Jamil Khair, R.N.
Dept.of Paediatric Gastroenterology & Nutrition, Queen Elizabeth Children’s Service, St. Bartholomews
Hospital, London, phone & fax +44-?-020-7601-8486
Learning Objectives

To list the routes available for enteral feeding in children

To identify the devices and methods of insertion available for enteral feeding

To select the most appropriate route and device for children with different requirements for feeding
Secondary / Hospital-acquired Malnutrition in Children
As far back 1979 a study of paediatric patients in a North American, metropolitan hospital revealed that one third of them showed signs of acute PEM (protein-energy malnutrition) - half of those being below 75 % of expected weight-for-age [1]. More recently, the application of a new, nutritional risk-scoring tool to 228 hospitalised children, in Paris in 1998, identified weight-loss in 56% of these children with 33% having lost more than 5% of their admission weight [2].
Whilst the importance of correcting secondary malnutrition in adults is still under debate, the implications of failure to address this phenomenon in paediatric patients have been well-described [3] and include:

increased susceptibility to infection

poor healing

perioperative complications

reduced response to treatment

stunting

developmental delay

an overall increase in morbidity and mortality
UK Children (<16) on HETF in 1999
40
30
20
10
POINT PREV
% (n=3318)
0
G.I.
CARDIAC RESP C.N.S.
OTHER
Of the 3.318 HETF (Home Enteral Tube Feeding) children registered with BANS (British
Artificial Nutrition Survey) in 1999 the largest group were those with central nervous system disorders - particularly cerebral palsy (19.8%)[4].

Choosing the Best Method
When the need arises to supplement a child’s feeding by artificial means we are left with a decision as to the most appropriate route and feeding device to use. Our choice must be governed by the following objectives:
 Ensuring the child’s safety
 Allowing the development of ‘normal’ feeding behaviour

Minimising trauma and discomfort

Reducing the length of admission
The first step will be to decide whether the child can be fed safely into the stomach or will require post-pyloric feeding. Making this decision may require evidence from clinical investigations such as video-fluoroscopy, a gastric-emptying study, oesophageal pH monitoring or surface electrogastrography; in order to establish the patency and function of both the stomach and the swallowing mechanisms.
Point Prevalence of Registered Paediatric HETF Patients in the UK by
Administration Route
70
60
50
40
30
20
10
0
-
1996 % (n=3334)
1999 % (n=2109)
This table shows an increase in the numbers of patients using nasogastric feeding at home, and a decreasing trend for gastrostomy feeding. This change is not related to changes in diagnosis or age [4].
Nasogastric Feeding
Nasogastric feeding is the simplest and most obvious route for commencing enteral feeding. Selection of an appropriate size and type of nasogastric tube will depend on the materials used in its construction and the anticipated duration of feeding [5].
Indication:

the child has a functioning
G.I. tract, but is unable to meet his or her total nutritional requirements orally
Problems/Complications

misplacement (trachea/cranium[6]
/small intestine)

accidental removal

occlusion

dysphagia / nausea / oral/nasal phobia

body-image

trauma / ulceration / perforation
Contraindications:

persistent vomiting

severe delayed gastric emptying

complete intestinal obstruction

uncontrolled gastro-oesophageal reflux with a risk of pulmonary aspiration

Gastrostomy Feeding
Although nasogastric tube-feeding is feasible for extended periods, children who are likely to require feeding for more than three months should be considered for gastrostomy placement.
Indications

as for nasogastric feeding plus:

congenital abnormalities such as oeso-phageal / choanal atresia or tracheo-oesophageal fistula

requirement for long-term feeding

oesophageal injury

Oesophageal dysmotility
Contraindications/Problems [7] Contraindications

Large bowel perforation / fistula

Accidental displacement: can

as for nasogastric feeding plus:

gross ascites / severe obesity result in partial closure of the stoma

Infection

Over-granulation

Occlusion

Migration

clotting abnormalities

gastroparesis

oesophageal/gastric varices
and/or ulceration
Gastrostomy Feeding Devices
Surgical formation of a gastrostomy is possible by laparotomy, gastrotomy and perforation of the abdominal wall with a trochar. Although this technique is still commonly used in very small infants or patients with a requirement for other gastric surgery (such as Nissen fundoplication) the advent of the percutaneous endoscopic insertion (PEG) technique, in
1980, has vastly increased the availability and acceptability of gastrostomy feeding in paediatric practice.
A variety of feeding devices are available for use in both surgically and endoscopicallyformed gastrostomy. The advantages of each will be discussed in the presentation.
Post-pyloric Feeding
Since evidence from adult patients has shown that feeding above the level of the ligament of Treitz can result in duodeno-gastric reflux [8], post-pyloric feeding normally refers to jejunal placement.
Indications

persistent vomiting

severe delayed gastric emptying

gastroparesis
Problems/Complications
 ‘Dumping Syndrome’

Migration

Displacement

uncontrolled gastro-oesophageal reflux

Perforation

pulmonary aspiration
Contraindications

complete intestinal obstruction

gross ascites

severe obesity

clotting abnormalities
Types of Feeding Devices
Jejunal feeding can be achieved using naso-jejunal, jejunostomy (NCJ), trans-pyloric jejunostomy or trans-gastric (PEGJ) placement. With the exception of trans-gastric tubes, most patients with jejunostomy tubes also require a nasogastric tube or gastrostomy for gastric decompression.
Guidelines for “Post-pyloric Feeding”
If a decision has been made that a child is to receive postpyloric feeding, it may be assumed that feeding into the stomach is contra-indicated. For this reason, it is essential that correct positioning of the feeding device is confirmed - particularly for naso-jejunal and trans-gastric/pyloric tubes which can migrate back into the stomach. All feeds should be given continu ously, using a pump, to prevent diarrhoea or ‘dumping syndrome’. In addition, the

jejunum does not have the same acid protection as the stomach so every effort should be made to prevent contamination of feeds or feeding equipment.
Summary
Artificial enteral feeding in paediatrics needs, above-all, to be safe and beneficial to the child. The risks of choosing an inappropriate route, method or device can be both severe and long-lasting. A complete understanding of the risks and benefits of all available options is imperative in order to make the best selection.
References
1. Merritt RJ, Suskind RM. Nutritional survey of hospitalized pediatric patients. Am J Clin Nutr. 1979; 32: 1320-5
2. Sermet-Gaudelus I, Poisson-Salamon AS, et al. Implementation of a simple pediatric nutritional risk score. Clin Nutr
1998; 17: 29-30
3. Fuchs GJ. Secondary malnutrition in children. In: Suskind RM, Lewinter-Suskind L (eds.) The Malnourished Child.
New York: Raven Press, 1990: 25
4. Elia M et al. Trends In Artificial Nutrition Support. In: The UK During 1996-1999. A Report by the British Artificial
Nutrition Survey (BANS). Maidenhead, Berks: BAPEN 7.3, 2000: 41 & 44
5. Taylor J. A guide to NG feeding equipment. Professional Nurse 1998; 11: 91-94
6. Fremstad JD, Martin SH. Lethal complication from insertion of nasogastric tube after severe basilar skull fracture. J
Trauma 1978; 18: 820-822
7. Michaud L et al. Late-onset complications of percutaneous endoscopic gastrostomy (PEG) in infants and children.
Clin Nutr 1999; 18: 56
8. Moore MC, Greene HL. Tube Feeding in Infants and Children. Pediatric Clin North Am 1985; 32: 402