Overview
Definition:
Enteral feeding tubes are devices used to provide nutrition and hydration directly into the gastrointestinal tract when oral intake is insufficient or impossible
Common types in pediatrics include nasogastric (NG) tubes, gastrostomy (G-tubes), and gastrojejunal (GJ-tubes).
Epidemiology:
The use of feeding tubes in pediatrics is significant, with prevalence varying based on underlying conditions such as prematurity, congenital anomalies, neurological impairments, and severe gastrointestinal disorders
Rates can range from a few percent in neonates to higher percentages in specialized pediatric populations.
Clinical Significance:
Appropriate feeding tube selection and management are crucial for ensuring adequate nutritional support, promoting growth and development, preventing complications, and improving outcomes in pediatric patients with feeding difficulties
Mismanagement can lead to significant morbidity and impact long-term health.
Tube Types And Indications
Nasogastric Tubes:
Inserted through the nose into the stomach
Indicated for short-term feeding (days to weeks) in infants and children who can tolerate gastric feeding but cannot ingest enough orally
Used for gastric decompression, medication administration, and nutritional support in conditions like prematurity, feeding intolerance, or post-operative recovery.
Gastrostomy Tubes:
Surgically or endoscopically placed directly into the stomach through the abdominal wall
Indicated for long-term enteral feeding (months to years) in patients requiring nutritional support due to chronic conditions affecting oral intake, such as severe neurological impairment (cerebral palsy), congenital anomalies (e.g., esophageal atresia), or failure to thrive
Allows for larger bore tubes and easier administration of thicker formulas.
Gastrojejunal Tubes:
Placed through the stomach into the jejunum, either endoscopically or surgically
Indicated when gastric feeding is not tolerated due to gastroparesis, GERD, vomiting, or aspiration risk
Useful for patients who require post-pyloric feeding for continuous enteral nutrition, allowing for better tolerance and reduced risk of aspiration
Can be placed as a combined G-J tube allowing for both gastric decompression and jejunal feeding.
Placement And Confirmation
Nasogastric Tube Placement:
Typically inserted orally or nasally by a trained clinician
Confirmation of placement is critical and includes: aspiration of gastric content (pH <5.5), auscultation of air insufflation (though less reliable), and radiographic confirmation, especially for initial placement or suspected dislodgement.
Gastrostomy Tube Placement:
Usually performed via percutaneous endoscopic gastrostomy (PEG) or surgical gastrostomy
PEG is generally preferred due to its minimally invasive nature and lower complication rates
Confirmation involves visual inspection of tube position and aspiration of gastric contents.
Gastrojejunal Tube Placement:
Can be placed endoscopically (PEG-J) or surgically
Endoscopic placement involves guiding the jejunal extension through the pylorus under direct visualization
Radiographic confirmation is essential to ensure accurate placement in the jejunum, checking for post-pyloric position.
Complications And Management
Nasogastric Tube Complications:
Common complications include nasal irritation/erosion, sinusitis, otitis media, accidental bronchial intubation, vomiting, abdominal distension, and dislodgement
Management involves proper securement, nasal care, monitoring for signs of infection, and regular confirmation of placement.
Gastrostomy Tube Complications:
Early complications: leakage, peristomal infection, bleeding, buried bumper syndrome, peritonitis
Late complications: tube obstruction, granulation tissue formation, skin irritation, gastrocolic fistula
Management: meticulous stoma care, appropriate tube changes, managing leakage with barrier creams, and prompt treatment of infections.
Gastrojejunal Tube Complications:
Similar to G-tubes, plus specific issues related to jejunal placement: jejunal obstruction, malabsorption, electrolyte imbalances, dumping syndrome
Management requires careful monitoring of fluid and electrolyte balance, slow initiation of feeds, and assessment for malabsorption.
Feeding Protocols And Monitoring
Initiation Of Feeds:
Feeds are typically started at a low rate and concentration, gradually advanced as tolerated
For NG and G-tubes, continuous infusion is common
For GJ-tubes, continuous feeding is often preferred to minimize risks of malabsorption and dumping syndrome
Bolus feeds may be used cautiously in older children with G-tubes.
Formula Selection:
Choice of formula depends on the patient's nutritional needs, age, caloric density requirements, and tolerance
Standard infant formulas, specialized formulas for prematurity, or disease-specific formulas may be used
Consultation with a pediatric dietitian is vital.
Monitoring Parameters:
Regular monitoring includes daily weight, intake and output, abdominal assessment (distension, bowel sounds), stool output and consistency, signs of aspiration (coughing, fever), and laboratory assessments (electrolytes, glucose, renal and liver function tests)
Tolerance to feeds, including presence of vomiting or diarrhea, is also crucial.
Key Points
Exam Focus:
Understand the primary indications for NG, G-tube, and GJ-tube in pediatrics
Know the methods for confirming placement and common complications associated with each
DNB/NEET SS often test scenarios requiring selection of the appropriate tube for specific clinical situations.
Clinical Pearls:
Always confirm NG tube placement radiographically after initial insertion
For GJ tubes, ensure distal tip is in the jejunum
if continuous feeds cause GI upset, consider switching to bolus feeds if appropriate and tolerate
Regular stoma site care is essential for G and GJ tubes to prevent infection and irritation.
Common Mistakes:
Incorrect confirmation of NG tube placement leading to aspiration
Using an NG tube for long-term feeding needs
Not considering post-pyloric feeding for patients with gastroparesis or severe GERD
Inadequate stoma care leading to complications with G/GJ tubes
Over-advancing feeds too rapidly, especially in GJ tube feeds.