A Feeding Tubeout the Psych Ward

Tube Feeding

Tube feeding (enteral feeding) is a way of giving liquid nutrition (often formula) directly into the stomach or small bowel.

About

Tab Content 1

Tube feeding can be used for children or youth who:

cannot take food by mouth
have not learned to take food by mouth (oral aversion)
need extra nutrition
have problems swallowing

This is information about surgically placed feeding tubes.

There are many different types of feeding tubes and approaches to enteral feeding. The procedure and the type of feeding tube chosen for your child will depend on their healthcare needs. Tubes placed directly in the stomach are called gastrostomy tubes (GT). Tubes are sometimes placed in the small bowel (jejunum) when feeds are not tolerated via the stomach. These tubes are called jejunostomy tubes (JT).

These are the different surgical procedures used to place feeding tubes at BC Children's Hospital:

percutaneous endoscopic gastrostomy (PEG)
open gastrostomy
laparoscopic gastrostomy
jejunostomy
gastrojejunal feeding tube (transgastric feeding tube)
open jejunostomy
Roux-en-Y jejunostomy
Braun jejunostomy

Terms used in tube feeding

Abdomen - contains the stomach, small and large intestines, liver, gall bladder, spleen, pancreas and bladder.

Aspiration - fluid in the lungs.

Abscess - a localized collection of pus in a tissue or body part resulting from the invasion of bacteria.

Decompression tube - a device which allows air/fluid to escape (venting) from the stomach via a feeding device.

Gastric decompression - removal of pressure in the stomach (usually through a nasogastric tube or gastrostomy tube).

Gastric outlet obstruction - blockage at the end of the stomach.

Gastrostomy tube (GT) - a feeding tube that supplies food directly into the stomach through a permanent surgical opening (gastrostomy) made into the stomach.

Gastrojejunal tube (GJ) - a feeding tube (transgastric) that passes through the stomach through the gastrostomy into the jejunum.

Hypergranulation tissue (proud flesh) - an overgrowth of fleshy tissue (granulation tissue) that often grows up around the tube.

Ileus - an intestinal obstruction either mechanical or functional.

Jejunal tube (JT) - a feeding tube that supplies food directly into the small intestine (jejunostomy) made possible through a surgical opening into the small intestine or through a transgastric feeding tube into small intestine.

Jejunum - the second portion of the small intestine (small bowel).

Laparoscopy - a surgical procedure that explores the abdomen using a type of endopscope (a camera) called a laparoscope.

Laparotomy - the surgical opening of the abdomen.

Nissen fundoplication - an operation that is used in the treatment of stomach acid reflux into the esophagus. It is an operation where there is a 360 degree wrap of the greater curvature of the stomach around the intraabdominal esophagus.

Peristomal - area around the stoma.

Pyloroplasty - this is an operation where the pylorus muscle is partially divided to enlarge the outlet of the stomach and facilitate gastric emptying.

Reflux - backward flowing of a substance (e.g. return of fluids to the mouth from the stomach).

Roux en Y jejunostomy - surgical procedure that takes a portion of the jejunum and creates a limb that forms the stoma for the jejunostomy tube; this allows for a button or skin level device to be used as a feeding tube.

Stoma - an artificial opening.

Types of tube

PEG

A PEG feeding tube can last for 1-2years. You can discuss changing to a lower profile feeding tube after 3 months. Most children are admitted for daycare surgery to have the PEG tube removed. The adapters (at the end of tube) sometimes leak - they can be easily changed (once a month). We recommend taping the tube to the abdomen to stabilize the tube.

MIC G (balloon-type device)

MIC G tubes are sometimes used as primary (initial) tubes. They have a balloon - subsequent tube changes can be done in the clinic or at home.

MIC KEY (balloon-type device)

MIC KEYs are a balloon-type device as well. These tubes last anywhere from 3-6 months on average (depending on many factors).They are most often changed in the clinic or at home once families are comfortable with the process.

Nutriport (balloon-type device)

Nutriports are a balloon-type device as well. These tubes last anywhere from 3-6 months on average (depending on many factors).They are most often changed in the clinic or at home once families are comfortable with the process.

Bard Button (mushroom-type device)

Bard buttons are a mushroom-type device that are most often changed in a clinic setting or operating room because we believe removing and replacing the device can be uncomfortable. Some children tolerate the tube changes in clinic without sedation, while others require medication to help them with the tube change.

Jejunostomy Tubes

For Roux-En-Y or a Braun jejunostomies - the above low profile-type tubes may be used.

Here are 3 types of Jtubes:

Cook catheter - for transgastric jejunal feeding
MIC - for a surgical jejunostomy
Foley with no balloon - replacement tube for a surgical jejunostomy

There are several types of jejunostomy tubes used in our program. The type of tube used will depend on the way the jejunal feeding has been established. A lower profile device can be used to access Roux-En-Y jejunostomies and Braun jejunostomies.

Transgastric jejunal feeding tubes

Cook catheter for transgastric jejunal (GJ) feeding

The type of tube is inserted through an established gastrostomy tract in the radiology department. This tube needs to be well secured (taped) to the abdomen to prevent it from falling out. These tubes can be easily pulled out if not secured well. It is very important to make sure that medications are given separately and flushed well to prevent the tube from becoming blocked. We often suggest that the tube is changed every 3 months on a routine basis.

MIC low profile transgastric jejunal feeding tube with gastric port

photo to come

MIC low profile transgastric jejunal feeding tube without gastric port

MIC transgastric jejunal feeding tube

What to do if the GJ tube falls out
If the GJ tube becomes blocked

A GJ tube is a radiologically inserted tube that is placed through the already established gastrostomy stoma and threaded into the jejunum in the x-ray department.

GJ tubes are used for children who cannot tolerate feeding into the stomach, usually due to gastroeshophageal reflux (GERD).

To change a GJ tube in radiology:

a requisition must be sent to the x-ray department for every tube change
the requisition must be signed by a doctor with admitting privileges at Children's
the GJ feeding tubes are routinely replaced on Thursdays

Important things to know about a GJ tube

feeding will now need to be continuous - the small bowel can not handle bolus feeds like the stomach can - you will no longer be able to bolus feed with this type of feeding tube
the length of feeding time will increase if you have been bolus feeding
the GJ tube may not be as secure as the GT, it can fall out if it is not taped and secured well (if a Cook catheter is used)
the GJ tube tends to block easier that the GT (flush tube well before and after medications)

Preventing the tube from falling out

If a Cook catheter is being used - you need to keep the GJ tube well secured - there is no balloon or disc that keeps the tube in the small bowel.

keep tube well secured to the abdomen with waterproof tape
you may find that a piece of duoderm on the skin helps to protect the skin from the tape needs to be changed frequently
remember to always carry a replacement tube with you
you will need to place the replacement tube into the stoma to stop the stoma from closing
you can purchase an emergency kit at the outpatient pharmacy at in the Ambulatory Care Building

If the tube falls out

If the GJ tube falls out, a replacement tube needs to be placed into the stoma as soon as possible so that the hole does not close over. You can use a Foley catheter to keep the stoma open until the GJ tube can be replaced.

if your child can tolerate medications and fluids via the gastrostomy – you can use this route until the tube can be replaced
if your child can NOT tolerate any fluid via the gastrostomy you will need to take your child to a hospital for intravenous fluid until an appointment can be arranged to replace the GJ feeding tube

Do not panic

If the stoma is new (the gastrostomy tube itself was less than six weeks):

cover the stoma with a clean gauze or cloth
you need to see a doctor to put the tube back in as soon as possible (within two hours)
the stoma will close pretty quickly (within four to six hours)

If the stoma is more than six weeks old:

you need to place a feeding tube into the stoma as soon as possible

gather equipment:
-feeding tube (Foley catheter or skin level tube)
-wash cloth
-tape
-5ml syringe – to inflate the balloon
-5ml water – to inflate the balloon
-water-soluble lubricant (like KY jelly)
draw up 5ml of water into the syringe
check the balloon on the new tube before putting it into the stoma by inflating the balloon with 5ml of water
deflate the balloon by pulling the water back into the syringe
moisten the end of the tube with water or water-soluble lubricant (to make the tube go in easier)
insert the new tube about 2 inches into the stoma - inflate balloon with the 5 ml of water in the syringe – remove the empty syringe from the tube
gently pull back on the tube – to feel it (the balloon) snug against the stomach wall
you will need to arrange to have the GJ tube replaced

your doctor will have to arrange to have the tube changed
if your child can not have medications and/or fluids via the gastrostomy route – you will need to go to the hospital for intravenous fluid until an appointment can be booked to have your tube changed

If the GJ tube becomes blocked

First try using warm water and use a firm push/pull action with a 60ml syringe to unblock the tube. If this is not successful a mixture of cotazyme and sodium bicarbonate can be used to unblock the tube. Your doctor will need to supply you with a prescription for the cotazyme capsules.

Supplies

doctor must prescribe a cotazyme capsule (pancreatic enzyme)
cotazyme capsules are available at a pharmacy
sodium bicarbonate 1 tablet (325mg) or ½ teaspoon of baking soda
warm water
syringe (60ml)
small cup

Method

Try to unblock tube with warm water using a firm push/pull action.
Pull out as much of the contents of the tube as you can.
Place contents of cotazyme capsule (just the powder) and crush sodium bicarb tablet (baking soda) into cup.
Add 10-15ml of warm water to the powders and mix very well
Draw up this solution into the syringe (60ml).
Put the solution into the blocked tube and let it sit for 15-30 min.
You can "milk" the tubing to move the solution through the tube.
Flush the tube with warm water using the push/pull action .
If tube is still blocked, repeat above. You may leave the solution in place for one (1) hour.
If two (2) attempts to unclog the tube do not work – contact your doctor or remove the tube and use as a gastrostomy until the GJ tube can be replaced.

Managing

Tab Content 2

	Problem	Possible Causes	Action
1.	blocked tube prevention is the key flush, flush, flush	feeds too thick residue build up in the tube medicine too thick (some medicines can block the tube)	flush tube with warm water before & after feeds & medications ensure that blender prepared foods are in liquid form crush tablets to a fine powder and dissolve in a small amount of warm water do not give enteric coated and time releases medication through the tube if tube is blocked, may need to order for cotazyme and bicarb to unblock tube do not mix medications together
2.	irritation around tube site (stoma) sucralfate/desitin (3% in 25 grams) for "burned" skin cicatrin powder for wet and mucky skin proshield as a protective barrier if required	tube movement tension on the tube leaking from around the tube	ensure that tube is secured to decrease movement gently pull up on tube to ensure balloon/end of tube is up against the stomach wall be aware of marking of tube at abdomen (if it is not a low profile tube) assess patency of balloon, ensuring that water in balloon is intact for established tracts (more than 6 weeks old)
3.	migration of the tube	internal migration tube sliding further into the stomach external migration tube sliding out and sticking to the stomach wall intraperitoneal tube - out of the stomach - between stomach and skin	observe for signs of obstruction: vomiting, epigastric pain, increased leakage around the tube stop feeds immediately if migration to peritoneal cavity presumed call doctor if: pain, abdominal distension, nausea, vomiting, fever, swelling around the tube site and pain on feeding or flushing
4.	granulation tissue (hypergranultion tissue) – proud flesh around the tube site	body "walling off" from the tube body's reaction to the tube	may cauterize with silver nitrate sticks or treat with a short term low dose cortisone cream consult surgical nurse or physician ensure that tube is stable
5.	choking or coughing during feed	tube in the wrong place gastroesophageal reflux	elevate head for feedings notify physician if continues
6.	constipation	low stool volume lack of bulk in diet inadequate fluid intake medications	consult physician and/or dietician encourage activity increase water intake
7.	vomiting	too rapid infusion of feed excessive amount of feed	reduce rate of feed if vomiting continues, stop feed and reassess rate, type and consult a physician or dietician
8.	diarrhea	feed infusing too quickly feed too cold contamination of food or feeding equipment lack of bulk in diet high osmolaty of formula	reduce rate of feed infuse feed at room temperature check proper handling of equipment consult dietician for dietary changes or rate and concentration of formula
9.	psychosocial and emotional concerns	feelings of dependency, loss of control, loss of social aspect of eating, feelings of being different and change in body image	preoperative session for information exchange set goals adjust feeding schedule around activities and schooling plan feeding around meal times include the enterally fed child with family meals

Blocked tube

Supplies

D octor must prescribe a cotazyme capsule (pancreatic enzym e).
Cotazyme capsules are available at a pharmacy.
Sodium bicarbonate 1 tablet (325mg) or ½ teaspoon of baking soda
Warm water
Syringe ( 60ml)
Small cup

Method

Try to unblo ck tube with warm water using a firm push/pull action.
Pull out as much of the contents of the tube as you can.
Place contents of cotazyme capsule (just the powder) & crush sodium bicarb tablet (baking soda) into cup.
Add 10-15ml of warm water to the powders and mix very well.
Draw up this solution into the syringe (60ml).
Put the solution into the blocked tube and let it sit for 15-30 min.
You can "milk" the tubing to move the solution through the tube.
Flush the tube with warm water using the push/pull action.
If tube is still blocked – repeat above. You may leave the solution in place for one (1) hour.
If two (2) attempts to unclog the tube do not work – contact you r doctor.

Gastrotomy tube falls out

If the stoma is new (the tube has been in for less than six weeks)

Cover the s toma with a clean gauze or cloth.
You need to have a doctor put the tube back in as soon as possible (within two hours).
The stoma will closed pretty quickly (we usually say four to six hours).
Often times an Xray with contrast (dye) will be taken to make sure the tube is in the right place before feeds can be restarted.

If the stoma is more than six weeks old

You ne ed to place a feeding tube into the stoma as soon as possible.
PEGs and Bard buttons can not be replaced. You will have to use the Foley catheter from your emergency kit.
MIC KEYs and MIC Gs can be reinserted.
Always make sure you get contents returned before restarting fee ds.

Remember to always carry a replacement tube with you.

You will need to place the tube into the stoma to stop the tract/hole from closing.

Gather equ ipment
- feeding tube (Foley catheter or skin level tube)
- wash cloth
- tap e
- 5ml syringe – to inflate the balloon
- 5ml water – to inflate the balloon
- water solub le lubricant (like KY jelly)
Draw up 5ml of water into the syringe.
Check the balloon on the new tube before putting it into the stoma by inflating the balloon with 5ml of water.
Deflate the balloon by pulling the water back into the syringe.
Moisten the end of the tube with water or water-soluble lubricant (to make the tube go in easier).
Insert the new tube about two inches into the stoma.
Inflate balloon with the 5 ml of water in the syringe – remove the empty syringe from the tube.
Gently pull back on the tube – to feel it snug against the stomach wall.
Clean and dry the skin – tape the tube to the skin to secure.
If using a catheter you should mark where the tube comes out of the body – you can use this as a "check-mark" for placement.
Check the placement of the tube by withdrawing stomach contents – make sure this fluid goes back into the stomach.
If unable to withdraw stomach contents – reposition and try agai n. If you can not get any stomach contents – wait ½ hour and try again. If unsure that the tube is in the stomach – do not use the tube.

GJ tube falls out

Remember to always carry a replacement tube with you.

If the stoma is new (the tube has been in for less than six weeks):

Cover th e sto ma with a clean gauze or cloth.
You need to have a doctor put the tube back in as soon as possible (within two hours).
The stoma will close pretty quickly (we usually say four to six hours).

If the stoma is more than six weeks old:

You need to pla ce a feeding tube into the stoma as soon as possible.
You will have to use the Foley catheter from your emergency kit to keep the stoma/hole open until a new GJ tube can be rein serted.

Steps to reinserting a gastrostomy tube (even if you child/youth does not tolerate feeds via the stomach - you still need to place the tube to keep the stoma open)

Gather equipment:
- feed ing tube (Foley catheter or skin level tube)
- wash cloth
- tape
- 5ml syringe – to inflate the balloon
- 5ml water – to inflate the balloon
- wat er
- solu ble lubricant (like KY jelly)
Draw up 5ml of water into the syringe.
Check the balloon on the new tube before putting it into the stoma by inflating the balloon with 5ml of water.
Deflate the balloon by pulling the water back into the syringe.
Moisten the end of the tube with water or water-soluble lubricant (to make the tube go in easier).
Insert the new tube about two inches into the stoma.
I nflate balloon with the 5ml of water in the syringe – remove the empty syringe from the tube.
Gently pull back on the tube – to feel it snug against the stomach wall.
Clean and dry the skin – tape the tube to the skin to secure.
You w ill need to arrange to have the GJ tube replaced.

If your child can not have medications and/or fluids via the stomach (GT)– you will need to go to the hospital for intravenous fluid until an appointment can be booked to have your tube changed.

Your primary healthcare physician will need to arrange to have the GJ tube replaced in the Xray department.

Jejuonstomy tube falls out

Roux-en-Y

If the stoma is new (the tube has been in for less than six weeks)

Cover the stoma with a clean gauze or cloth.
You need to see a doctor to put the tube back in as soon as possible (within two hours).
The stoma will close pretty quickly (we usually say four to six hours).

If the stoma is more than six weeks old

You nee d to place a feeding tube into the stoma as soon as possible.
The Foley catheter of a MIC KEY – remember to use only 2-3ml of water to inflate balloon.

Braun jejunostomy

We usually replace Braun-type jejunostomy tubes in clinic as they can be a little more difficult to place.

Gather equipment:
feeding
Draw up 2-3ml of water into the syringe.
Check the balloon on the new tube before putting it into the stoma by inflating the balloon with 5ml of water.
Deflate the balloon by pulling the water back into the syringe.
Moisten the end of the tube with water or water-soluble lubricant (to make the tube go in easier).
Insert the new tube about two inches into the stoma.
Inflate balloon with the 2-3ml of water in the syringe – remove the empty syringe from the tube.
Gently pull back on the tube.
Cle an and dry the skin.

Hypergranulation tissue

Hypergranulation tissue is believed to occur as a result of an extended inflammatory response. We believe it may be caused by a reaction to the tube - the body is in fact "walling off" the tube. Pressure, moisture and friction may also contribute to the development of hypergranulation tissue. Hypergranulation tissue is the body's way to fight the gastrostomy tube - the body does not think the tube belongs there.

Hypergr anulation tissue is not harmful.
Hypergranulation tissue is red, moist and bleeds when rubbed.
Hypergranulation tissue oozes a yellow, sticky drainage.
Hypergranulation tissue can affect how the gastrostomy or jejunostomy tube fits in the stoma.
Hypergranul ation tissue is common in the first 3 months.

If granulation tissue occurs

Call your nurse of doctor to ask about silver nitrate sticks – they help to remove the hypergranulation tissue. Currently we recommend that the site be kept as clean and dry as possible. We treat the tissue with either silver nitrate sticks or a low dose cortisone cream (Triacet 0.1%) for 5-7 days.

For Silver Nitrate application - the following steps are done once a day for five days:

Put a layer of petroleum jelly (Vaseline) on the healthy skin around the granulation tissue before using the silver nitrate stick – the silver nitrate will injure the healthy skin.
Moisten the tip of the silver nitrate stick with water.
Touch the silver nitrate stick onto the granulation tissue – red, raised skin.
Protect clothing from being stained by the silver nitrate (will turn black) by putting a small gauze square over the area and taping it.
If there is no improvement in five to seven days, call the nurse or doctor.

Placing feeding tubes

There are several ways that an individual can have a feeding tube placed (inserted). The surgeon will choose the procedure that is most appropriate for each individual child and their healthcare situation.

This is a percutaneous endoscopic gastrostomy. The child is given an anesthetic or is sedated during the procedure.
An endoscope is passed down the child's throat and all the way into the stomach.
The doctor makes an incision (stoma) into the stomach and a thread is inserted into the stoma, then pulled back through the child's throat and out the mouth.
The feeding tube (PEG tube) is tied onto the thread and pulled out through the opening in the stomach wall (stoma).
The tube has a disc that prevents the tube from pulling all the way out of the stoma.
A bumper or disc is attached to the tube from outside the body to help stabilize the tube and work with the internal disc to keep the stomach wall tight against the abdomen.
Most often the tube can be used for feeding the same day.
Healing is quick – there is one small incision.
The PEG method can not be performed on all children.

A surgical gastrostomy may be required if a scope can not be easily passed to the stomach, the abdomen is already surgically opened for another procedure, or the doctor finds that the position of the bowel will impede the insertion of the tube through the PEG route.
The surgical method makes two incisions (cuts).
The surgeon puts a tube with a balloon or mushroom-shaped bulb at one end and into the stomach through the larger incision.
The other end is pulled through the second small incision (stoma) and the tube is secured.
The stomach is stitched to the abdominal wall.
The bulb/balloon helps prevent the tube from falling out.
A Foley catheter, Malecott catheter, Bard button, MIC KEY button or MIC G tube are examples of tubes that may be used in a surgical gastrostomy.

This is a minimally invasive approach to inserting a gastrostomy tube using an endoscope called a laparoscope.
Often a skin level device or a MIC G tube is placed as the primary tube.
There will be two small incisions at the umbilicus (belly button).

There are several ways to create a jejunostomy feeding tube:

Open Jejunostomy

This surgical method requires two abdominal incisions. They are made a small distance apart.
The surgeon creates an opening into the jejunum through the first and larger incision.
A feeding tube is placed into the jejunum and the tube is pulled through the other incision – a MIC jejunostomy tube or a Foley are used to access this site (as a feeding tube).
The jejunum is stitched against the abdominal wall and the larger incision is closed.
A stitch may be put in to secure the tube to the skin to hold the tube in place during the healing phase.

Roux-en-Y

This is another type of jejunostomy.
The surgeon takes a portion of the jejunum and creates a short blind-ending limb into which the tube is inserted for the JT.
There is one incision, and a separate opening for the JT (usually a MIC G).
A skin level device may be inserted after three months.

Braun-type jejunostomy

Information to follow

This is a feeding tube that goes into the jejunum (small bowel) through an already established (more than 6 weeks) gastrostomy.
The tube is guided into place with the help of x-ray type images that show up on a special screen.
The tube is inserted by the radiology department - insertion/reinsertion is arranged through the radiology department.

Living with a feeding tube

Wait at least five days after surgery before swimming or bathing. If you have a PEG tube, ensure the tube is securely taped to abdomen with waterproof tape.
Children can lie in any position they find comfortable including their stomach. The tube can be covered up with clothes to try and keep the child from pulling or playing with tube.
Children can participate in sports once the new site is no longer tender. For PEG tubes, ensure they are securely taped to abdomen. If there is a blow to the abdomen, there may be some pain, but it is not an emergency unless there is severe pain, persistent pain that does not improve, bleeding, or bruising. If this occurs, then contact your doctor.

(GOAL: keep the site as clean and dry as possible)

DO NOTroutinely turn the new tube for 6 weeks following surgical placement.
DO NOT deflate the balloon on a new tube for at least 6 weeks after surgical placement.
ALWAYS wash your hands before caring for stoma or feeding tube. Hand washing is one of the best ways you can prevent the spread of illness.
Clean area around the tube at least twice a day and inspect surrounding skin for any signs of redness, irritation or infection.
Clean around the tube with a clean wash cloth, cotton balls or Q-tips and some warm, mildly soapy water - rinse and dry the area well.
Gently clean under the disk or around tube, the outside of tube and skin surrounding the tube with warm soapy water. RINSE with warm water and then gently pat dry or let air dry.
Exposure to air is an excellent way to heal skin and to keep it in healthy condition.
When securing tube with tape, rotate the position of tape so it does not cover the same piece of skin each time - this practice will help to maintain healthy skin and decrease irritation.

Inspect the feeding tube for cracks and or leaks.
For PEG, MIC G and Foley tubes -KNOW the correct length of your child's feeding tube. Measure the length of the tube that is on the outside of the body. If it is shorter than usual, gently pull on it until it is appropriate length. If it is longer than usual-DO NOT USE the feeding tube and call your doctor. Knowing the correct length of the feeding tube helps ensure that tube is in correct position in the body for safe feeding.
Low profile tubes may require measuring if there is a weight gain or loss or change in abdominal girth - tubes can be measured to ensure they fit correctly.

(IMPORTANT in preventing the growth of bacteria)

After every feeding, wash equipment (feeding bag, tubing, etc.) with hot soapy water and use a bottle brush if necessary to ensure all formula is removed from the bag. Rinse well with hot water. Make sure to remove excess water from the feeding set and adapters.
Between feeds - wrap the equipment in a clean towel and store in the refrigerator. The cool temperature helps decrease the growth of bacteria.
Once a day syringes need to be taken apart and washed with hot soapy water, rinsed and let air dry.
AFTER LAST FEEDING of the day, wash the bag and tubing as usual with hot soapy water and then RINSE WITH A VINEGAR SOLUTION (1/4 cup vinegar to 1 cup water). Rinse again with hot water and store as usual in the refrigerator.
Feeding bags and syringes are usually changed twice a week or earlier if necessary.
Adapters and connectors are changed every two to four weeks (sometimes more often if feeds are continuous).

If the tube feeding bag is starting to smell (sour) or starts changing to a different color. THROW IT AWAY.
Allow formula to warm up to room temperature before using. Cold formula can cause cramping.
DO NOT MICROWAVE the formula, as this can cause the proteins in the formula to break down.
Throw out open containers of formula if not used within 24 hours, even if they were refrigerated.
Throw out any formula that has been left at room temperature for more than four hours.
REMEMBERthathand washing is key in the prevention of spreading bacteria.

It is important for maintaining the normal conditions of the mouth when children cannot have foods orally.

Steps you can take to ensure proper mouth care:

Rinse your child's mouth out four to six times a day with water, mouthwash, a cloth, or Toothette.
It is important to make sure your child's teeth are brushed twice a day.
Keep lips moist.
At the advice of a doctor, candies, soothers, etc. can sucked to help with the flow of saliva - oral stimulation.

It gives the child sensory experiences in an around the mouth and encourages use of the lips, jaw and tongue.
Oral stimulation is used in children who cannot take food by mouth because the mouth is rarely used (stimulated) and it can develop a hypersensitivity to touch which makes the possible return to oral foods much more difficult.
Through stimulating the mouth with touch, tastes and different temperatures of food, hypersensitivity can sometimes be prevented.

Oral stimulation is important because it:

allows a child to develop and maintain movement patterns for eating and swallowing
prevents hypersensitivity
allows the child to experience pleasures associated with tastes, textures, smell, touch and social time surrounding eating

What you can do to promote oral stimulation?

before feedings, use a wash cloth and gently wash face, wash cheeks and forehead first and slowly move towards mouth, if child shows distress, stop and try again the next day
a soother, toothbrush, child's hand can be used in the mouth
associate meal time and eating with a pleasurable time
consult your physician or occupational therapist for additional ideas and advice on what your child can have in their mouth

Resources

Tab Content 3

Frequently Asked Questions About Tube Feeding (PDF)
Gastrostomy Reinsertion Using a Foley Catheter (video)
Nasogastric Tube Feeding at Home (A Guide for Families and Care Givers) (PDF)
Reinserting a MIC Key Gastrostomy Tube (video)
Tube Feeding at Home (A Guide for Families and Care Givers) (PDF)

A gastrostomy is a way to feed directly into the stomach and a jejunostomy feeds directly into the small bowel (intestine).
You can not bolus feed through a jejunostomy tube as the diameter of the small bowel will not tolerate the volume as does the stomach.

Flush, flush, flush.
Flush with water after each feed and after each medication.
Do not mix medications in the same syringe.
Try to use a liquid form of medication if available.
Avoid using the antibiotic clarythromycin.

Try to flush with warm water using a push/pull method to try to unplug the tube.
If this is unsuccessful, try using a cotazyme capsule mixed with sodium bicarbonate and water to unplug the tube.
Mix the powder of a cotazyme capsule with 1/2tsp of baking soda or 325mg of sodium bicarbonate with a some warm water.
Put this mixture into the feeding tube.
Use the push/pull method to try to unblock the tube.
You can repeat this two (2) times.
You can leave the solution inside the tube for up to one (1) hour.
If this is unsuccessful, you will need to arrange to have the feeding tube changed.

Hypergranulation tissue is believed to occur as a result of an extended inflammatory response
We believe it may be caused by a reaction to the tube - the body is in fact "walling off" the tube
Pressure, moisture and friction may also contribute to the development of hypergranulation tissue
Hypergranulation tissue leaks a yellow, sticky drainage and it is often described as itchy, this tissue may bleed easily

Hypergranulation tissue (proud flesh) can affect the seal of the feeding tube. It may increase the amount of stomach contents that leak from the stoma. The drainage from the tissue can be irritating to the surrounding skin.

Silver Nitrate application

Silver Nitrate sticks can be used to cauterize (burn) the hypergranulation tissue. We suggest a five-day course of once daily treatments. Ensure that the surrounding skin is well protected prior to treating the hypergranulation tissue.

Cortisone cream application

A short course of a low dose cortisone cream can also be applied to the hypergranulation tissue as ordered by a healthcare provider.

Do not panic – this is not an emergency.
When a feeding tube is pulled out, the stoma will start to close. Some stomas can close in a few hours.
Always carry your emergency replacement kit which should include:

replacement feeding tube (Foley / replacement tube)
5 ml syringe
water
clamp or cap (for Foley)
washcloth
water-based lubricant
waterproof marker
emergency phone numbers
change for a phone call
notes on replacing the GT

If the gastrostomy is new (the operation / procedure was in the last six weeks) a doctor should reinsert the tube (to make sure that the feeding tube goes back into the right spot) unless otherwise directed by your doctor.
Otherwise you need to:

Wash your hands.
Draw up 5ml water into your 5ml syringe.
Have child lying flat – relaxed if possible.
Fill the balloon with water – to check the balloon for leaks.
Remove the water from the balloon.
Put lubricant on the end of the tube.
Put the moist tube into the stoma – hold the end of the tube upright – so it won't leak on you.
Use the syringe to put 5ml of water into the balloon port, then remove the syringe.
If you feel resistance, don't use force – try again.
Pull gently on the tube to ensure that the balloon is snug against the stomach wall.
Close the tube and clean the skin around the tube well.
Mark the tube (if using a Foley) at skin level with a waterproof marker.
Secure the tube in place - with tape.
If you are not sure that the feeding tube is in the right place –DO NOTuse the tube for feeding. Contact your doctor.

Most children who are on home feeding regimes are under the care of a pediatrician. Your pediatrician of family doctor will follow your child's feeding and weight gain concerns.
Map out a plan of who is available in your community – you can discuss this with your healthcare provider.
Call your child's surgeon if there is a fever, redness, swelling or green drainage from the stoma site around the time of surgical insertion (first 3 months).

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Source: http://www.bcchildrens.ca/health-info/coping-support/tube-feeding