Basic guide to gastrostomies and gastrostomy care

Introduction

The aim of this booklet is to give you basic information about your child’s gastrostomy tube and how to care for the tube. It is natural that you may be a little apprehensive at this stage but there will be a nurse available to answer any questions you may have.

What is a gastrostomy tube?

A gastrostomy tube is a small feeding tube that is inserted directly into the stomach through which your child will be fed.

Your child will require a general anaesthetic for the gastrostomy tube to be put in place. This is a procedure that will be thoroughly explained to you by your nurse and a doctor.

Why does my child require a gastrostomy tube?

It is not possible for your child to tolerate enough diet or fluids to benefit from a healthy balanced diet in order to maintain your child’s nutritional needs. Your child needs a gastrostomy tube to help them to grow properly.

Are there any alternatives to a gastrostomy tube ?

If your child cannot tolerate enough fluid or food by mouth a nasogastirc tube (tube passed through the nose into the stomach) can be used to allow feeds into the stomach. These tubes can be uncomfortable, require frequent changes and cause irritations to the nose.

What sort of gastrostomy tube will my child have?

There are a variety of different gastrostomy tubes. Following discussion with your child’s surgeon it will be decided which tube is most suitable for your child. The most commonly used tube is the percutaneous endoscopic gastrostomy otherwise known as a PEG tube

The other types of tubes that are commonly used are as follows:

• The Medicina Gastrostomy Tube
• The MicKey Gastrostomy Tube
• The MicKey Button
• The AMT Button

Your nurse may come to see you at home to show you examples of the gastrostomy tubes available and talk about the procedure as a whole.

Can my child have a bath or shower?

Once the stoma site has fully healed your child can go back to their normal bath time routine. Always ensure that the tube and the clamp are fully closed. Ensure that you dry the stoma area fully afterwards.

Can my child go swimming?

Once the stoma site has fully healed your child can go back to normal activities. It may be advisable to cover the site with a waterproof dressing. Please ensure that the tube and clamp are fully closed. Ensure that you dry the stoma area fully afterwards.

Will I be able to move my child around as normal?

Yes. The gastrostomy tube should not restrict your child’s movements or normal activities.

If my child is not using the tube what care is required?

The tube must be flushed once a day and the stoma site cleaned once a day.

What potential problems may occur at home?

• If there are any signs of swelling, irritation, redness, skin-breakdown or soreness this may indicate a wound infection. Please contact your healthcare professional who will advise you.
• Leakage of food around the gastrostomy site. Contact your healthcare professional.
• Nausea and vomiting, diarrhoea or constipation. Stop feeding and contact your healthcare professional
• If the tube falls out contact the hospital immediately. It is often possible to replace the tube easily, but if left the hole will close down quickly.

What do I do if my child’s tube becomes blocked?

If you find you are unable to flush your child’s tube then try the following:

1. Ensure all clamps are open and the tube is not kinked.
2. Connect a 50ml syringe to the end of the gastrostomy tube and draw back (aspirate) to remove any excess fluid.
3. Flush with 10 to 20mls of warm water (not boiling hot water) and leave for 30 minutes to dissolve any fat globules. Reflush.
4. If the tube remains blocked then flush with 20mls of carbonated water and leave for 30 minutes. Reflush.
5. If you are still unable to flush the tube then contact your nurse for advice.

Never use excessive force and never attempt to unblock the tube using a sharp instrument.

Also ensure that you keep the feeding port of your gastrostomy tube clean and free from any debris. Your nurse will show this to you.

What are the risks of having gastrostomy insertion?

General anaesthetic is very safe in children, but may have more problems if your child has other underlying problems.

Common problems following insertion are:

• Bleeding from the insertion site – this usually settles.
• Infection which can lead to the hole becoming larger and leaking.
• Pain for a few days – which can be controlled by painkillers.
• Rarely the tube may fall out soon after the operation – if this happens it requires a further operation to re-insert it.
• The tube may become blocked – this can usually be cleared by flushing.
• Rarely the blockage is due to tube becoming buried in the wall of the stomach – a further operation is required.

If your child has gastro-oesophageal reflux (where food passes back into the gullet from the stomach causing vomiting) this may be made worse by insertion of the gastrostomy.

When will my child’s gastrostomy tube require changing?

This will obviously depend upon the type of tube your child has in place. The PEG gastrostomy, if it is well cared for, can remain in place for several years. If your child’s PEG requires changing this will have to be done under a general anaesthetic. The other types of tubes mentioned above require changing at varying times; on average this is every 3 to 4 months. Your child does not require a general anaesthetic to change these tubes; you will be taught how to change the tube at home by your nurse.

How will I know the amount and type of feed my child will require?

Always wash your hands with soap and water before feeding and cleaning the tube.

A dietitian will assess your child. The dietitian will prescribe a commercially prepared liquid feed, which contains all the essential nutrients your child will need on a daily basis. The dietitian will write an individual feeding regime following discussions with you.

There are a variety of ways that the feed can be delivered such as a bolus or as a continuous feed. The feeding regime will be designed to fit in with your child and the family routine as far as possible.

The following are the 2 main types of feeding:

Bolus feeding

This is a method of feeding by which feed is given at regular times by use of a gravity pack. The gravity pack consists of a syringe connected to the gastrostomy tube through which the feed is allowed to go into the stomach over 15 to 20 minutes. The nursing staff will teach you how to give this feed.

Continuous feed

A computerised pump is used to deliver your child’s feed slowly over a period of time. This can be anything from 1 to 24 hours. Nursing staff will teach you how to deliver this type of feeding.

You can also use both of these methods of feeding within your child’s feeding regime; for example an overnight feed plus 3 bolus feeds in the day. The feeding plan will be tailored to your child’s needs.

Feeding

1. Check tube length and position of fixation plate daily.
2. Ensure that connectors for feeding do not stretch the gastrostomy tube.
3. The child should be sat up or laid at a 30 degree angle during the feed and for 30 minutes after feeds, to prevent the risk of reflux and vomiting.
4. Bolus feeds should run in by gravity and should take the same time as a meal 15 to 20 minutes. Never use force to make the feed go in more quickly.
5. Continuous feeds should be administered by a suitable feeding pump. The doctor or dietitian will recommend the best method of feeding for your child.
6. Flush the tube after use with 10 to 20mls of water to ensure that it is clear and to reduce bacteria
7. Your nurse will show you how to vent the tube if your child is unable to ‘burp’ after the feed or has abdominal discomfort or distension, in some children it may be necessary to vent the tube prior to a feed as well.

Can I give my child medications via the gastrostomy tube?

The answer is yes providing all medications are in liquid form.

Suspensions

Suspensions are recommended. Dilute thick suspensions with water.

Tablets

Please check with the nurse whether tablets can be crushed prior to administering via the tube.

Any tablets that can be crushed must be thoroughly crushed before being administered.

Always flush the tube before and after the administration of medication.

How do I care for the skin surrounding my child’s gastrostomy tube?

Always wash your hands with soap and water before feeding and cleaning the tube.

The area where the tube enters your child’s stomach is called the stoma site. The first 7 to 10 days following your child having their gastrostomy tube there may be some discharge, do not worry about this it will clear up once the stoma site has healed.

It is important that you clean the stoma site on a daily basis and keep it dry. The nurse involved with your child will advise you on how to clean your child’s site.

If you notice any redness, pain, odour or discharge around your child’s stoma site, contact your nurse who will advice you over the phone or arrange a home visit. The nurse may need to take a wound swab to identify what is causing the problem. Your doctor may prescribe antibiotics, which you can give to your child via their gastrostomy.

You will also be advised to rotate your child’s tube once a day. Your nurse will show you this simple procedure.

The steps to follow are:

1. Open the fixation catch.
2. Detach tube from groove in fixation plate.
3. Move plate away from skin.
4. Holding the tube between 2 fingers push the tube in approximately 1cm and turn 360 degrees.
5. Pull the tube back into position so that the disc is on the stomach wall and fix triangle on outside to hold it in position.
6. Secure the tube in a different position to where it had previously been.
7. Ensure that the tube is secured in place with tape. This will discourage the tube from moving in and out and therefore prevent over granulation, weeping and discharge. The fixation plate should not be too tight but neither should it be too loose.
8. Your child’s fixation plate should not be too tight. If you are unsure then ask the nurse for advice.

How often should I flush my child’s gastrostomy tube?

Your child’s tube should be flushed with 10 to 20mls of water following every feed and medication given. If your child is not having any feed or medication via the tube you should always flush the tube once a day.