Several studies in adults compared the clinical effects of feeding via NG tubes and gastrostomy (70,71). NG tube feeding had a higher rate of discomfort and complications (irritations, ulceration, bleeding, displacement, clogging). Gastrostomy feeding was superior with regard to nutritional efficacy, acceptability, and reduced rates of both gastroesophageal reflux and aspiration pneumonia, thus improving quality of life.
In children with neurological disabilities, both NG and gastrostomy feeds improved nutritional status, often accompanied by improved perception of well-being (72). In children with end-stage renal disease on peritoneal dialysis (PD), both methods were associated with similar complication rates, although somewhat different types of complications were seen (73).
The preoperative preparation should also include obtaining informed consent, laboratory tests (haemoglobin, platelet count, and coagulation studies), and preprocedure fasting (6 hours of solid food, 4 hours of breast milk, 2 hours of water) (74).
Considering antibiotic prophylaxis, in adults, 2 recent systematic reviews of RCTs, 1 with a meta-analysis, concluded that administration of systemic prophylactic antibiotics for PEG placement reduces peristomal infection (75,76). Most guidelines related to adults suggest that a single dose of broad-spectrum antibiotic administered before PEG insertion significantly reduces the incidence of peristomal infection (77–79). In children, a nonrandomised trial showed similar infection rates with a single dose of ceftriaxone prophylaxis compared to 2 doses of ceftriaxone plus oral metronidazole (80). No evidence-based guidelines on the use of prophylactic antibiotics for the insertion of PEG in children are available.
The most frequent source of wound contamination is oropharyngeal flora. Therefore, some preprocedure preparation guidelines in adults recommend oral decontamination with chlorhexidine gluconate 12 hours and immediately before the procedure (81). Application of povidone-iodine in combination with systemic antibiotics was shown to significantly reduce stomal infection at the end of the first week following PEG insertion (82). A sufficiently large abdominal incision and prevention of pressure ischaemia may also reduce the risk of wound infection.
The most frequent complication is wound infection. Increased infectious complications have been reported after PEG placement in patients with ventriculoperitoneal shunts (VPS; ascending meningitis) or PD catheter (fungal peritonitis). The presence of VPS is not a contraindication and the presence of PEG does not increase the risk of shunt infection; however, it has been suggested that PEG insertion should be deferred at least 1 week after VPS insertion (93). PEG placement before initiation of PD appears to be safe, although following PD, there is a high risk for fungal peritonitis and potential PD failure (94). Antibiotic, antifungal prophylaxis and withholding PD for 2 to 3 days are suggested precautions for lowering this risk. When gastrostomy placement does not occur before or at the time of initiating PD, the risks and benefits of percutaneous versus open placement must be carefully weighed (94,95).
Late complication rates as high as 44% have been described in children, and in some studies, stoma-related complications have been reported in 73% of patients, suggesting that PEG may be associated with significant late morbidity, mainly occurring within the first 2 years after PEG insertion (96). Gastrocutaneous fistula after PEG removal has been reported to occur at a rate as high as 24% of children and sometimes requires surgical closure (97). A retrospective review of 121 children undergoing PEG found a high rate of parental and caregiver satisfaction with the procedure (98). Long-term complications are set out in Table 5.
Although continuous formula infusion is often recommended as a means of improving feeding tolerance and minimising complications, published data are limited. Intermittent bolus feeding is thought to be more physiological, providing cyclical surges of the gastrointestinal hormones that have a trophic effect on intestinal mucosa (99), whereas continuous enteral feeding has been associated with impaired gallbladder emptying in infants (100). Several studies comparing continuous versus intermittent feeding regimens in children and in adults, also including patients in the intensive care unit, showed no significant difference in food tolerance or complication rate (presence of diarrhoea) (101,102). A comparison of continuous with intermittent feeding in children with severe diarrhoea reported improved enteral balance and weight gain in children fed on a continuous schedule (103). Continuous enteral feeding was also shown to improve weight gain in children with complex congenital heart lesions who failed to gain weight adequately despite the use of hypercaloric formulas and nutritional supplementation (104,105). A prospective controlled study in 45 children from an Australian paediatric intensive care unit found that continuous and intermittent gastric feeding regimens have similar outcomes with respect to feeding tolerance and complications (diarrhoea and vomiting) (106,107).
Refeeding syndrome is a term used to describe the various metabolic complications that can arise as a result of implementing nutritional support (enteral or parenteral) in malnourished patients (108). Problems arise because starvation causes adaptive reductions in cellular activity and organ function accompanied by micronutrient, mineral, and electrolyte deficiencies. The major sources of energy in catabolic patients are fat and muscle; total body stores of nitrogen, phosphate, magnesium, and potassium are depleted. Sudden reversal of catabolism through nutritional support (particularly excessive carbohydrate) leads to a surge of insulin secretion, which causes massive intracellular shift of phosphate, magnesium, and potassium with a subsequent fall in serum concentrations. The clinical consequences of hypophosphataemia include haemolytic anaemia, muscle weakness, and impaired cardiac function, leading potentially to cardiac failure, fluid overload, arrhythmia, and death.
Children with severe chronic weight loss are at highest risk (eg, anorexia nervosa, cancer cachexia), with the greatest risk being during the first week of feeding. Refeeding syndrome, however, is a potential complication of nutritional support in any malnourished patient. Because the nature of refeeding precludes randomised trials of treatment, recommendations are derived from expert opinion. Following a review of the literature, Afzal et al (109) suggested the following strategy for reducing the risk of refeeding syndrome: Before starting nutritional support, assess nutritional status and hydration, serum electrolytes, magnesium, and phosphate; monitor electrolytes, phosphate, magnesium, calcium urea, and creatinine daily, and assess cardiac status (pulse, heart failure, electrocardiogram, ultrasonography). The initial enteral feeding regimen should be limited in terms of volume and energy content to provide around 75% of requirements in severe cases (<7 years, 60 kcal · kg−1 · day−1; 7–10 years, 50 kcal · kg−1 · day−1; 11–14 years, 45 kcal · kg−1 · day−1; 15–18 years, 40 kcal · kg−1 · day−1). If tolerated, initial intakes may be increased for 3 to 5 days; frequent small feeds with an energy density of 1 kcal/mL should be used to minimise fluid load. Protein intake may start at 0.6 to 1 g · kg−1 · day−1 and increase to 1.2 to 1.5 g · kg−1 · day−1. Supplements are given as follows: Na+ 1 mmol · kg−1 · day−1; K+ 4 mmol · kg−1 · day−1; Mg2+ 0.6 mmol · kg−1 · day−1; phosphate up to 1 mmol · kg−1 · day−1 intravenously and up to 100 mmol · kg−1 · day−1 orally for children older than 5 years of age; hypocalcaemia should be corrected. Thiamine, riboflavin, folic acid, ascorbic acid, pyridoxine, and fat-soluble vitamins must be supplemented and additional trace elements may also be needed. In addition, the National Institute for Health and Clinical Excellence guidelines for adult nutrition are relevant to adolescents (110). For patients who have little food intake for more than 5 days, it is recommended that nutritional support be introduced at 50% of requirements for the first 2 days before increasing to meet full needs if close clinical and biochemical monitoring reveals no refeeding problems. Much greater care is advocated for those patients with the following characteristics: BMI <16 kg/m2, unintentional weight loss of >15% within the previous 3 to 6 months, little or no nutrient intake for >10 days, and low levels of potassium, phosphate, or magnesium before any feeding. Besides initially restricting protein and energy intake, these patients should be given thiamine and other B-group vitamins, along with a balanced multivitamin and trace element supplement; supplementation of potassium, magnesium, and phosphate are also likely to be required (110).
Microbiological contamination of enteral tube feeds given to children at home and in hospital is common (111). It is uncertain how often this results in symptomatic illness, although sepsis has been reported in both adult and paediatric patients, confirming that a certain risk is involved. Children who are immunocompromised, such as those undergoing chemotherapy or when the gastric acid barrier is impaired, may be more vulnerable. Coagulase-negative staphylococci, streptococci, and Gram-negative bacilli are among the organisms isolated from feeds. Risk factors for contamination include the environment and manner in which the feed is prepared, inadequate hand-washing techniques, poor attention to hygiene when handling the feed container and giving set, and repeated topping up of the feed container (with repeated touching of the giving set and transfer of bacteria from the hands). In 1 study, following an enteral feeding protocol that encouraged strict adherence to good hygiene, there was a significant reduction in the proportion of feeds with bacterial contamination, both in hospital and at home (112). The optimum feed hang time is uncertain, but bacterial contamination of commercial products may occur when opening and decanting feeds from source containers, so that frequent feeds may be unwise unless giving sets are also changed (113). Commercially available “ready to hang” closed enteral feeding systems are designed to limit handling procedures to the introduction of the giving set spike into the pack. Although this may reduce the risk of microbiological contamination resulting from poor handling procedures before feeding, retrograde contamination of the set may occur, the risk of contamination increasing with duration of feed (114). Ongoing training of ward staff and careful instruction of home caregivers by specialist nurses is an additional important component in reducing bacterial contamination. This is an area that mandates regular audit.
Many patients receiving enteral tube feeding will also be taking medications. Unrecognised interactions between drugs and nutrients may adversely affect clinical outcomes. Medications designed to be taken orally are often given via an enteral feeding tube; crushing or dissolving solid preparations to administer in this way can affect drug bioavailability as well as lead to tube occlusion. An enteral feed or 1 of its components may adversely affect the absorption, metabolism, or excretion of a drug (eg, phenytoin). Flushing the tube with water before and after a medication improves drug bioavailability. Many commonly used liquid drug preparations have a high osmolality (>3000) and can thereby provoke diarrhoea when given via a jejunal tube if not first diluted (115).
Although the choice of specialised paediatric formula has rapidly expanded, the optimal micronutrient content has not been fully defined. The European Union Commission Directive on Dietary Foods for Special Medical Purposes stipulates the composition of feed (8) with recommendations including minimum and maximum values for vitamins, minerals, and trace elements; deviations are permitted for disease-specific formulations. Surprisingly, with the exception of calcium and vitamin D, no distinction is made between adult and paediatric feeds. In fact, there is little information on the bioavailability of vitamins, minerals, and trace elements in paediatric feeds and there is variation in absorption and utilisation of micronutrients. In addition, there is deterioration in the vitamin content of feeds throughout their shelf life. For example, gross clinical scurvy has been described with a commercial feed despite an apparently adequate intake of vitamin C (116). Such cases highlight the fact that feed preparation and administration as well as drug–nutrient interactions may affect nutrient delivery. Conversely, high blood concentrations of vitamin B12 and copper have been described in some children receiving ENS, suggesting that upper limits for nutrient intake also merit further examination (117).
The aims of home enteral tube feeding (HETF) include provision of effective nutritional support, promotion of patient and family autonomy (taking into account their preference for route of feeding and care plan), ensuring safe and trouble-free maintenance of nutritional support, and maximising the potential for improved lifestyle and optimised disease management. All of the children in the community receiving enteral tube feeding should be supported by a multidisciplinary team, where possible including dietitian, specialist nurse, general practitioner, paediatrician, and community pharmacist. Close liaison between the team and parents or caregivers regarding the purpose of nutritional support, prescription of feed and equipment, and potential problems is essential. Suggested standards of practice for HETF have been published by the British Association for Parenteral and Enteral Nutrition (118). Good communication between patient, family, and health care professionals is a prerequisite for effective discharge planning. The needs of the child and family must be clearly identified to prepare transfer from hospital to home. It is also essential that continuing care arrangements are in place with coordinated action from all of the agencies involved (eg, family, health care professionals, social services, education, voluntary bodies). Equipment supply should be arranged before discharge.
Parents or caregivers and children (when of appropriate age) should receive training and information from members of the multidisciplinary team on the following topics: information about the reasons for HETF and likely duration; safety aspects of care; checking tube placement; infection control issues; hand-washing techniques; feed preparation (use ready-made feeds whenever possible); familiarity with feeding equipment; advice regarding social and practical implications for child and family; problem-solving advice and what to do in an emergency; the importance of maintaining oral stimulation; telephone contacts for hospital and community staff; and detailed information about how to obtain equipment and supplies.
The use of an enteral feeding pump is essential for continuous feeding and is preferable in bolus feeding. EN pumps should be easy to set up, operate, and clean, and be durable, small, lightweight, portable, and accurate. There should be an optional bolus feeding setting available, and the pump must be tamper proof, operate quietly, have occlusion, have empty and low battery alarms, and be reliable. Teaching material should be provided, including a step-by-step guide to setting up the pump, written instructions on the side of the pump and in pamphlet form, and a training video. Cost and servicing arrangements are important considerations when considering pump purchase.
The main objective of monitoring nutrition support is to ensure safety and optimal growth and to detect and treat clinical complications as quickly as possible. It is important to consider and regularly review the objectives of nutritional support in individual patients and assess the extent to which these have been achieved. There may be a need to alter the type of nutritional support to improve effectiveness or minimise metabolic risk. Monitoring will include regular review of nutritional status including intake, weight, height, biochemical and haematological indices, general clinical state, well-being, gastrointestinal function, tube integrity, and any tube-related complications. The type and frequency of monitoring will depend on the nature and severity of the underlying disease.
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