Gastrostomy feeding and care

Welcome to the Gastrostomy Care and Feeding training presentation. The aims of the session, are that we will deliver the same standard of high quality care to all of our young people, that all care will be given safely and that you will understand the procedure and the need and relevance of the training. And that when the time comes, everyone will feel confident and competent in the care that you deliver.

It's important to consider normal digestion. Nutrition and fluids usually pass through the body via the following organs of the digestive system. The mouth, the oesophagus, the stomach, the liver, the small bowel, large bowel and the anus. And any problems with the function of each of these organs will impact on the child being able to eat and drink normally.

The mouth. Normally teeth break up, the food and saliva binds to facilitate swallowing. The tongue pushes through to the back of the mouth to allow swallowing, and the palate gives you something to chew against. For a child who has cerebral palsy, for example, a lack of muscle co-ordination for chewing and lifting of the tongue to swallow means that they could not swallow food safely. The functions of the oesophagus or the food pipe. This is a hollow tube that runs from the mouth to the stomach. Food moves in small ball like pieces by the tightening and relaxing of muscles.

The oesophagus is situated directly behind the trachea, hence the risk of choking. The epiglottis is a flap of tissue that covers the trachea when food or drink is swallowed to stop aspiration into the lungs. If a child has an impairment of muscle co-ordination, such as those with cerebral palsy, then their swallow may be unsafe.

The functions of the stomach. This is a muscular sack which collects and stores the food. This is why we can eat large platefuls of food because it expands. The stomach acts to acidify and clean food. Hydrochloric acid is a very strong acid, and it will kill lots of bacteria, but it will burn the food pipe if the lower oesophageal sphincter is not working properly. This means it's able to track back up. Food mixes with enzymes, which are chemicals that break down the food, and these enzymes work best in acid. The stomach churns the food into chyme, which is a vomit like substance, and the muscles at the entry to the stomach should prevent backflow into the oesophagus. If backflow occurs, this is known as reflux. A child with cerebral palsy may have problems with reflux because the sphincter at the bottom of the stomach will not be held as tightly as it should be due to the lack of muscle co-ordination. Chyme coming back up will burned the food pipe and if the food is released too quickly from the stomach, it could overload the bowel and cause the child significant pain and diarrhoea.

The functions of the liver. Liver is a very complex organ and has over 500 functions. The most important function is to break down food and convert it into energy when you need it. Your liver also helps the body to get rid of waste products, which then pass into the intestines to be excreted. Functions of the small bowel. The main function of this is to absorb nutrients. The small bowel can be as long as ten metres, and it has a huge surface area because of finger like projections called villi. Each villus has its own tiny blood supply. Peristalsis is the term used to describe how food is moved along the small bowel. This is a rhythmical movement of the bowel and can be altered and slowed down in children with cerebral palsy. Liquefied food is now mixed with bile to neutralize the acid and prevent burning of tissues. It's mixed with enzymes from the pancreas, which break down the food into absorbable particles. Food continues to be absorbed through the villi into the bloodstream. This blood then leaves the small intestine carrying away nutrients, water, electrolytes, vitamins, minerals, fats and medicines to the entire body.

Functions of the large bowel. The function of the large bowel is to help manage fluid balance in the body. It’s function also is to absorb water from the remaining indigestible food matter and then pass useless waste material from the body. Stool collects in the rectum and nerve endings called stretch receptors, then tell the brain when you need to have your bowels open. The stool is then passed through the anal sphincter or the anus. The anus has receptors that send signals to the brain, which then tells us that we need to have a poo. The anus is controlled by muscles, so once again this may be altered for children with cerebral palsy or other neurological conditions.

What is a Gastrostomy? This is a surgical opening made through the abdominal wall into the stomach through which a feeding tube can be passed.

What is a feeding tube. A feeding tube is a medical device used to provide fluid, food and medication to people who cannot obtain all of their nutritional requirements by swallowing.

Why is it needed? A feeding tube might be needed for complicated feeding difficulties. As children who suffer malnourishment are at much higher risk of infection and poor brain development. A tube may be needed for the following reasons: Children who are unable to eat or drink all they need for their growth and development; Children who have congenital malformations of the mouth, oesophagus or stomach or have failed to thrive; Those who have difficulty with normal sucking, chewing or swallowing, such as cerebral palsy; digestive disorders, respiratory or cardiac diseases which cause breathlessness whilst eating; those children who have a condition where extra nutrition is required for growth and development, such as those with cystic fibrosis; conditions that alter behaviour may make people have selective diets or not eat enough; In autism and extreme cases where children may refuse to take their medication orally, they may need a Gastrostomy.

The advantages are of improve safety, but this is compared to having a nasogastric tube where there are more risks involved during feeding because of displacement of the tube. It's more user friendly for children, and people can do their own care much more easily. It's more discreet than having a tube coming out of the nose. There are medium and long term solutions to the feeding problems by having a gastrostomy tube. We do have improved body image compared to nasogastric tube, which is visible, and we can use it to administer bolus or continuous feeds. As food enters the stomach, the normal function is used where acid cleans the food and passes it through to the bowel.

There are some disadvantages to having the tube. There may be a loss of the normal feeding regime and normal feeding behaviours of the family. This might impact the child in the family, and they may feel a loss. A general anaesthetic is needed for initial insertion, and for children who have poor respiratory function, this can pose a risk. After three months, some types of tube can be changed to one that is changed by parents or nurses in the community. Original peg tubes can last for three years, but they do create a surgical wound, risking infection. Tubes can become displaced, and that can alter a child's body image. It may exacerbate reflux and vomiting by pushing milk into the stomach and if the muscles at the top of the stomach are weak, this might be forced into the oesophagus, as previously discussed. If the tube falls out, it requires urgent replacement within one to two hours. The child may also give up oral feeding altogether. They may be at risk of leakage of stomach acid around the stoma and infection, but these are manageable.

Disadvantages for the young person. Having a tube may cause embarrassment or anxiety, and the child might be fearful of the tube coming out or having to go to hospital. It may cause discomfort, and there will be lots of professionals involved and hospital appointments to attend.

Privacy. How can we support the child or young person's privacy during the feed? It's important to think about the ways that the child that you care for would prefer to protect their privacy and how they would like their feeding done. This means that the family, including the child, may not wish to discuss their feed or feeding regime with people who have no consent to share the information with.

Dignity. Always ask the child's consent to give the feed. Think about the child's individual communication needs and use whatever techniques you have to support this. Ask how they would like it done. Feeding and eating is a special time for all of us and be aware of this at all times. Treat children, young and people as you would like to be treated yourself, respecting their beliefs and values.

The checks prior to the feed. Have we got the right feed, the correct one for the child, the correct amount, an intact container that is in date, the correct time of the feed, the right temperature and the amount of flush. Have the child sitting at no less than 30 degrees. It's better for a child to sit if they're able because it aids digestion and reduces the risk of reflux.

Before you attach the feed, look at your child and listen to what they're telling you. Are they well? does the child or young person look unwell? And you must consider whether it's a good idea to start the feed or not? If the child has a Nissen fundoplication and they are unable to vomit, their stomach gets too full, this may be a problem. Look at the gastrostomy site. Are there any signs of infection? Look at the feeding tube. Is it normal length and does it look intact? If you're concerned about the tube placement, the sight of the stoma, the length of the tube or the child, do not feed and get help using the care plan. If you are happy, flush the cheap, connect the feed and let it flow at the appropriate rate. Ensure the child or young person is not left alone during the feed and observe any coughing, retching or signs of pain. You must immediately stop the feed.

Flushing the tube. To ensure the line remains clear, flush with water before and after feed or any medications. If it's a button device, use the extension set and never use any excessive force. A minimum of a 20ml syringe should be used. Do not insert the syringe directly into the button unless this is a specific for your child, as it will break the valve. Cooled boiled water can be used in residential settings and hospital, but usually at home tap water can be used. Check your child's food plan. Normally, we use 20mls of water for a flush, but the care plan will tell you if there's anything different. Make sure there's no visible feed in the tube after you've given the feed and flush with water. And if so, flush again. You should flush between medications to ensure there's no mixing of medications.

When the feed is complete, give the appropriate flush of water. Disconnect and ensure the child or young person is comfortable and the clothing is neat. Dispose of any single use equipment, clean the equipment and document.

Recordkeeping. We need to document the time that the feed was started and when it finished. What the feed was, how much was given and if the full amount wasn't given the reason for this and why we stopped the feed. We need to document if there were any concerns about how the child or young person was through the feed, how the site looked and anything unusual and who you reported that to.