Nasojejunal tube feeding in children: knowledge and practice.

Nasojejunal tubes (NJ) are used in small numbers of children outside of neonatal and paediatric intensive care units. There is limited evidence on which to base practice aside from insertion techniques. Ongoing care and management is largely based on historical practice and extrapolation from nasogastric tube practice. This paper presents the historical caseload data for 36 babies and children over a five year period. The children ranged from 0 to 13 years of age, and 95% were less than 2 years old. They had a median of 4 tubes each (range 1 - 46). The paper presents data from two surveys of health professionals that demonstrate a lack of consistency in practice. There are concerns about ongoing position checks and about the radiation burden in these children. Local practice is described that aims to reduce dependence on x-ray procedures and to stimulate debate. Finally, an argument is made for a better evidence base for future practice.

Optimising wound care in a child with an infected gastrostomy exit site.

The percutaneous endoscopic gastrostomy (PEG) tube has become a widely used feeding tube for long-term delivery of fluids, liquid feed and medicines. PEG tube insertion can be considered a minimally invasive technique, associated with rapid recovery and early discharge from hospital but is not without risk (Vervloessem et al 2009; Naiditch et al 2010). A lack of nationally agreed, evidence-based clinical practice guidelines makes PEG exit site care a matter of local clinical practice and clinical judgement. In paediatric practice, children experience care shared across several healthcare settings, meeting clinical teams with varying levels of knowledge and experience of PEG care. This can lead to conflicting advice, which can have a negative effect on patient safety and experience. The case history in this article demonstrates how PEG tube insertion is never a minor procedure for a child and family (Vervloessem et al 2009; Khattak et al 1998). It highlights areas of potential conflict in clinical management of PEG exit sites, and it shows how application of wound care principles, along with a range of modern products can have a positive outcome.

How accurate are X-rays to check NG tube positioning?

The position of a nasogastric tube is vitally important for patients' safety and wellbeing. X-rays are sometimes used to determine whether nasogastric tubes are correctly positioned, but how effective are they? To find out, we undertook an audit of data from the radiology information system, collating all reports that included the word "nasogastric" from 1 January 2010 until 15 May 2011. For each report the description of tube position was put in one of six categories from "fully compliant with NPSA [National Patient Safety Agency] requirements" to "image missing". In a second, smaller dataset (cases in which some anatomy was described), we investigated the position of the tube tip as classified using descriptions from radiology reports. None of the reports contained all of the information required to comply with NSPA's (2011) guidelines, but most nasogastric tubes (70%) were in the stomach. Twenty-one per cent were reported as being in the oesophagus; advice varied from advancing it further (if uncomplicated) to removing it (if coiled or looped). Four per cent of tubes were seen in the airways (lung or bronchus) with advice for immediate removal.

General paediatric surgical provision of percutaneous endoscopic gastrostomy in a district general hospital--a 12-year experience.

INTRODUCTION: A small, but significant, number of children require long-term nutritional support. The aim of this study was to demonstrate the safety and efficacy of providing a percutaneous endoscopic gastrostomy (PEG) service for children in a district general hospital and to raise awareness of the suitability of the procedure to be performed on paediatric surgery lists in similar hospitals across the UK. PATIENTS AND METHODS: A multidisciplinary paediatric nutrition team was established and all children accepted for PEG insertion between 1995 and 2007 were entered onto a database prospectively and are included in this study. PEG tubes were inserted by the standard pull-through technique under general anaesthetic. RESULTS: A total of 172 procedures were performed in 76 children. The median age at first tube insertion was 3 years (range, 0.5-18 years). Length of follow-up ranged from 1 month to 12.6 years. Fifty-eight children (76%) had a neurological abnormality, the commonest being cerebral palsy. All but one procedure were performed successfully, of which 63 (37%) were new insertions, 99 change of tube, 4 changed from surgical gastrostomy and 6 from PEG to button gastrostomy. The median hospital stay was 2 days (range, 2-7 days) for new insertions and 1 day for tube changes. There were 10 (6%) early complications within 30 days, the commonest being peritubal infection (6). The 39 late complications included 16 peritubal infection/granulomata, 9 'buried bumpers', 4 worsening of gastro-oesophageal reflux disease, 2 gastrocolic fistulae, 3 gastrocutaneous fistulae and 4 tubal migration. There was no mortality. CONCLUSIONS: We have demonstrated that paediatric PEG procedures and continuing management by a supporting team can be successfully and efficiently provided in the district general hospital. It should be possible for the majority of similar hospitals to provide local access and increase the availability of PEG feeding for children.

The needs of patients requiring home enteral tube feeding.

A report by the British Artificial Nutrition Survey of the British Association for Parenteral and Enteral Nutrition has highlighted the needs of patients using home enteral tube feeding. Many are frail and elderly and require careful discharge planning from hospital and co-ordinated, multidisciplinary care in nursing homes or their own homes on return to the community.