities that may prompt a need to consider nonoral feedings, (2) a systematic way to support the child and family in clinical decisions related to initiating nonoral feeding, (3) information on surgical options that the family may need to consider in that decision-making process, and (4) pediatric guidance for ongoing care after initiation of nonoral feeding intervention, including care of the gastrostomy tube and skin site; American Academy of Pediatrics.
When a G-Tube is Dislodged (Brown University)
From the Hasbro Children's Hospital Surgery Handbook – a detailed explanation of what to do when a new (<2 month old) G-tube becomes dislodged. This is for professionals and includes symptoms of dislodgement.
2009 Enteral Nutrition Practice Recommendations ( 859 KB)
Bankhead et al. Journal of Enteral and Parenteral Nutrition. 2009; 33; 122 originally published online Jan 26, 2009.
Administering Drugs Via an Enteral Feeding Tube (ISMP)
Summary of tips and precautions for medications given by enteral feeding tube from May 6, 2010; Institute for Safe Medication Practices.
Continuous Drip Nasogastric Feeding with Pump (Cincinnati Children's Hospital)
Instructions for parents using a continuous drip tube feeding with pump. Includes supplies, preparation, general information, and a link to instructions in Spanish.
G-Tube Tips (Special Child)
Parents of children with feeding tubes share problems and offer successful tips.
Health, Disease, and Special Needs Community (Circle of Moms)
Online community offering tips and opportunities to ask questions and share stories related to children with special needs and feeding tubes.
Kids with Tubes
Information about tube-feeding from families, for families. Although the site is not updated often, the information remains valuable.
Enterostomal Therapy (Primary Children's Medical Center)
Website for Primary Children’s Medical Center’s Enterostomal Therapy service, with information, videos, diagrams, and common questions and answers; pertains to G-tubes and other kinds of ostomies.
Gastrostomy Tube Home Care (Cincinnati Children's Hospital)
Parent instructions on caring for a gastrostomy tube. Includes cleaning, flushing, giving meds, venting, protecting and problem solving.
Home Care Instruction (Boston Children's Hospital)
Parent instructions on caring for a child in the first week after having a PEG tube placed. Includes short instructional videos.
Gastrostomy Feeding by Syringe (Cincinnati Children's Hospital)
Instructions for parents on gastrostomy feeding - includes explanation, supplies, procedure and safety tips. Also available in Spanish.
Ostomy Care ( 246 KB)
Transcript from 2007 Medical Home conference call; provides information about ostomy care and resolving problems with gastrostomy tubes; includes a "Let's Talk About" on gastrostomies.
Gastrostomy-Jejunostomy Tubes (Cincinnati Children's Hospital)
Includes information about flushing, protecting, adding medications, and solving problems related to gastrostomy-jejunostomy (G-J) tubes.
G-Tube Tips (Special Child)
Parents of children with feeding tubes share problems and offer successful tips.
See all Developmental Pediatrics services providers (5) in our database.
See all Nutrition/Dietary services providers (53) in our database.
See all Pediatric Gastroenterology services providers (3) in our database.
For other services related to this condition, browse our Services categories or search our database.
|Author:||Jennifer Goldman-Luthy, MD, MRP, FAAP - 5/2013|
|Content Last Updated:||4/2015|
Friedman JN, Ahmed S, Connolly B, Chait P, Mahant S.
Complications associated with image-guided gastrostomy and gastrojejunostomy tubes in children.
Pediatrics. 2004;114(2):458-61. PubMed abstract
Heyman MB, Harmatz P, Acree M, Wilson L, Moskowitz JT, Ferrando S, Folkman S.
Economic and psychologic costs for maternal caregivers of gastrostomy-dependent children.
J Pediatr. 2004;145(4):511-6. PubMed abstract
Patrick J, Boland M, Stoski D, Murray GE.
Rapid correction of wasting in children with cerebral palsy.
Dev Med Child Neurol. 1986;28(6):734-9. PubMed abstract
Petersen MC, Kedia S, Davis P, Newman L, Temple C.
Eating and feeding are not the same: caregivers' perceptions of gastrostomy feeding for children with cerebral palsy.
Dev Med Child Neurol. 2006;48(9):713-7. PubMed abstract
Sullivan PB, Juszczak E, Bachlet AM, Thomas AG, Lambert B, Vernon-Roberts A, Grant HW, Eltumi M, Alder N, Jenkinson C.
Impact of gastrostomy tube feeding on the quality of life of carers of children with cerebral palsy.
Dev Med Child Neurol. 2004;46(12):796-800. PubMed abstract
Sullivan PB, Lambert B, Rose M, Ford-Adams M, Johnson A, Griffiths P.
Prevalence and severity of feeding and nutritional problems in children with neurological impairment: Oxford Feeding Study.
Dev Med Child Neurol. 2000;42(10):674-80. PubMed abstract