Divisions of Gastroenterology and Perinatology, Department of Pediatrics, Wheaton Franciscan Health Care-St Joseph's Regional Hospital, Children's Hospital of Wisconsin, and the Medical College of Wisconsin, Milwaukee, WI.
Address correspondence and reprint requests to Steven Werlin, MD, Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 (e-mail: email@example.com).
Received 20 September, 2010
Accepted 15 February, 2011
The authors report no conflicts of interest.
Background and Objective: Percutaneous endoscopic gastrostomy (PEG) tubes have been placed in children for more than 2 decades to provide nutrition to those unable to adequately and safely feed orally. Despite the well-documented success of PEG placement in older children, there is only 1 published article documenting the safety of PEG placement in small infants. In all children, PEG studies demonstrate the major complication rate to vary from 0.5% to 17%. The objective of this study was to evaluate the incidence of acute complications of PEG placement in medically complicated infants with a weight of less than 6 kg.
Patients and Methods: We reviewed the charts of all infants cared for in the neonatal intensive care unit of Wheaton Franciscan Health Care-St Joseph's Regional Hospital, Milwaukee, WI, who received a PEG tube between January 2001 and June 30, 2008.
Results: Forty infants with a mean gestational age of 29 weeks (range 23–41 weeks) with a mean weight of 3250 g (range 2100–5600 g) at time of PEG placement were included. The primary indication for most infants was dysphagia or inability to orally feed safely. A PEG was successfully placed in 38 of 40 (95%) infants. There was 1 major complication: a 38-week infant with Prader-Willi syndrome developed a pneumomediastinum caused by a tear at the upper esophageal sphincter. In a second infant the PEG bumper could not be passed beyond the upper esophageal sphincter. Sixteen infants had other surgical procedures performed at the time of PEG placement. For those infants only having a PEG placed, the mean procedure time was 10 minutes.
Conclusions: PEG placement is both feasible and safe in small, medically complicated infants.
Percutaneous endoscopic gastrostomy (PEG) tubes have been used successfully in children for more than 2 decades to provide nutrition to those unable to adequately feed orally (1). PEG tubes are often recommended if oral intake is insufficient, whether from an underdeveloped or poor suck and swallow mechanism or a structural abnormality (2).
Infants in the neonatal intensive care unit (NICU) who cannot safely feed orally are supplemented using a nasogastric (NG) tube or orogastric (OG) tube. Both methods provide nutrition safely and avoid the risks of parental nutrition. NG tubes can cause nasal mucosal edema and increase secretion buildup that reduces the patency of the nasal airway (3) and cause permanent nasopharyngeal irritation that may impair the infant's instinctive desire to feed (4). Both NG and OG tubes can become dislodged and require replacement. PEG tubes offer convenient and stable enteral access, and reduce feeding time and caregiver stress (2) in infants who may have difficulty with oral feeding for an extended period.
Until recently, gastrostomy tubes had been placed surgically in infants because of assumed safety concerns and the lack of published experience with PEG placement in infants. There have been no large pediatric reviews that report the safety of PEG tube placement in small (less than 6 kg), medically complicated neonates. Most published data documenting PEG placement in infants younger than 1 year old are difficult to interpret because most authors combined data from infants and children. A single report by Wilson and Oliva-Hemker (5) examined PEG insertion in neonates. They showed that PEG placement was safe in a cohort of 26 infants with a mean weight of 3 kg (2.3–3.5 kg). PEGs were placed successfully in all 26 cases and only 5 infants had minor complications (5).
The purpose of this retrospective cohort study was to determine the safety of PEG placement in small (mean weight <3.5 kg) premature infants.
PATIENTS AND METHODS
The charts of all of the infants who had a PEG placed in the NICU of Wheaton Franciscan Health Care-St Joseph's Regional Hospital Milwaukee, WI, between January 2001 and June 30, 2008 were reviewed. Data extracted included demographics, gestational age, birth weight, primary and secondary diagnoses, indication for PEG placement, gestational age and weight at PEG placement, and adverse events (classified as acute [first week] and subacute [first month] after placement). Time to initial and full gastrostomy feedings was also recorded. All of the data were entered into a Microsoft Excel spreadsheet for statistical analysis using SAS (SAS Institute Inc, Cary, NC).
Before the procedure, all of the infants had an upper gastrointestinal barium study to evaluate anatomy. PEGs were placed jointly by a pediatric gastroenterologist and a pediatric surgeon. Patients were given doses on cefazolin, before and 8 hours following PEG placement. PEG insertion was performed with the standard pull-through technique described by Gauderer and Stellato (6) in the operating room under general anesthesia with the following modifications to facilitate PEG placement in small infants. A 6-mm outer diameter upper endoscope is used to limit tracheal compression. Gastric insufflation is minimized to prevent abdominal distension and decrease the risk of interposition of bowel between the abdominal wall and the stomach. To avoid laryngeal tears caused by traction on the PEG tube, if there was resistance to the passage of the PEG bumper through the upper esophageal sphincter, the tip of the scope is used to gently push the bumper through. Once the gastrostomy site is chosen by transillumination, reverse transillumination using the operating room light delineates the shadows produced by the liver and the transverse colon and identifies any interposing organ. Once secured, the position of the PEG was confirmed by gastroscopy. Depending on the size of the infant, and at the discretion of the gastroenterologist, either a 12-F Corpak-R (Corpak Systems, Wheeling, IL) or a 14-F MIC-R (Kimberly-Clark, Roswell, GA) PEG tube was placed. In addition to PEG, circumcision was performed in 5 patients, bilateral inguinal hernias were repaired in 3 patients, and 6 patients had both procedures performed.
This study was approved by the institutional review boards at Wheaton Franciscan Health Care-St Joseph's Regional Hospital, and Children's Hospital of Wisconsin, Milwaukee, WI.
PEG placement was attempted in 40 infants between January 2001 and June 30, 2008 (55% boys). The mean gestational age at birth was 29.9 weeks (range 23–41 weeks). Thirty-three neonates were premature (gestational age <37 weeks). The mean birth weight was 1550 g (range 500–4410 g). The mean weight at placement was 3251 g (range 2100–5600 g). The primary indication for PEG placement was dysphagia (60%) or inadequate oral skills. Secondary diagnoses included chronic lung disease, patent ductus arteriosus, gastroesophageal reflux, and intraventricular hemorrhage. The remainder of the demographics are found in Table 1.
PEG insertion was successful in 39 of 40 infants. One procedure was abandoned and converted into an open gastrostomy because the PEG bumper failed to pass through the upper esophageal sphincter.
The mean time for PEG placement was 10 minutes (range 4–18 minutes). The mean total anesthesia time was 55 minutes. Initiation and advancement of feeds were dependent on the clinical status of the patient and managed by the neonatology attending. The mean time to initial feeding was 20 hours (range 3–103 hours), and the mean time to full feeding (100 kcal/kg) was 60 hours (range 18–145 hours). The relatively long anesthesia time resulted from 16 infants having other surgical procedures performed at the time of PEG placement.
Minor postoperative events resolved with local care, which did not affect feeding, and included stomal leakage in 17 erythema of the wound site in 17 and granulation tissue in 2 patients.
Gastrostomy tubes were placed exclusively by laparotomy until 1980, when Gauderer showed that the PEG technique was more cost-effective and safer than surgical gastrostomy (1,7,8). Others contend that the PEG technique is better because it avoids the morbidity associated with laparotomy, causes less incisional pain, has a quicker recovery period, and can be performed more rapidly, with the average PEG taking less than 15 minutes compared to 35 minutes for a surgical gastrostomy (7,9). Because of the paucity of PEG data in infants younger than 1 year old (10,11), many surgeons and gastroenterologists have chosen alternative gastrostomy options for smaller (<10 kg) or younger (<1 year) children (9,12).
The placement of a gastrostomy tube is a practical and beneficial alternative to prolonged NG or OG feeding for premature infants who require long-term enteral nutrition (13). Previous reports document an overall complication rate (major and minor) ranging from 5% to 75% in pediatric patients (8,14,15). Many of the complications documented, such as erythema and leakage, are common and are of little clinical significance. Severe complications occur in 0.5% to 17% of children undergoing PEG placement (2,13,16).
Recently Vervloessem et al (17) reported a major complication rate of 13.2% following PEG placement in children. Although their complication rate was higher than the rate we report (2.5%; 1/40), they noted a significant decrease in their complication rate with time, suggesting that the incidence of PEG-related complications decreases with operator experience. In our cohort all of the PEGs were placed by experienced pediatric gastroenterologists and surgeons. Vervloessem et al (17) also noted that children with a ventriculoperitoneal shunt had a higher incidence of a major complication. No patients in our series had ventriculoperitoneal shunts.
The lack of pediatric data to support PEG placement in small children has caused some gastroenterologists and surgeons to elect to use either the laparoscopic gastrostomy or the more recent laparoscopic percutaneous gastrostomy tube placement. The major complication rate with laparoscopic gastrostomy is documented at 0% to 4% (14,18,19). In addition, the mean procedure time with the laparoscopic technique is 48 minutes (range 27–125 minutes) (20). Although the data are limited with the laparoscopic-assisted percutaneous gastrostomy technique, Vervloessem et al (17) reported no major complications in 19 children.
Only 1 major procedure-related complication occurred in our series. A 38-week-old infant with Prader-Willi syndrome who weighed 2730 g at the time of PEG placement experienced an esophageal tear at the upper esophageal sphincter and a pneumomediastinum. The infant recovered with conservative treatment of the esophageal tear. One infant required surgical gastrostomy for procedure failure.
In our review, those younger than 28 weeks and those older than 28 weeks achieved full feeds at similar rates, spent similar time on the ventilator, and endured similar minor complications, which further suggest that the primary diagnosis or indication for PEG placement is not a significant factor in predicting successful placement or incidence of complications.
Although some have suggested restricting PEG insertion to infants who are at least 5 to 10 kg (9,12), our findings and those of Wilson et al demonstrate that PEG placement is safe and feasible in small infants. With the success that some researchers have shown with laparoscopic gastrostomy placement, a large, multicenter randomized trial comparing the 2 procedures in children younger than 1 year old would help better define the risks and benefits associated with each technique.
1. Gauderer MWL, Ponsky JL, Izant RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980; 80:240–243.
2. Khattak IU, Kimber C, Kiely EM, et al. Percutaneous endoscopic gastrostomy in pediatric practice: complications and outcome. J Pediatr Surg 1998; 33:67–72.
3. Sporik R. Why block a small hole? The adverse effects of nasogastric tubes. Arch Dis Child 1994; 71:393–394.
4. Behrens R, Lang T, Muschweck H, et al. Percutaneous endoscopic gastrostomy in children and adolescents. J Pediatr Gastroentrol Nutr 1997; 25:487–491.
5. Wilson L, Oliva-Hemker M. Percutaneous endoscopic gastrostomy in small medically complex infants. Endoscopy 2001; 33:433–436.
6. Gauderer MWL, Stellato TA. Percutaneous endoscopic gastrostomy in children: the technique in detail. Pediatr Surg Int 1991; 6:82–87.
7. Ljungdahl M, Sundbom M. Complication rate lower after percutaneous endoscopic gastrostomy than after surgical gastrostomy: a prospective, randomized trial. Surg Endosc 2006; 20:1248–1251.
8. Stiegmann GU, Goff JS, Silas D, et al. Endoscopic versus operative gastrostomy; final results of a prospective randomized trial. Gastroint Endosc 1990; 36:1–5.
9. Loser C, Asch G, Hebuterne X, et al. ESPEN guidelines on artificial enteral nutrition-percutaneous endoscopic gastrostomy (PEG). Clin Nutr 2005; 24:848–861.
10. Coughlin JP, Gauderer MWL, Stellato TA. Percutaneous endoscopic gastrostomy in children under 1 year of age: indications, complication and outcome. Pediatr Surg Int 1991; 6:88–91.
11. Ni YH, Chang MW, Hsu HY, et al. Percutaneous endoscopic gastrostomy in infants. J Formos Med Assoc 1995; 94:635–637.
12. Pennington C. To PEG or not to PEG. Clin Med 2002; 2:250–255.
13. Avitsland TL, Kristensen C, Emblem R, et al. Percutaneous endoscopic gastrostomy in children: a safe technique with major symptom relief and high parental satisfaction. J Pediatr Gastroentrol Nutr 2006; 43:624–628.
14. Zamakhshary M, Jamal M, Blair GK, et al. Laparoscopic vs. percutaneous endoscopic gastrostomy tube insertion: a new pediatric gold standard? J Pediatr Surg 2005; 40:859–862.
15. Pederson AM, Kok K, Peterson G, et al. Percutaneous endoscopic gastrostomy in children with cancer. Acta Paediatr 1999; 88:849–852.
16. Gauderer MW. Percutaneous endoscopic gastrostomy: a 10-year experience with 220 children. J Pediatr Surg 1991; 26:288–294.
17. Vervloessem D, Van Leersum F, Boer D, et al. Percutaneous endoscopic gastrostomy in children is not a minor procedure: risk factors for major complications. Semin Pediatr Surg 2009; 18:93–97.
18. Tomicic JT, Luks FI, Shalon L, et al. Laparoscopic gastrostomy in infants and children. Eur J Pediatr Surg 2002; 12:107–110.
19. Rothenberg SS, Bealer JF, Chang JH. Primary laparoscopic placement of gastrostomy buttons for feeding tubes. A safer and simple technique. Surg Endosc 1999; 13:995–997.
20. Jones VS, La Hei ER, Shun A. Laparoscopic gastrostomy: the preferred method of gastrostomy in children. Pediatr Surg Int 2007; 23:1085–1089.