Gastrostomy Tube Placement
Who will take care of my child and teach me about the gastrostomy tube?
Once the need for a gastrostomy is identified, the pediatric surgeon will evaluate your child. The surgeon will determine what type of tube will be placed and by what method. You will meet many different hospital staff who will help you learn about your child's new gastrostomy tube. These people will include the surgeon, the surgery nurse practitioners, the staff nurses, the dietician, and the home care coordinator. Each of these people will help you with different aspects of your child's care and be available to answer your questions and assist you with problem solving.
Back to Basics - Anatomy and Physiology of the Gastrointestinal Tract
The gastrointestinal (GI) tract is a continuous path from the mouth to the anus. In the normal GI tract food enters the mouth where it is chewed and partially broken down by saliva. When swallowed, food then enters the esophagus where it is transported to the stomach. The area between the esophagus and the stomach is the GE junction. Normally at the GE junction the angle into the stomach is such that food is contained in the stomach and not allowed to back up into the esophagus. So that the body can use the nutrients, acids in the stomach digest food. The digested food then moves through the pyloric muscle and into the small intestine. In the small intestine the body absorbs more nutrients and water. The waste remaining moves into the large intestine and is produced as stool. Problems in the GI system can occur at any point along the way. (Insert a picture/diagram with labeled anatomy and maybe chart that tells what happens where?)
What is a gastrostomy feeding tube?
A gastrostomy feeding tube is either a tube or a button (skin level device) that is surgically placed into the stomach through the abdominal wall. There are a wide variety of tubes and skin level devices available. Your surgeon will choose the device which best meets you and your child's needs with the least invasive technique.
Who needs a gastrostomy?
Children require gastrostomy feeding tubes for a variety of reasons. The primary indication for gastrostomy is the child's inability to take adequate nutrition or liquids by mouth for growth and development. The reasons why the child is unable to take proper nutrition can be developmental, mechanical, or secondary to other health problems.
What does the preoperative evaluation entail?
There are several studies the surgeons often do before arranging gastrostomy placement. These studies are done to be sure whether or not your child has gastroesophageal reflux. If significant reflux is present the surgeon will discuss with you the possibility of surgically treating the reflux at the same time that the gastrostomy is done. Your child may not require all of these studies. The studies include the following:
- Upper GI/Swallow Study: For this study the child swallows (if able) a small amount of contrast (barium) and its progress is monitored through the upper gastrointestinal tract by x-ray. If the child is unable to swallow, the barium is given through a feeding tube placed through the nose into the stomach. If movement of barium back into the esophagus from the stomach is seen, the child has reflux. This study also provides the surgeon with an x-ray picture of the child's gastrointestinal tract anatomy. This study is done as an outpatient.
- pH Probe: This study is done if the clinical history is suspicious for gastroesophageal reflux but reflux is not clearly demonstrated on an upper GI. Pediatric patients are admitted to the hospital for 24 hours. A small wire with a sensor is placed through the nose and into the esophagus. The sensor sits just above the stomach and measures any acid or reflux episodes. After the probe is placed, the child wears a small monitor and is free to move around the hospital unit and eat and drink normally. A diary of activity and diet is kept during this time.
- Gastric Emptying Study: This study evaluates the time it takes for the stomach to empty a specific amount of food. Delayed emptying often significantly contributes to gastroesophageal reflux. This study is done as an outpatient.
Once the studies are complete you and your child will return to the pediatric surgery clinic for a consultation with the surgeon. The results of the studies will be reviewed with you and the surgeon will discuss the surgical recommendations. If you choose to plan the surgery, scheduling and necessary paperwork will be completed at that time. You will also be offered an opportunity to talk with the pediatric anesthesiologist.
What is gastroesophageal reflux?
As mentioned in the previous section, before placement of a gastrostomy feeding tube is planned, the presence or absence of gastroesophageal reflux must be determined. Gastroesophageal reflux is the movement of food and acid from the stomach back into the esophagus. Reflux often causes gagging, vomiting, and epigastric pain or burning. Many children with reflux have frequent upper respiratory infections, inadequate weight gain, and/or inability to recline without pain or vomiting. It is common for newborns to have some degree of reflux and most stop refluxing as they grow bigger. There are some children whose reflux is significant enough to interfere with growth. For children with significant reflux, placement of the gastrostomy feeding tube alone is not recommended. Surgical treatment of the reflux at the same time as the gastrostomy is usually recommended. The antireflux procedure is called a fundoplication. If your child requires this procedure more information will be provided to you.
Planning the Surgery/Expected Hospital Stay
Once the pre-operative evaluation is complete, the surgery will be scheduled. Generally, children come to the hospital the day of the surgery and are admitted after the procedure is over. Most children will stay in the hospital one to two days if only a feeding tube is placed, or three to five days if both a feeding tube placement and fundoplication are done. Your child's time in the hospital will be spent recuperating from surgery and beginning feedings through the gastrostomy tube. You will be taught how to care for the gastrostomy tube and administer feedings. Arrangements will be made for home care delivery of feeding supplies.
Caring for the Gastrostomy Tube At Home
Securing the tube: How a gastrostomy tube is secured is dependent upon what type of tube is placed. All tubes have a balloon or mushroom shaped part on the inside of the stomach and a disk, clamp, or crossbar on the outside to keep them in place. Initially most tubes will also have a stitch or suture holding it in place. It is extremely important that the tube stay in good position to avoid problems with leakage. If the balloon or mushroom sinks into the stomach or if the outside disk or clamp is too loose, stomach contents may leak out around the tube. The disk, clamp or crossbar should fit snugly enough to hold the tube in proper position, but not leave an indentation on the skin.
Cleaning around the tube: It is important for the area around the gastrostomy tube to be kept clean and dry. For the first 2-3 days the gastrostomy site should be cleaned two to three times per day with with half-strength hydrogen peroxide. This keeps the area clean and promotes healing. After the first 2-3 days, the site should be cleaned with mild soap and water. If there is a crossbar on your child's tube, rotate it & turn once per day. Antibiotic ointments or creams are not necessary on a routine basis.
Bathing: You will need to keep your child's new gastrostomy site dry for the first two days. Your child may shower after two days. Clean the site and pat dry after showering. Your child may bathe or swim after one week unless there is a stitch in place. If there is a stitch, your child may not bathe or swim until the stitch is removed.
Venting/Burping the tube: Some children have a difficult time with gas after gastrostomy tube placement. In particular those children who have had a fundoplication find it very difficult or even impossible to burp. It may be necessary for you to help your child relieve the gas by venting or burping the gastrostomy tube. Place a 60cc syringe with the plunger removed into the end of the gastrostomy tube. If the tube is clamped, open the clamp (DO NOT OPEN THE CLAMP ON THE DRAIN TUBE ATTACHMENT). Hold the syringe above the child's stomach for a few minutes. If gas is present you should hear the gas bubble up through the tube or sometimes even see stomach contents back up into the tube and syringe. Once the gas is relieved allow the formula, if stomach contents also came out, to flow slowly back into the stomach. Your child may need to have this done frequently especially during the first few days after surgery.
Activity Restrictions: Your child should not lift anything heavier than 5 pounds and should not participate in vigorous activity for two weeks after the surgery. After two weeks your child may resume regular activities.
What Happens if the Tube Comes Out?
It is possible for your child's gastrostomy tube to accidentally come out. If this should happen DO NOT PANIC. The site may bleed a little, stomach contents may leak out of the hole, and your child may complain of pain or discomfort. Cover the hole with a clean, dry cloth and call our office or after hours number immediately. Once the tube is out, your child's gastrostomy hole will begin to close and may close completely in only four to six hours. If you live near the hospital, we will ask you to come in immediately. If you live far from our office, we will direct you to your local hospital emergency room. The local ER should be able to get a temporary tube in place until you can come to our office. If your child's tube has been replaced within the first few weeks after surgery, the new tube should be checked under x-ray for proper placement.
Feeding Through the Gastrostomy Tube at Home
There are several ways to feed through the gastrostomy tube and there are several types of feedings. The surgery nurse practitioner, dietician, and surgeon will help you to design a feeding plan that meets your child's needs and allows your child to return to a regular lifestyle as soon as possible. Following are some definitions that will help you understand your feeding plan:
- Continuous: Over an extended time period feedings are given by a pump at a slow rate. An example would be 30cc per hour for 24 hours.
- Bolus: A larger amount of feeding is given 3-6 times per day. Sometimes given by a pump over a certain amount of time (one hour) or simply allowed to run into the stomach by gravity using a roller clamp to slow down flow as necessary.
- Direct: Direct feeds are given with the feeding set hooked directly into the gastrostomy tube.
- Chimney: Chimney feeds are given by dripping the feeding into a vent that is attached to the gastrostomy tube.
Most children are discharged on a continuous feeding plan, that is a slow rate over a longer time period. This feeding is then advanced as your child tolerates to your preferred plan over the course of the first week or two at home. When the gastrostomy tube is new, a full stomach can sometimes cause or encourage leakage and poor healing around the tube. Most children are able to change from a continuous feeding plan after about one week. Children who have also had fundoplication may be advanced more slowly and may initially need to be chimney fed to allow for continuous venting of gas.
Troubleshooting Your Child's Gastrostomy
|Tube comes out
||Balloon broken, pulled
||Replace if you know how, if not, follow emergency plan
|Leakage around tube
||Tube too loose, balloon broken, tract enlarged, stomach too full or child constipated.
||Check water in balloon, check placement of tube, re-secure tube, stop tube feedings, clean and protect skin, CALL PEDIATRIC SURGERY
|Mucus around tube
||Normal drainage, amount may increase when child has a cold.
||Keep site clean and dry. Clean more frequently when mucus increased.
|Pink/red bumpy tissue around tube
||Granulation tissue (or proud tissue), bleeds easily and creates increase in mucus drainage, may also cause site to leak.
||Treat with silver nitrate sticks or Kenelog ointment if you know how, otherwise call office for appointment to see either surgeon or nurse practitioner.
|Skin irritation or bleeding
||Granulation tissue, slight leak of stomach acids, yeast infection, infrequent cleaning, tape irritation
||Keep skin clean and dry, clean more frequently and/or change dressing more often, consult with nurse practitioner
Switching to a skin level device or "button"
Once your child's gastrostomy site is well-healed and the tract is developed it is possible to switch to a skin level feeding device. These devices are commonly called "buttons." There are several types of buttons. The most common are the Button made by Bard and the MIC-Key made by Medical Innovations Corporation. The change to a button can be done once the tube has been in place for a minimum of 8 weeks.
|Easy to change, little or no pain
||Balloon breaks so needs more frequent change
||Only needs to be changed once per year
||Difficult to change, more painful
|Can be changed at home by parent
||Higher profile because valve is outside body
||Low profile because valve inside stomach
||Can only be changed in surgery office
|Comes in wide variety of sizes
||Stiffer silicone tube
||Softer silicone tube
||Limited size range
|Has locking feeding adaptor
||Feeding adaptors do not lock into place
||Needs different adaptor to vent
Information for school
When your child returns to school, the school nurse will need some basic information about the g-tube. If your child will be receiving feedings and/or medications via the g-tube during the school day, they will need instruction forms filled out by you and signed by either your primary care doctor or your surgeon. If you will need forms for school to be completed by the surgeon, let us know well in advance of the day you need them.
Who should I call with questions or concerns?
Office Hours: Monday-Friday 8am-5pm:
Office Phone: (734) 764-4151
After hours, weekends, or holidays for emergent issues only, call the hospital paging operator and ask for the pediatric surgeon on call at (734) 936-6267
This information is provided by the University of Michigan Department of Surgery, Section of Pediatric Surgery and
is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care
provider for advice about a specific medical condition.
For additional health information, please contact your
health care provider or our office.