Revision of long-term gastrostomy.

PURPOSE: Insertion of gastrostomy has become a popular choice for children with feeding problems. With the passage of time, gastrostomies require revision for various reasons. The aims of the present study are to report our experience of the revision of long-term gastrostomies, to ascertain the reasons for revision, and to discuss any measures that may prevent the need for revision. METHODS: We conducted a retrospective review of all of the patients requiring gastrostomy revision by the senior author between 2005 and June 2011. The patients had had their original operation in several different hospitals within the United Kingdom, between 1997 and 2008. We excluded those patients requiring the revision for an acute complication (within 1 month) or required revision for subsequent fundoplication. The patients' hospital notes were reviewed to identify the reasons for revision and a literature search was done to find ways to prevent these. RESULTS: There were 15 patients who required revision of gastrostomy. Epithelialisation of the gastrostomy track with gastric mucosa was the most common cause (9/15). Other reasons were buried bumper syndrome (BBS) (4/15) and migration of the gastrostomy exit site toward the rib cage (2/15). The mean interval before revision due to the epithelialisation of the tract was 101 months since the insertion of the gastrostomy. The mean for other complications was 26 months for BBS and 95 months for migration of the exit site. CONCLUSIONS: We believe that the incidence of gastrostomy revision could be reduced. Preventing epithelialisation is difficult and may be minimised by aggressive and generous use of topical silver nitrate. The gastrostomy exit site needs to be as far away from the rib edge as possible. Checking the bumper regularly or use of a gastrostomy balloon button instead of a tube eliminates BBS. Parents need to be aware of the possibility that a long-term gastrostomy may need surgical revision.

A double-blind, randomized, controlled trial of tongue-tie division and its immediate effect on breastfeeding.

AIM: This study investigated if a maternally reported, immediate improvement in breastfeeding following division of tongue-tie is due to a placebo effect. METHODS: This randomized controlled trial was conducted at Southampton General Hospital, Southampton, UK, in 2003-2004. Sixty breastfed babies 5-115 days old (mean, 32 days; median, 23 days) were randomized to division (Group A) or non-division (Group B). The mother and a trained observer were blinded and assessed breastfeeding before the intervention. Fifty-seven babies were analyzed because blinding failed in three of the babies in Group A. Following the intervention, the mother's and observer's views were noted, and then those infants allocated to non-division had their tongue-tie divided. RESULTS: Seventy-eight percent (21 of 27) of mothers in Group A reported an immediate improvement in feeding following the intervention, compared with 47% (14 of 30) in Group B (two-tailed χ(2) p<0.02; 95% confidence interval, 6-51%). At 1-day follow-up, 90% (54 of 60) reported improved feeding following division. At 3-month follow-up, 92% (54 of 59) still reported improved feeding, with 51% (30 of 59) continuing to breastfeed. CONCLUSIONS: There is a real, immediate improvement in breastfeeding, detectable by the mother, which is sustained and does not appear to be due to a placebo effect.

Randomized, controlled trial of division of tongue-tie in infants with feeding problems.

OBJECTIVE: To determine whether, in infants with a tongue-tie and a feeding problem, the current medical treatment (referral to a lactation consultant) or immediate division works best and enables the infants to feed normally. METHODS: Between March and July 2002, all the babies in the district of Southampton with tongue-ties were followed in order to see if they had any feeding problems. If they developed problems, the mothers gave written consent and were enrolled in an ethics committee approved, randomized, controlled trial, comparing 48 h of intensive lactation consultant support (control) with immediate division. RESULTS: A total of 201 babies had tongue-tie, of whom 88 had breast-feeding or bottle-feeding problems. Thirty-one were not enrolled, so 57 were randomized. Of the 29 controls, one improved (3%) and breast-fed for 8 months, but 28 did not. At 48 h, these 28 were offered division, which all accepted, and 27 improved (96%) and fed normally. Of the 28 babies who had immediate division, 27 improved and fed normally but one remained on a nipple shield (P < 0.001). Twenty-four mothers breast-fed for 4 months (24/40, 60%). Overall, division of the tongue-tie babies resulted in improved feeding in 54/57 (95%) babies. CONCLUSIONS: This randomized, controlled trial has clearly shown that tongue-ties can affect feeding and that division is safe, successful and improved feeding for mother and baby significantly better than the intensive skilled support of a lactation consultant.