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Gastrostomy management

A gastrostomy is a feeding tube that is inserted directly into the stomach either surgically under direct vision (open or laproscopic), endoscopically (with a camera), or radiologically (x-ray guidance). A gastrostomy tube allows the delivery of supplemental nutrition and medications directly into the stomach. It also provides a mechanism to drain gastric contents if required. In order for gastrostomy feeding to be successful the child or young person must have a functioning gastrointestinal tract.

A gastrostomy is the most appropriate method for long-term enteral feeding (Singh et al, 2013; Erdil et al, 2005). Enteral feeding is a very useful method of ensuring adequate intake of nutrients in patients who, for a variety of reasons are unable to use the oral route, or are unable to take sufficient nutrients to maintain growth and development (El-Matary, 2008; ESPEN, 2005). 

The preparation of enteral feeds is governed by the requirements of the Food Safety Act (1990).

As with any interventional procedure, there is potential for complications (including chemical peritonitis, infection, bowel perforation, haemorrhage, and aspiration pneumonia) but prompt recognition of these complications with early action reduces the risk of serious harm or death (National Patient Safety Agency (NPSA), 2010).

Gastrostomy tubes - introduction

Many children/young people at Great Ormond Street Hospital (GOSH) have a gastrostomy device and health care professionals caring for these patients need to have a good understanding of the different types of device in use as well as the skills and knowledge to look after the device, the gastrostomy site and to identify problems (Rationale 1). The device may have been inserted at GOSH or in another hospital.

Within GOSH three specialities insert gastrostomy devices: General Surgery, Interventional Radiology and Gastroenterology. 

Three types of Gastrostomy are inserted at GOSH:

  • a MalecotTM gastrostomy tube
  • a Freka gastrostomy tube
  • a button gastrostomy device 

See Appendix 1 for more information regarding different types of gastrostomy devices available.

This guideline describes the management of the Freka gastrostomy which can be inserted as a percutaneous endoscopic gastrostomy (PEG) by General Surgery or Gastroenterology, or a radiologically inserted gastrostomy (RIG) by Interventional Radiology. When a 'button' gastrostomy device is described it refers to the Mic-key low profile feeding device.

Reasons for gastrostomy insertion

If a child or young person requires long-term enteral feeding support, ie longer than three months, insertion of a gastrostomy feeding device should be considered (Braegger et al, 2010). The device may also be necessary for children or young people who require decompression of the stomach, or in those who have non-compliance with drug therapy.

Clinical indications

There are a number of indications for gastrostomy feeding. These include:

  • children or young people having high dose chemotherapy regimens (usually part of the oncology protocol), where they will develop mucositis and will not tolerate naso-gastric feeds 
  • cystic fibrosis 
  • renal disease 
  • cerebral palsy 
  • inherited metabolic disorders
  • gastrointestinal problems 
  • trauma eg damage from caustic substances 
  • abnormalities of the swallowing mechanism 
  • complex cardiac defects 

Inform the child or young person and family

The decision to place a gastrostomy is often made in the outpatient setting, as a result of the need for continuing enteral feeding support. The child or young person is often on a feeding regimen via a naso-gastric tube (NGT), which is not ideal for long-term enteral feeding due to the trauma of regular re-passing of tubes, and problems with body image for the child or young person and the parent/carer(s). Also many community teams are unable to support overnight feeding via the NGT due to the risk of tube misplacement.

It is important therefore, that when a decision to proceed to gastrostomy insertion is made, the child or young person and parent/carer(s) is given the opportunity to discuss this with a specialist nurse or a doctor who is fully informed of the procedure to be performed. If the child or young person cannot see a nurse or doctor at GOSH, then the community nursing team should be contacted, and involved in giving the appropriate information to the family (Rationale 2). They must also be made aware of any other procedures that may be carried out at the same time (Department of Health (DH), 2009). 

Pre-operative key points

  • Utilise integrated care pathway (ICP) for insertion of gastrostomy.
  • It is essential to comply with the hospital policy on informed consent. Provide appropriate written information to back up any discussion with the family.
  • Ensure the child or young person and family understand the reason for insertion of gastrostomy and gastrostomy feeding (Rationale 3).
  • Explain to the family how long the procedure will take (Rationale 4).
  • Provide the Living with a gastrostomy feeding device booklet (Rationale 5), ensuring to fill out the type and size of device as well as the contact details for the hospital gastrostomy CNS.
  • Written information should also be given to the child or young person and family which they can use as reference at a later date, along with the contact details for the hospital gastrostomy CNS.
  • Pre-operative discussion and demonstration of the device to the child or young person and parent/carer(s) is vital.
  • Prepare the child or young person for theatre in accordance with GOSH guidelines. 

Percutaneous endoscopic gastrostomy (PEG) insertion

The first device to be inserted may be a gastrostomy tube placed during an endoscopic procedure, ie PEG, or this may referred to as a Radiologically Inserted Gastrostomy (RIG) if inserted by Interventional Radiology. 

A general anaesthetic (GA) is required and the child or young person and family must be prepared for this. The play specialist should be involved in the preparation of the child or young person, using their special skills and aids to help the child or young person to understand what they are having done. The dietitian must be informed.

The insertion of a PEG requires an overnight admission; the child or young person ideally should have been seen by their local community dietitian prior to admission and have a feeding plan in place. Within GOSH there is an integrated care pathway (ICP) for children or young people undergoing PEG insertion. This pathway should be followed by all patients having insertion of PEG unless otherwise stated by the clinician who has inserted it.

PEG post-operative care

The child or young person will have had a GA for this procedure. The National Patient Safety Agency (NPSA, 2010) issued a rapid response alert identifying the post-operative care needs for patients following gastrostomy insertion. 

Post-operative observations of temperature, pulse, respirations, blood pressure must be performed in line with the Observations and CEWS policy. The child/young person should also have regular recording of their pain score and observation of the surgical wound for bleeding, leakage of gastric contents or tube displacement (Rationale 6).

The post-operative plan written in the operation notes/care pathway will give details of the type of device, size, make and lot number and these should be recorded in the medical and nursing records (Rationale 7, 8).

Post-operative red flags

Any pain on feeding, prolonged or severe pain post-procedure, fresh bleeding or external leakage of gastric contents must be escalated to the appropriate medical team. All feeding should stop immediately in these circumstances (Appendix 2, 3)(NPSA, 2010)(Rationale 6).

Prior to touching the child or young person, or gastrostomy device, ensure hand hygiene is performed and appropriate personal protective equipment is worn if required (Rationale 27).

On the child or young person’s return to the ward check that the external fixation plate is secure, and that it is not too tight or too loose (Rationale 9). If the triangle does not appear to be right please contact the gastrostomy CNS via switchboard or the speciality who inserted the PEG.

Inspect the stoma site for signs of redness, swelling or pus formation and check that the gastrostomy tube is secure (Rationale 10).

Ensure adequate pain relief is administered (Rationale 11). Analgesia is often given in theatre, both systemically and locally. During the procedure the stomach is inflated with air, which may cause some discomfort post-operatively, even though the stomach is deflated routinely immediately after the procedure in theatre.

If the child or young person is in discomfort the stomach should be decompressed by attaching a gravity bolus feed set to the PEG end. Ensure the feed set is held above the level of the stomach (usually shoulder height) and release the roller clamp. This will allow air to escape naturally from the stomach (Rationale 12). Alternatively, the surgeon may request that the tube is left open and attached to a drainage bag for a period of time or for the gastrostomy tube to be aspirated using a 20ml oral syringe to remove air. Check the child or young person’s operation note on return to the ward for specific instructions.

On return to the ward, there may be dry blood on the skin around the stoma, which is under the external fixation plate. This should be cleaned using sterile gauze and normal saline. This can be done without undoing the external fixation plate, by gently lifting the plate and cleaning in a circular motion around the stoma (Rationale 13). It is important not to open the triangle for the first 10 days to allow time for the tract to heal (Rationale 14).

The child or young person can shower as normal or have a shallow bath. The stoma site should not be immersed fully in water until the site has healed. The site should be cleaned daily with gauze swabs and water and dried thoroughly (Rationale 15), and inspected for signs of irritation or infection.

Rotating the PEG

Manufacturers of gastrostomy devices recommend regular rotation of the device in the stoma (Rationale 16). Check manufacturer’s instructions regarding optimal frequency of rotation.

The first rotation should be carried out 10 days post insertion; this allows time for the site to heal (Rationale 17). After the initial turn the PEG requires turning on a weekly basis.

Wash hands with soap and water. Open the clamp of the fixation plate. Lift the tube free of the channel in the fixation plate, and move the plate away from the skin. Clean the stoma, surrounding skin and fixation plate with gauze and water ensuring the area is dried thoroughly afterwards.

Push the tube into the stomach for one to two centimetres and rotate a full 360°. Pull the tube back gently until resistance is felt. Replace the fixation plate back into the original position above the stoma, reinsert the tube into the channel of the plate and close the clamp. Check that the tube is not too tight or too loose.

The usual practice (at GOSH) is that the PEG tube should be changed every two years or before if needed. This is in accordance with the manufacturer’s instructions (Rationale 18). This requires a GA and is usually a day case procedure. Ideally plans for routine change should be considered at primary insertion.

If the child or young person requires an anti-reflux procedure or a trans-oesophageal route is inappropriate a gastrostomy tube can be placed by the general surgery team using a laparoscopic or open procedure.  Balloon devices are not routinely used as a primary device within GOSH; a MalecotTM tube is used initially which is changed at a later date for a balloon device.

MalecotTM tubes: general principles of care

MalecotTM tubes contain latex so it is important to check if the child or young person is allergic to latex before their insertion.

The tube is sutured in place at skin level, and two small ‘lugs’ act as the internal securing mechanism.  A male luer connector is taped into the open end and left in place (Rationale 19).  

It is important to ensure that the tube is secured to the abdomen at all times as it can be easily displaced (Rationale 20). ClinifixTM dressings are recommended. If these are unavailable Elastoplast can be used. It is important to check whether the patient is allergic to the chosen tape before using it. An alternative tape should be used if this is the case. The tube should be secured as close to the site as possible ensuring that there is no loop in the tube (Rationale 21).

Due to the increased risk of tube migration MalecotTM gastrostomy tubes should have their correct position confirmed before commencing feeds or administering medications (Rationale 20). Attaching a 20ml oral syringe to the male leur connecter, aspirate a small quantity of gastric content and test with universal testing paper to confirm position (Rationale 32).

Due to the tube being made of latex, it is common to see a small area of redness around the stoma site; you will also see a ‘crust’ forming. This is caused by the latex irritating the tract; this helps the healing process and is expected. Although it is difficult to clean the stoma site due to the suture, it is important to be scrupulous with this (Rationale 15). The site should be cleaned daily with gauze swabs and water ensuring the skin is dried thoroughly after.

The MalecotTM tube is usually removed at the six-week clinic appointment. The replacement device of choice is a low profile balloon device commonly referred to as a ‘button’. If the patient is very small it may be advisable to use a gastrostomy tube as the first replacement device (Rationale 22).

The gastrostomy tube can then be replaced with a button device at a later date when the child or young person has grown or gained weight.

Balloon buttons

The balloon button device is held in place inside the stomach using an inflatable balloon; feeds are given by attaching an extension set. The buttons are made of silicone and the manufacturers recommend they are changed every three to six months, as discussed on discharge.

There are many different manufacturers of balloon buttons and it is important to find out the make the child or young person has as the extension sets used for feeding and giving medication are different for each.

Attaching the extension sets

In order to use the button you must first open the lid. There is an anti-reflux valve within the button to prevent stomach content from leaking out. To attach the set:

  • Lift up the safety cap from the feeding port. 
  • Line up the black line on the extension set with the black line on top of the button. 
  • Push the extension set into the feeding port, whilst gripping the external stabilizer to prevent putting undue pressure on the child or young person’s abdomen. 
  • Turn the extension set clockwise until it stops. 
  • The extension set is now locked in place and ready for use.  

After use wash the extension set under running water and syringe it through with a mild detergent solution (Rationale 23). Follow this with a thorough rinse with cold drinking water (Rationale 24). Shake and allow the extension set to dry. For children under one year old and immune-compromised patients the extension set should rinsed with sterile water. Extension sets should not be left attached if not in use (Rationale 25).

Changing the water in the balloon

The water used to inflate the balloon that holds the gastrostomy in place requires changing once weekly (Rationale 26).

Wash hands and wear non-sterile disposable gloves (Rationale 27). Remove the water from the balloon of the button to be changed, by attaching a syringe to the balloon port labeled BAL. Grip the external fixation hub, avoiding putting pressure on the child or young person’s abdomen. Withdraw the water; the balloon contains 3-5mls, depending on the size of the child or young person. Check with the parent/carer if more or less water has been used (Rationale 28). Insert the new syringe with the clean water and inflate the balloon. The colour and volume of water removed from the balloon may be different from what was inserted.

Changing the balloon button

Equipment required:

  • new gastrostomy balloon button
  • 2x 5ml IV slip syringes
  • lubricating jelly
  • extension set
  • 20ml enteral feeding syringe
  • universal testing paper 

Prepare the child or young person and parent for the procedure, involving the play specialist if appropriate (Rationale 29).

Gather the necessary equipment and prepare the clinical room for the procedure.

Assess if any significant change in weight/growth has taken place since last change. If so the stoma tract needs to be measured using a stoma measuring device for balloon devices to determine which size of button will be used (Rationale 30). Have a range of sizes to hand.

Remove the water in the balloon as described in the section above.

Changing the water in the balloon

Remove the button by gently pulling whilst placing a hand on the abdomen. Inspect the removed balloon to ensure that it has been removed intact. Insert the new button into the tract and inflate the balloon with the recommended amount of water. 

Recommended maximum filling volumes for balloons.

Balloon volumes
 Under 1 year 3ml
 Toddler 4ml 
 Older child/young person 5ml

Avoid overfilling the balloon (Rationale 31).

Check that the button has been correctly inserted. Attach an extension set to the feeding port and allow a small quantity of gastric content to flow into the set. Remove and test with universal testing paper to confirm position (Rationale 32).

Occasionally the balloon may fail which could cause the device to fall out. The child or young person and parent/carer(s) must be aware of what action to take (Rationale 33). The child or young person and parent/carer(s) should always have a replacement button with them for such emergencies. It is also useful to provide them with a NGT of a size close to the diameter of the button (Rationale 34). Many parents learn how to insert the button themselves, avoiding the need to seek the support of a health care professional in this situation. It is important parents are provided with universal testing paper so that they can confirm the position of the button post-insertion (Rationale 32).

Important note: there may be specific instructions from the surgeon regarding not rotating the device or deflating the balloon depending on the procedure carried out. Current GOSH practice is a PEG is not rotated in the first 10 days. The water in a balloon button device is not checked for the first two weeks post-insertion if it is a primary device. Always read the post-operative theatre note to determine if this is the case (Rationale 35).

Stoma care for all gastrostomy devices

The gastrostomy site should be cleaned every day and the site inspected for signs of infection, and formation of granulation tissue.

If the skin is clean and intact dressings are not required. If there are concerns with the site and you suspect an infection, a swab should be sent for MC&S (Rationale 36).

If leakage occurs from the site it is important to use a skin barrier product such as Cavilon®, to protect the peri-stomal skin. If feed is leaking from the site, stomach acid will also be leaking which will cause an acid burn. It is important to detect the reason for leakage and resolve the problem.

The new gastrostomy should not be immersed in water until the tract is fully healed (Rationale 37).

If granulation tissue has formed, early treatment is preferable (Rationale 38). For small amounts of granulation, treat with Maxitrol eye ointment topically twice daily. For larger amounts of granulation tissue, silver nitrate 75 per cent caustic applicator sticks may be required. These are available from the gastrostomy CNS. When using silver nitrate it is important to ensure contact is with the granulation tissue only. Protect the surrounding skin with a thick layer of yellow soft paraffin to prevent discolouration of peri-stomal skin (Rationale 39).

Ongoing care of the gastrostomy

The stoma site should be monitored for signs of the following:

  • redness 
  • bleeding 
  • purulent exudates 
  • pain or discomfort 
  • leakage around the tube from the stoma 
  • leakage from the device (Rationale 40 and 41) 

General observation should include noting any changes in stool output, eg increased loose stools or diarrhoea, with or without fever (Rationale 42, 43 and 44).

Only MalecotTM tubes and newly inserted button devices require their position confirming using universal testing paper.

Maintaining patency of the gastrostomy

The gastrostomy tube should be flushed with water before and after feeds (Rationale 45, 46 and 47).

Drinking water can be used for flushing gastrostomy tubes. For children under one year or immune-compromised children and young people the water should be boiled and cooled or sterile water may be used. Follow manufacturers' recommendations on flushing volumes and syringe sizes to be used.

If blockage does occur, attach a 50ml syringe filled with 10ml of warm water and try a push/pull technique (Rationale 48). It also helps to rotate and massage the tube between the fingers to try and dislodge the blockage. Carbonated water or preparations such as Corflo© Clog ZapperTM may be helpful to try and clear the tube.

Infection control

Always wash hands thoroughly before and after accessing the gastrostomy (refer to infection control policy: hand washing) (Rationale 15). When preparing feeds for administration the principles of asepsis should be followed. An aseptic non-touch technique (ANTT) should be used (see section below on Administration of enteral feeds).

Follow section below on administration of enteral feeds on hanging times for enteral feeds.

Administration of enteral feeds – principles

Do not decant feeds on the ward (Rationale 49).

To change feed bottles put on an apron, perform a hand wash and put on non-sterile gloves (Rationale 15).

When hanging feeds, do not touch any inner parts of the Spike Set.

Use the Freego feeding pump and Freego giving set when continuous enteral feeds are administered, and a Kangaroo paediatric gravity feeding set for bolus feeds (Rationale 50, 51, 52 and 53).

Do not heat continuous enteral feeds prior to administration (Rationale 54). Feeds should not be diluted on the ward (Rationale 49). 

Place feed bottles from the Special Feeds Unit and the infant ready-to-feed bottles into the designated hanging bags so that they can be hung from the drip stand. The hanging bag can be used for 24 hours.

Sterile ready-to-hang Abbott feeds have a hook on the bottle’s base so that they can be hung from the drip stand.

Feeding

Gather equipment for bolus or continuous feeds, or for administering medications (Rationale 55).  See sections on Attaching extension sets if required. Wash hands before accessing the gastrostomy and preparing feeds (Rationale 15).

Prime the feeding set tubing, and extension set if required, ensuring the feed reaches the end and there is no air in the line.

Commence the feed according to the prescribed feeding regimen, using a feeding pump to control flow rate in continuous feeds. Document the rate and time of commencement in the child or young person’s fluid chart (Rationale 56).

When the feed has been completed flush the tube with 5-10ml of water (Rationale 23). Remove the extension set and close the cap.

NB All pre-registration student nurses and healthcare assistants must have all feeds double checked by a registered member of the nursing staff prior to administration.

Hanging times

Special feeds sent in bottles from the Special Feeds Unit can hang for six hours. 

Expressed breast milk can hang for four hours.

Ready to feed normal infant formulas can hang for six hours.

The above times are inclusive of any breaks in the administration; if disconnecting place a cap on the feed set and replace cap on gastrostomy device (Rationale 15). Sterile feeds in the manufacturer’s ready to hang bottles can hang for 24 hours IF the system is closed for the duration of the feed.

Administration of medicines

Liquid medicines are mostly suitable for administration via gastrostomy, but some may be too thick to flush through the fine bore of the tube.

Staff should check with pharmacy which tablets/capsules are suitable for crushing and mixing with water/sodium bicarbonate for administration. Some drugs will not be suitable for administration via a gastrostomy. If a patient requires calcium carbonate a dispersible preparation should be used (Rationale 57). Some drugs are designed for slow release, and these should not be crushed (Rationale 58).

Always flush the gastrostomy with water before and after administering medications.

Check with the pharmacist if you are unsure if medications can be administered via gastrostomy.

Discharge planning

Where the child/young person is discharged within 72 hours (three days) of gastrostomy insertion the NPSA (2010) state that:

  • Systems are in place to ensure senior review before discharge. 
  • Patients and their carers are warned of the danger signs that need urgent attention (verbally and through using labels (Appendix 4) or an equivalent high visibility warning on local patient information) and are given an appropriate local contact number for urgent aftercare advice that is available overnight and at weekends.
  • Staff answering this contact number understand that the signs listed above are symptoms that need an urgent response, and have local protocols to guide them on what actions to take. 

If the child or young person is commenced on enteral feeding whilst he/she is an inpatient at GOSH and it is envisaged that this method of feeding will continue following discharge, discharge planning should commence at the earliest opportunity (Rationale 59 and 60).

Appendix

Appendix 1: Types of gastrostomy devices (PDF 130KB)

Appendix 2: NPSA rapid response report NPSA/2010/RRR010 (PDF 52KB)

Appendix 3: NPSA child inpatient labels NPSA/2010/RRR010 (Word doc 48KB)

Appendix 4: NPSA patient and carer labels NPSA/2010/RRR010 (Word doc 45KB)

Rationale

Rationale 1: A gastrostomy is any artificial device opening into the stoma.
Rationale 2: If a child or young person and family are under the wrong impression of the procedure it could delay their acceptance of the device, and their ability to manage its care.
Rationale 3: To ensure child or young person and family are fully aware of reasons for gastrostomy insertion, and are psychologically prepared.
Rationale 4: To allow the family to be prepared for appropriate length of wait.
Rationale 5: To provide further information, and act as a backup to verbal information.
Rationale 6: To detect any post-operative complications and ensure effective escalation and management.
Rationale 7: To ensure that the gastrostomy tube is used at the appropriate time post-operatively. There may have been other procedures carried out eg biopsies, which influence when it is safe to use the tube.
Rationale 8: This information must be passed on to the community nurses, who will arrange for a spare device, appropriate connections and on-going supplies to be ordered. The lot number may help detect faulty batches if there is any problem with the device.
Rationale 9: If it is too tight the stoma will protrude through the fixation plate, causing pain and discomfort to the child or young person, and if it is too loose it will cause the tube to move back and forth. This would cause irritation to the tract, and could result in stretching of the tract diameter, and cause stomach contents to leak on to the skin.
Rationale 10: To detect signs of bleeding, infection or tube migration.
Rationale 11: To keep the child or young person pain free, and allow a comfortable recovery period. This will also allow the child or young person to accept the tube and make handling and accessing the device easier and the child or young person more co-operative.
Rationale 12: To ensure the child or young person is comfortable and pain free.
Rationale 13: To keep the skin clean and dry around the stoma site.
Rationale 14: The stomach has been pulled up to the abdominal wall by the internal retention disc and is held in place by the external fixation triangle. Any movement of the external fixator can result in the stomach moving away from the abdominal wall, with the potential of stomach content leaking into the peritoneum.
Rationale 15: To prevent infection.
Rationale 16: This is to prevent ‘buried bumper syndrome’, where the internal fixation disc becomes buried, with the stomach lining growing around it.
Rationale 17: This stoma should be healed and free of infection or discharge before rotating.
Rationale 18: The Freka® devices (9F and 15F) have an internal flange that can get embedded in the wall of the stomach if left in situ for too long. If this happens (‘buried bumper syndrome’), it makes the device very difficult to remove and removal/replacement can require open surgery and resection of part of the gastric wall.
Rationale 19: This method is useful because the end of the tube soon becomes loose if the adaptor is removed after each use. It can then cause the tube to leak and become very difficult to manage.
Rationale 20: If the suture is broken the MalecotTM tube can migrate through the stomach into the pylorus or fall out.
Rationale 21: Any loop in the tube could lead to the tube accidently being pulled out.
Rationale 22: The shorted length button device may be too long for the gastrostomy tract and the stomach may be too small to accommodate a balloon.
Rationale 23: To prevent a build up of feed debris; this could lead to contamination causing infection.
Rationale 24: To remove all traces of detergent.
Rationale 25: Leaving an extension set attached can lead to the tube being accidently pulled out. If it is required to be used for long periods of time it is advisable to use a ClinifixTM dressing to secure it to the abdomen.
Rationale 26: Due to osmotic pressure water can be lost through the membrane of the balloon.
Rationale 27: To avoid introduction of infection or cross infection from other patients. To comply with hospital policy on standard precautions when there is a possibility of contact with body fluids.
Rationale 28: To ensure the patient’s comfort throughout the procedure. Failure to fully deflate the balloon before removal could cause pain or discomfort to the child or young person, which in turn could lead to them not co-operating with future changes. 
Rationale 29: To avoid causing stress to the child or young person and to remove the fear of an unknown procedure.
Rationale 30: To ensure that the device is not too tight which causes skin damage/ulceration or too loose if weight loss has occurred, causing the button to leak from around the balloon.
Rationale 31: To prevent damaging the balloon. 
Rationale 32: To ensure correct placement has taken place before using the device for administration of feeds or medication, thus avoiding potential complications from misplacement. An acidic reaction would be indicative of stomach content. It must be noted that many children or young people who have gastrostomies require antacids which can alter the pH of the stomach; also some specialist feeds have an alkaline pH which can also affect the pH reading. Obtaining milk contents on aspiration should also be indicative of correct position.
Rationale 33: The stoma can close very quickly – over a matter of hours, making it difficult or impossible to insert a new tube. 
Rationale 34: This can be inserted a few centimetres into the tract and secured with tape, preserving the tract until the new tube can be inserted.
Rationale 35: There may be a danger of losing the newly formed tract.
Rationale 36: To rule out any bacterial growth and establish sensitivities if antibiotics are required.
Rationale 37: Shallow baths can be given but full immersion in water ie swimming should be avoided until the tract has healed.
Rationale 38: To reduce the spread of granulation tissue.
Rationale 39: To prevent surrounding skin from damage from contact with the treated area.
Rationale 40: These could be signs of infection and/or device failure. Check the patient’s temperature and obtain a specimen of exudate if present for microbiological assessment. It may be necessary to commence topical, oral or intravenous antibiotics depending on the patient’s clinical condition, and whether they are immune-suppressed.
Rationale 41: The anti-reflux valves of the low profile devices are known to be prone to colonization with Candida. This can cause the valve to fail, resulting in stomach contents leaking from the device. Leakage can cause severe excoriation to the surrounding skin and should be dealt with promptly.
Rationale 42: Increased stool output could indicate intolerance to the feed volume or type.
Rationale 43: The feeding regimen may need to be re-assessed by the dietitian.
Rationale 44: Diarrhoea could indicate infection due to contamination of feeds.
Rationale 45: To prevent the tube from becoming blocked by feed debris.
Rationale 46: To prevent damage of the tube by increased pressure due to build-up of feed deposits.
Rationale 47: It is important to confirm that the device is working before commencing the feed to prevent interruptions to the feed once running, and to prevent the child or young person being disturbed by the pump alarming due to blockage.  
Rationale 48: To attempt to clear the blockage. 
Rationale 49: To prevent contamination of the feed (Anderson and Fearon, 1995).
Rationale 50: To maintain a continuous flow of feed.
Rationale 51: To prevent blockage of the tube/feeding set.
Rationale 52: To avoid back-drainage of stomach/intestine content into the feeding system.
Rationale 53: To ensure accurate delivery of rate and volume of feed.
Rationale 54: To prevent bacterial growth in warmed feeds, which are left at room temperature for up to six hours.
Rationale 55: To ensure a smooth uninterrupted procedure.
Rationale 56: To provide accurate feed record of intake and tolerance of feeds. 
Rationale 57: Calcium carbonate will block the tube.
Rationale 58: The slow release properties of the drug will be destroyed.
Rationale 59: To facilitate smooth and effective discharge planning.
Rationale 60: To prevent a delay in the child or young person’s discharge.
Rationale 61: To adhere to standard precautions.

References 

Rationale 1
Anderson ID, and Fearon KCH (1995) Paralytic ileus and enteral feeding. British Journal of Intensive Care 5(4): 117-8 

Rationale 2
Braegger I, Desci T, Dias JA, Hartman C, Kolacěk S, Koletzko B, Koletzko S, Mihatsch W, Moreno L, Punits J, Shamir R, Szajewska H, Turck D, Van Goudoever J (2010) Practical Enteral Nutrition: a Comment by the ESPGHAN Committee on Nutrition. Journal of Paediatric Gastroenterology and Nutrition 51(1): 110-122 

Rationale 3
Department of Health (2009) Reference guide to consent for examination or treatment (2nd Edition). London, Department of Health. 

Rationale 4
El-Matary W (2008) Percutaneous endoscopic gastrostomy in children. Canadian Journal of Gastroenterology and Hepatology 22(12): 993-998 

Rationale 5
ESPEN (2005) ESPEN guidelines on artificial enteral nutrition Percutaneous endoscopic gastrostomy (PEG). 

Rationale 6
Erdil A, Saka M, Ates Y, Tuzun A, Bagci S, Uygun A, Yesilova Z, Gulsen M, Karaeren N, Dagalp K (2005) Enteral nutrition via Percutaneous Endoscopic Gastrostomy and Nutritional Status of Patients: Five Year Prospective Study. Journal of Gastroenterology Hepatology 20(7): 1002-1007 

Rationale 7
National Patient Safety Agency (NPSA) (2010) Early detection of complications after gastrostomy. NPSA/2010/RRR010 http://www.nrls.npsa.nhs.uk/resources/?EntryId45=73457. Viewed on: 01/12/2014 

Rationale 8
Singh R, Eaton S, Cross KM, Curry JI, De Coppi P, Kiely EM, Roebuck DJ, Pierro A (2013) Management of a Complication of Percutaneous Gastrostomy in Children. European Journal of Pediatric Surgery 23: 76-79

Document control information

Lead author

Tricia McAndrew, Gastrostomy Clinical Nurse Specialist

Additional authors
Vanessa Shaw, Head of Department, Dietetics
Leah Adcock, Assistant Practice Educator, Surgical Division

Document owner

Tricia McAndrew, Gastrostomy Clinical Nurse Specialist

Approved by
Guideline Approval Group

First introduced: 6 June 2005
Date approved: 24 November 2014
Review schedule: Three years
Next review: 24 November 2017
Document version: 3.0 
Replaces version: 2.1