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Gastrostomy management

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.

Note: While this guideline refers to the ‘child’ throughout, all activities are also applicable to young people.

Successful use of the enteral route to supply nutrients is dependent on the child having a functioning gastrointestinal tract.

Enteral feeding is governed by the requirements of the Food Safety Act (1990).

Key points

This guideline covers percutaneous endoscopic gastrostomy ('PEG'), gastrostomy placed under radiological conditions ('RIG') and 'button' gastrostomy devices (Rationale 1).

Key management of 'PEG' and 'RIG'

  • Clean and dry as part of normal daily bathing, ensuring the area beneath the fixation plate is cleaned and thoroughly dried (Rationale 2).
  • Weekly turning – full 360 degrees (Rationale 3).
  • Initially post-op clean with saline or boiled and cooled tap water until healing has occurred (Rationale 4).
The usual practice at Great Ormond Street Hospital (GOSH) is that the tube should be changed every two years or before if needed. However for routine change of a gastrostomy device, it is strongly recommended that all Freka® PEG devices are changed routinely every 18-24 months and that this is planned in advance when a device is inserted. This is in accordance with the manufacturer’s instructions and the rationale for this is given below (Rationale 4). This requires a general anaesthetic and is usually a day case procedure.

It is also strongly recommended that all Mic-key* button gastrostomy (G) and gastrojejunal (GJ) devices are changed routinely at least every six months. The rationale for this is given below (Rationale 5). Mic-key* button G tubes are usually changed more frequently than this for various reasons (usually failure of the device) and this can be done by the ward or community staff. Mic-key* button GJ tubes need to be changed by the IR department, almost always as a day case procedure without anaesthetic or sedation.

Key management of 'buttons'

As for PEG/RIGSs with the addition of: 
  • Check the water weekly. Remove water from the balloon and replace with fresh water (Rationale 6).
  • Usually needs to be replaced between three to six months as per manufacturers’ guidelines.
  • Extension sets must not be left attached when not in use (see how to connect below).

Discharge planning

If the child 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 7 and 8).

Please refer to the enteral feeding clinical guideline for further information about discharge planning.

Gastrostomy tubes – introduction

Many children at GOSH have a gastrostomy device and nurses 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. The device may have been inserted at GOSH or in another hospital.

When a new device is to be inserted the nurse must ensure that enough time is allocated to allow the parent/carer(s) to feel confident in looking after the device. A structured training programme should be used, and written information given to support this.

See Appendix 1 for information about the different types of gastrostomy tubes that are available.

Reasons for gastrostomy insertion

If a child 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 who require decompression of the stomach, or in children who have non-compliance with drug therapy.

Often a decision to insert a gastrostomy is made in a clinic environment, and the child is then placed on a waiting list. It is important that the child and family have an opportunity to find out from the clinical team which type of device is to be used so that, when they are admitted for the procedure, they are fully aware of what to expect and have a clear idea of what type of device they will have. They must also be made aware of any other procedures that may be carried out at the same time (Department of Health (DH) 2009).

Clinical indications

There are a number of indications for gastrostomy feeding. These include: 
  • children 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
  • inborn errors of metabolism
  • gastrointestinal problems
  • trauma, eg damage from caustic substances
  • abnormalities of the swallowing mechanism
  • complex cardiac defects affecting nutritional status/development  

Inform the child and family

Ensure the child and family understand the reason for insertion of gastrostomy and gastrostomy feeding (Rationale 9).

Provide a sample of the device to be used and demonstrate how it will look in situ using a mannequin or pictures (Rationale 10).

Explain to the family how long the procedure will take (Rationale 11).

Provide the Living with a gastrostomy booklet (Rationale 12).

Percutaneous endoscopic gastrostomy insertion: pre-operative preparation

The first device to be inserted may be a gastrostomy tube placed during an endoscopic procedure, ie percutaneous endoscopic gastrostomy (PEG). This is also known as a ‘RIG’ when placed under radiological conditions (see Appendix 1 for further information).

The procedure to form the PEG/RIG can be undertaken by a number of different clinicians, for example a gastroenterologist, an interventional radiologist (IR) or a surgeon, depending on the type of stoma to be fashioned. A general anaesthetic is required and the child and family must be prepared for this. The play specialist should be involved in the preparation of the child, using their special skills and aids to help the child to understand what they are having done, and the dietician must be informed.

If the child is to be fed through the PEG/RIG then follow the guidelines for prevention of infection in the section on administration of feeds.

Pre-operative discussion and demonstration of the device to the child and parent/carer(s) is vital.

The decision to place a PEG/RIG is often made in the outpatient setting and as a result of the need for continuing enteral feeding support. The child is often on a feeding regime via naso-gastric tube, 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 the parent/carer(s).

It is very important that medical and nursing staff use the correct terminology when discussing gastrostomy devices.

It is important therefore, that when a decision to proceed to PEG/RIG insertion is made, the parent/carer(s) are given the opportunity to discuss this with a specialist nurse or a doctor who is fully informed of the procedure to be performed. If it is not convenient for the child to 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 13).

It is essential to comply with the hospital policy on informed consent. Provide written information to back up any discussion with the family.

There are a large variety of PEG/RIG devices on the market. Some are designed to be removed under GA and others by traction, the main difference being the internal fixation device.

If a child is admitted with a PEG/RIG, it is important to establish what type is in situ.

All the external parts of the tube are replaceable, thus in the event of any parts becoming damaged it is easy to correct the problem.

If the child is admitted for an elective insertion of a PEG/RIG device it is usually a two-day admission. They are often already on enteral feeding via naso-gastric tube.

The dietitian must be made aware of the child’s admission (Rationale 14).

If the child is not on enteral feeds at the time of admission but the intention is to commence enteral feeds post PEG/RIG insertion, the admission should be of long enough duration to facilitate adequate training of the family and to set up home enteral feeding prior to discharge (including the involvement of the local dietician) (Rationale 15). Please see section on discharge planning for home enteral feeding.

Gastrostomy insertion: post-operative care

The child will have had a general anaesthetic (GA) for this procedure. Follow guidelines for post-operative observations of temperature, pulse, respirations, blood pressure and observation of the surgical wound.

Follow the post-operative plan as written in the operation notes/care pathway (Rationale 16). The type of device, size, make and lot number should be recorded in the medical and nursing records (Rationale 17).

Inspect the stoma site for signs of redness, swelling or pus formation and check that the gastrostomy tube is secure (Rationale 18).

Ensure adequate pain relief is administered (Rationale 19). 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.

The stomach should be decompressed by attaching a syringe or bolus feed set to the PEG adaptor and releasing the clamp to allow excess gas to be released (Rationale 20).

Alternatively, the surgeon may request that the tube is left open and attached to a drainage bag for a period of time. Check the child’s health record on return to the ward for specific instructions.

On the child’s return to the ward check that the external fixation plate is secure and that it is not too tight or too loose (Rationale 21). 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 22).

The stoma site must be cleaned daily and inspected for signs of irritation or infection.

The stoma site should not be immersed in water for the first two to three weeks post-operatively to allow the stoma to heal but the child can have a shallow bath. The site should be cleaned daily with gauze swabs and water and dried thoroughly (Rationale 23).

Check the child’s operation notes for guidance on when the tube can be used post-operatively (Rationale 24). This may vary depending on whether other procedures were carried out at the time of insertion but is usually six hours as per PEG/RIG care pathway unless specific instructions are given.

Before use the position of the tube should be checked using pH indicator strips (Rationale 25). The tube is radio-opaque and can be x-rayed and confirmed to be in the stomach if there is concern about its position (Rationale 26).

Follow the manufacturer's guidelines for rotating the device (see section on rotation) (Rationale 27).
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 the device is not rotated in the first week and the water balloon is not checked for the first two weeks post-insertion if it is a first device. Always read the post-operative theatre note to determine if this is the case (Rationale 28).

Maintenance: observations

The stoma site should be monitored for signs of the following (Rationale 29 and 30): 
  • redness
  • bleeding
  • purulent exudates
  • pain or discomfort
  • leakage around the tube from the stoma
  • leakage from the device
General observation should include noting any changes in stool output, eg increased loose stools or diarrhoea, with or without fever (Rationale 31, 32 and 33).

Maintaining patency

The gastrostomy tube should be flushed with water before and after feeds (Rationale 34, 35 and 36).

Drinking water can be used for flushing gastrostomy tubes. For children under one year the water should be boiled and cooled or sterilised 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 37). 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.

Rotating the gastrostomy device

Manufacturers of gastrostomy devices recommend regular rotation of the device in the stoma (Rationale 38 and 39). Check manufacturer’s instructions regarding optimal frequency of rotation.

The first rotation should be carried out following discussion with the doctor, usually about seven to 10 days post-operatively (Rationale 40).

Wash hands with soap and water. Clean the external fixation plate with gauze and saline. 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 and surrounding skin with gauze and 0.9 per cent sodium chloride.

Push the tube into the stomach for one to two centimetres and rotate a full 360 degrees. Pull the tube back gently until resistance is felt. Place the plate a few millimetres above the stoma, reinsert the tube into the channel of the plate and close the clamp. Check that the tube is not too tight.

Infection control

Always wash hands thoroughly before and after accessing the gastrostomy (refer to infection control policy: hand washing) (Rationale 41). When preparing feeds for administration the principles of asepsis should be followed. An aseptic non-touch technique (ANTT) should be used (see section on administration of enteral feeds).

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

Stoma care

The gastrostomy site should be cleaned every day and the site inspected for signs of infection and formation of granulation tissue (Rationale 23).

The site should be clean and dry at all times. Prevent granulation tissue from spreading; use early non-invasive treatment should it occur. The skin should be kept clean and dry. No dressing is required if the skin is intact.

If excoriation of the skin does occur due to leakage of stomach contents from the site, a barrier product such as Cavilon® can be applied to protect the skin and allow healing to take place. 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 42).

If granulation tissue has formed, early treatment will hopefully prevent the need for surgical removal of the tissue (Rationale 43). Treat with maxitrol or silver nitrate sticks, ensuring contact is with the granulation tissue only. Protect the surrounding skin with a thick layer of white soft paraffin (Rationale 44).

Administration of enteral feeds – principles

Do not top-up enteral feeds into the reservoir of feeding systems (Rationale 45).

Do not decant feeds from bottles to bag sets on the ward.

To change feed bottles put on an apron, perform a clinical hand wash and put on non-sterile gloves (Rationale 41).

Be careful not to touch any inner parts of the spike set.

Use a feeding pump when continuous or intermittent enteral feeds are administered (Rationale 46, 47, 48 and 49).

Do not heat continuous enteral feeds prior to administration (Rationale 50). Feeds should not usually be diluted on the ward (Rationale 44). However, sterile water (or boiled, cooled water) should be used when this procedure is necessary and has been agreed with the ward dietitian (DH 2009).

Try to coordinate the administration of drugs into the feeding set with the change of the set (Rationale 51).

NB All three-year course pre-registration student nurses must have all feeds double checked by a qualified member of the nursing staff prior to administration.

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 for administration. Some drugs will not be suitable for administration via a gastrostomy. Calcium carbonate should never be administered through a gastrostomy tube (Rationale 52). Some drugs are designed for slow release and these should not be crushed (Rationale 53).

Always flush before and after administering medications.

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

MalecotTM tubes: general principles of care

The tube is sutured in place, 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 54).

An ‘H’ shaped strapping of elastic adhesive tape such as Elastoplast® is used (Rationale 55, 56 and 57). 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.

Although it is difficult to clean the stoma site due to the suture, it is important to be scrupulous with this (Rationale 23).

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 58).

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

Button devices: feeding

Gather equipment for bolus or continuous feeds, or for administering medications (Rationale 59). Wash hands before accessing the button and preparing feeds (Rationale 40).

After priming the set tubing, attach the extension set to the feed port ensuring the locking mechanism is secure (Rationale 60 and 61).

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’s abdomen.
  • Turn the extension set clockwise until it stops.
  • The extension set is now locked in place and ready for use.
Flush the set with 5ml of water to ensure the device is working. There is no need to confirm the position of the tube between uses. Attach the feeding set, ready primed with the child’s feed (see section on administration of feeds) (Rationale 62).

Commence the feed according to the prescribed feeding regime, using a feeding pump to control flow rate in continuous feeds. Document the rate and time of commencement in the child’s fluid chart (Rationale 63).

If giving a bolus feed follow procedure as described in section on administration of feeds.

When the feed has been completed flush the tube with 5-10ml of water (Rationale 64). Remove the extension set and close the safety plug.

There should be no backflow of feed if the anti-reflux valve is functioning.

Wash the extension set under running water and syringe it through with a mild detergent solution (Rationale 65). Follow this with a thorough rinse with cold water (Rationale 66). Shake and allow the extension set to dry.

A luer-lock extension set should be the standard set of choice and is particularly useful for overnight feed administration (Rationale 67).

Changing the gastrostomy button

Measuring the stoma

A measuring device is available (Rationale 68).

It is important to remember that as the child grows the length of the shaft will need to be considered. If you suspect that the child has put on weight or grown significantly since the last button change, it is important to measure the stoma (Rationale 69). A range of different lengths should be available.

Remove the button as previously described. Insert the measuring device through the stoma. Inflate the balloon with water and close the integral clamp. Pull back the measuring device until it stops. Push the disc until it is lightly touching the skin and take the next clear measurement above the disc.

Measure the stoma with the child in lying and sitting positions; take the measurement between the two (Rationale 70). Release the clamp, remove the water, and withdraw the device.

Insert the new button as described below.

Changing the button

Prepare the child and parent for the procedure, involving the play specialist if appropriate (Rationale 71).

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 (see section on measuring) to determine which size of button will be used (Rationale 72). Have a range of sizes to hand.

Wash hands (Rationale 73). Wear non-sterile disposable gloves (Rationale 74).

Check that the new button is patent before inserting it into the patient by inflating the balloon with 5ml of water (Rationale 75). Remove the water before inserting the button into the child.

Remove the water from the balloon of the button to be changed by attaching a syringe to the balloon port (Rationale 76). Grip the external fixation hub, avoiding putting pressure on the child’s abdomen. Withdraw the water, usually 5ml. Check with the parent/carer if more or less water has been used.

Remove the button by gently pulling whilst placing a hand over the abdomen. Inspect the removed balloon to ensure that it has been removed intact.

Insert the new button.

Inflate the balloon with water by attaching a 10ml syringe of water to the balloon port.

 Tube size
 Balloon volume
 12Fr  Up to 5ml
 14Fr-18Fr  Up to 7ml
 Sizes above 18Fr
 Up to 10ml
Recommended maximum filling volumes for balloons.

Avoid overfilling the balloon (Rationale 77).

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 indicator paper (Rationale 78).

Once correct insertion has been confirmed the tube is ready for use. Re-attach the extension set and flush with water (Rationale 79). Follow hospital policy for checking feeds prior to administration (Rationale 80).

If a different size of button has been inserted a spare button of the same size may be given to the parent/carer(s) to take home but the community paediatric nurse must be informed of any changes to the size of tube as soon as possible (Rationale 81 and 82).

A potentially serious complication is tube misplacement at the time of insertion. This is when the tube appears to be in place, but the end is not in the stomach, but in the abdominal cavity.

Always check the tube position is correct before using after insertion of a new tube. Universal indicator paper should be used to confirm that the tube position is correct.

A doctor should investigate abdominal pain and tenderness following tube insertion.

Occasionally the balloon may fail which could cause the device to fall out.  The parent/carer(s) must be aware of what action to take (Rationale 83). The parent/carer(s) should always have a replacement button at home for such emergencies. It is also useful to provide them with a naso-gastric tube of a size close to the diameter of the button (Rationale 84). Many parents learn how to insert the tube themselves, avoiding the need to seek the support of a health care professional in this situation.

The community paediatric nurse is usually involved in training the parent/carer(s) on how to change the button. Written information should be provided; there is a leaflet produced by the hospital called Living with a gastrostomy (see section on preparing for discharge).

Appendix

Appendix 1 - Types of gastrostomy devices (PDF)

Rationale

Rationale 1: A gastrostomy is any artificial device opening into the stomach.
Rationale 2: The stoma site does not have to be sterile once healed.
Rationale 3: To prevent disk from ‘bedding in’.
Rationale 4: 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 (a complication called ‘buried bumper’ in the literature), it makes the device very difficult to remove and removal/replacement can require open surgery and resection of part of the gastric wall.
Rationale 5: The Mic-key button devices have an internal balloon to hold the device in place so does not carry the risk of a buried flange. However, these devices have a finite life span, usually six months. They have a valve system in the top that tends to break/leak after a while and they can block/break, get dislodged or the balloon may burst. Routine planned change of devices should reduce the number of acute referrals for replacement of non-functioning tubes in tube-dependent patients.
Rationale 6: To ensure the balloon is working efficiently.
Rationale 7: To facilitate smooth and effective discharge planning.
Rationale 8: To prevent a delay in the child’s discharge.
Rationale 9: To ensure child and family are fully aware of reasons for gastrostomy insertion and are psychologically prepared.
Rationale 10: To ensure that there is no misunderstanding or surprises after the procedure has been performed, and to prepare the child and family for altered physical appearance.
Rationale 11: To allow the family to be prepared for appropriate length of wait.
Rationale 12: To provide further information and act as a back up to verbal information.
Rationale 13: If a child 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 14: He/she will need to perform a nutritional assessment of the patient.
Rationale 15: The dietitian will need to perform a nutritional assessment and initiate a feeding plan.
Rationale 16: 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 17: This information must be passed to the community nurses, who will arrange for appropriate connections and supplies to be made. The lot number may help detect faulty batches if there is any problem with the device.
Rationale 18: To detect signs of bleeding, infection or tube migration.
Rationale 19: To keep the child pain free, and allow a comfortable recovery period. This will also allow the child to accept the tube and make handling and accessing the device easier and the child more co-operative.
Rationale 20: To ensure the child is comfortable and pain free.
Rationale 21: If it is too tight the stoma will protrude through the fixation plate 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 22: To keep the skin clean and dry around the stoma site and prevent skin irritation from dried blood.
Rationale 23: To prevent infection and formation of granulation tissue.
Rationale 24: To ensure that the child’s safety is not compromised.
Rationale 25: To ensure correct positioning of the device. For example if the external fixation plate did not secure the PEG device the tube can migrate beyond the pylorus.
Rationale 26: It is possible that the tube can migrate beyond the pylorus. This can happen if the clamp on the external fixation plate has not been properly secured.
Rationale 27: To prevent the internal disc or balloon from becoming buried in stomach folds.
Rationale 28: There may be a danger of losing the newly formed tract.
Rationale 29: 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 immuno-suppressed.
Rationale 30: 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 31: Increased stool output could indicate intolerance to the feed volume or type.
Rationale 32: The feeding regime may need to be re-assessed by the dietitian.
Rationale 33: Diarrhoea could indicate infection due to contamination of feeds.
Rationale 34: To prevent the tube from becoming blocked by feed debris.
Rationale 35: To prevent damage of the tube by increased pressure due to build up of feed deposits.
Rationale 36: 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 being disturbed by the pump alarming due to blockage. This is particularly relevant where overnight feeds are administered.
Rationale 37: To attempt to clear the blockage.
Rationale 38: To minimise risk of introducing infection due to poor handling or allowing feeds to become contaminated.
Rationale 39: This is to prevent ‘buried bumper syndrome’, where the internal fixation disc becomes buried, with the stomach lining growing around it.
Rationale 40: The stoma should be healed and free of infection or discharge before rotating.
Rationale 41: To prevent infection.
Rationale 42: The stoma can be immersed in water after three weeks, including bathing and swimming. In the meantime a shallow bath is possible due to the position of the stoma.
Rationale 43: To reduce the spread of granulation tissue.
Rationale 44: To prevent surrounding skin from damage from contact with the treated area.
Rationale 45: To prevent contamination of the feed (Anderson and Fearon 1993).
Rationale 46: To maintain a continuous flow of feed.
Rationale 47: To prevent blockage of the tube/feeding set.
Rationale 48: To avoid back-drainage of stomach/intestine content into the feeding system.
Rationale 49: To ensure accurate delivery of rate and volume of feed.
Rationale 50: To prevent bacterial growth in warmed feeds, which are left at room temperature for up to six hours.
Rationale 51: Each time a connection is touched it increases the risk of introducing bacteria into the system from the hands or the environment.
Rationale 52: It is certain to block it completely.
Rationale 53: The slow release properties of the drug will be destroyed.
Rationale 54: 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 55: To prevent the tube from migrating too far into or beyond the stomach.
Rationale 56: To secure the tube to the skin.
Rationale 57: To prevent tube dislodgement.
Rationale 58: The button device may be difficult to access with the extension sets and cause some discomfort to the child.
Rationale 59: To ensure a smooth uninterrupted procedure.
Rationale 60: The extension set is designed to lock in place.
Rationale 61: The device will not function if the extension set is not fitted correctly.
Rationale 62: Priming the set avoids introducing large volumes of air, which causes abdominal distension.
Rationale 63: To provide accurate feed record of intake and tolerance of feeds.
Rationale 64: To avoid a build up of feed deposits in the tube.
Rationale 65: To prevent a build up of feed debris which could lead to contamination causing infection.
Rationale 66: To remove all traces of detergent.
Rationale 67: It is less likely to detach from the feeding set.
Rationale 68: To allow accurate measurement for the length of shaft required.
Rationale 69: If the button is too tight it could result in formation of a pressure ulcer.
Rationale 70: The sitting girth is usually different from the lying girth.
Rationale 71: To avoid causing stress to the child and to remove the fear of an unknown procedure.
Rationale 72: To ensure that the device is not too tight which causes skin damage/ulceration or too loose if weight loss has occurred, causing the tube to leak from around the balloon.
Rationale 73: To avoid introduction of infection or cross infection from other patients.
Rationale 74: To comply with hospital policy on universal precautions when there is a possibility of contact with body fluids.
Rationale 75: To avoid the possibility of inserting a damaged or faulty device.
Rationale 76: 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, which in turn could lead to them not co-operating with future changes.
Rationale 77: To prevent damaging the balloon, and to ensure the patient’s comfort.
Rationale 78: To ensure correct placement has taken place before using the device for administration of feeds, and thus avoiding potential complications from button misplacement.
Rationale 79: To clear the button of stomach contents which could have flowed back during checking.
Rationale 80: To ensure correct volume, rate and feed is given to the child, and that it has not exceeded the expiry date.
Rationale 81: To ensure that a correct size of button is available should the button fail for any reason.
Rationale 82: The community nurse will order the correct size for future use.
Rationale 83: The stoma can close very quickly – over a matter of hours, making it difficult or impossible to insert a new tube.
Rationale 84: This can be inserted a few centimetres and secured with tape, preserving the tract until the new tube can be inserted.

References

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

Reference 2:
Anderton A, Nwoguh CE, McKune I, Morrison L, Greig M, Clark B (1993) A comparative study of the numbers of bacteria present in enteral feeds prepared and administered in hospital and the home J Hosp Infect 23 (1): 43-9.

Reference 3:
Aneiros S, Rollins H (1996) Home enteral tube feeding Community Nurse 2 (3): 28, 31, 33.

Reference 4:
Bommarito A (1989) A new approach to the management of obstructed enteral feeding tubes Nutrition in Clinical Practice June 4(3): 111-4.

Reference 5:
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Document control information

Lead author(s)

Joanne Brind and Anna Hughes, Clinical Nurse Specialists, Nutrition, Gastroenterology

Additional authors
Vanessa Shaw, Head of Department, Dietetics
Helen Johnson and Monika Morova, Clinical Nurse Specialists, Stoma Care, Surgery
Alex Barnacle, Consultant Interventional Radiologist
Maggie Stewart, Former CNS Nutrition, Gastroenterology
Crispin Walkling-Lea (editor), Former Clinical guidelines and care pathway co-ordinator, Strategic development
Susan Macqueen, Former CNS, Infection control
Nettie Fabian, Former senior staff nurse, Transitional Care Unit

Document owner(s)

Joanne Brind and Anna Hughes, Clinical Nurse Specialists, Nutrition, Gastroenterology

Approved by
Clinical Practice Committee

First introduced: 6 June 2005
Date approved: 3 May 2012
Review schedule: Two years
Next review: 3 May 2014
Document version: 2.1
Replaces version: 1.0