Gastronomy tubes

Gastronomy tubes (G-tubes) are tubes placed through the abdomen into the stomach that allow nutrition and medication to be delivered directly into the stomach. The majority of pediatric G-tubes placed are surgically inserted, requiring your child to be given general anesthesia. The surgery consists of a small incision (cut) on the abdomen used to create the insertion site for the tube. There are a few different types of tubes that can be inserted and the type will depend on the length the G-tube will be used. From my experience, as a pediatric home health and hospital nurse in Colorado (may be different depending on the state/region), the most widely used, long term, G-tube is a Mic-Key button.

Common reasons your child might need a G-tube

1. Sucking and swallowing difficulties
2. Not eating enough food for stable nutrition and growth
3. Congenital (present at birth) abnormalities of the esophagus, mouth, stomach or intestines
4. Extreme difficulty taking medication

 Important things to have at all times

1. An extra G-tube
2. An extra extension tube
3. A card with (information can be found on the G-tube itself)
   1. The brand of G-tube
   2. Size of the tube (Fr)
   3. Length of the tube (cm)

Next Steps

Once the site has healed from the initial insertion your child most likely won’t notice it is present. You will also be taught, usually by a home health agency or by your child’s doctor, daily cares, how to use the feeding pump, as well as how to change the G-tube. Here are some supplies you will need to care for the G-tube.

Supplies

1. Replacement G-tube
2. Extension sets
3. Syringes
4. Gauze
5. Tape
6. Lubricant (for replacing the G-tube)
7. Feeding bags
8. Soap and water

Feedings and Medication

Continuous vs. bolus feedings:

Continuous feeds are generally smaller, slower feeds that usually take place over night. A pump is used to continually infuse the feed. These children generally cannot tolerate the larger bolus feedings. Bolus feeds are more like a “meal” where the child receives a large amount of fluid over a shorter period of time (usually an hour or two). The general goal is to have children on bolus feeds. The amount will start low and gradually increase depending on how your child reacts to the fluid volume. The child’s provider will determine the “goal” amount (in milliliters).

General feeding/ medication guidelines:

Always give medication and feeds per doctor instruction. After each administration, feed or medication, flush the G-tube with 10-15 ml/cc of warm water. This will help prevent clogging of the tube.

Give liquid medications directly into the G-tube. For pills, crush medications into a fine powder and mix with just enough water to make a liquid. Frequently flush water in between medications to avoid clogging the tube.

Flushing with the G-tubes

Use 10-15 ml/cc of warm water after each feeding and/or medication administration. The doctor may also order “water boluses” which are basically a large flush (the amount and frequency will be determined by the doctor).

Venting the G-tubes

Your child may not be able to “burp” or pass air that is trapped in their stomach. This is usually due to a procedure but can be caused by many things. In these cases “venting” the G-tube may be necessary. Follow the doctors instructions as venting can be done many ways. One example is connecting a 60ml/cc syringe (without the plunger) to the attachment tubing and holding the syringe up-right, while gently pushing on your child’s stomach thus allowing the air or excess fluid to get out (see picture). It is normal for fluid to come out of the G-tube and into the syringe during this process. Just be aware of over filling the syringe and ALWAYS re-feed (put back in) whatever comes out.

Assessment of G-tube site

Should be done on a daily basis.

• Wash hands thoroughly.
• Remove old dressing and look at the skin around the G-tube site. Look for redness, swelling, drainage or excess skin growth around the tube. The tube should be able to freely rotate. A small amount of clear drainage is normal.
• For G-tubes with balloons, like Mic-Key buttons, check the volume in the balloon every week. The volume will be ordered by the doctor (usually 4 or 5ml/cc).
  

  Checking the volume in the Mic-Key button G-tube

Cleaning and dressing the G-tubes

• Wash the skin around the G-tube with warm soapy water and dry thoroughly.
• Do not use lotions or ointments around G-tube site unless directed by your doctor.
• There are many different types of dressing and ways to dress the G-tube site. Follow your doctor’s instructions on the types of dressings. Here are a few examples…

Activity and clothing

Babies and children with G-tubes can do all the same activities they did before the surgery. They can crawl, walk, jump, swim and be just as “normal” as everyone else. The key is to make sure the G-tube is secured under their clothing. For babies and toddlers onesies come in handy, but for older children there is no special clothing needed.

Common issues when caring for G-tubes

Granulation tissue formation

Granulation is an over growth of capillaries that causes the skin around the G-tube site to look red, raised, raw and “beefy”. This is a very common and non dangerous problem with G-tube sites. Treatment can be painful, especially with the use of silver nitrate (a common treatment).

Skin infections and leaking G-tubes

While skin infections can be hard to diagnose there are a few symptom to look out for. Redness at the site and clear/ tan drainage is normal and by itself does not indicate an infection. Also keep in mind that fluids from the stomach can leak from the site and thus causes redness. The redness is a reaction from the stomach acid and is considered a chemical reaction and not a bacterial reaction (infection).

Symptoms of infection to watch for:

1. Spreading redness or
2. Raised and red skin
3. Pain/ tenderness that is more than normal
4. Fever without another cause (illness)
5. Excessive discharge or pus from the site

Call the doctor if you suspect an infection!

If your child’s tube is leaking assess the placement and measurement (size) of tube. It is possible that your child has grown enough they require a large size G-tube. If the G-tube is a balloon type (i.e. Mic-Key or button G-tubes) assess that the balloon is fully inflated with the correct amount of fluid.

Tube dislodgement

Do NOT panic!! If you followed my instructions (at the top of the page) and the doctor’s instructions you have a spare/ extra G-tube with you. If this is a mature/ healed site and you have changed the G-tube by yourself before, you know how to handle this situation. Insert the new G-tube into the site and call the doctor. If you do not have an extra/ new G-tube reinsert the old G tube and call the doctor.  If the site is fresh/ new (less than 6 months old) cover the opening with a clean piece of gauze and get to the nearest hospital quickly. G-tube sites close quickly (within 60 minutes the closing process has started) so do not delay getting to the hospital and make sure to bring the dislodged tube with you.

Clogged G-tubes

Thick formulas and medications can cause the tube to become clogged. The solution is to try and slowly flush the tube with warm water. About 10 ml/cc via syringe. Repeat the flush every 10-15 minutes. Keep in mind the amount of fluids you are giving your child, they may not tolerate the increased amount. Never stick anything in the tube and if all else fails change the G-tube or call the doctor.

Nausea, Cramping, Distention and Diarrhea

• The feeding is running too fast
• The formula is too cold (should be room temperature)
• Old formula? Check the expiration date and only keep open formula in the refrigerator for 24 hours.
• Direction your child is laying during feeds. Have them in a head elevated or sitting position
• Your child could be constipated

When to call the doctor

• A dislodged tube
• A blocked or clogged tube that you cannot get clear
• Any symptoms of infection
• Excessive bleeding or drainage from the site
• Severe abdominal pain
• Persistent vomiting or diarrhea
• Trouble passing gas or bowel movements
• If you notice a new granuloma

References: Cincinnati Children’s Hospital Medical Center, University of California, San Francisco, KidsHealth, Children’s Hospital Los Angeles, Children’s Hospital Colorado