guide to gastrostomy tubes

Guide to Gastrostomy Tubes© Rady Children’s Hospital-San Diego, 2012

Table of Contents

Introduction ………………………………………………………….....………….…

Important Contact Information ……………………………………....…......................

Personal G-Tube & Feeding Information …………………….……………...........….

Important Facts & When to Call the Doctor…………………………….....……......…

Anatomy of Digestive System ………………………………………..…….…………

Nissen Fundoplication and Tube Placement Surgery ……..………………................

Daily G-Tube Care ………….………………………………………………………...

Feedings & Care of Equipment ………………………………………………………

Medications …………………………………………………………………...………

Emergency Tube Replacement.............................……………………….…........…..…

Problem Solving & Common Questions …………………………………....…………

Going Home …………….……………………………………………………………..

Financial Resources.......................................................................................................

Quiz …………………………………….……………………………………..………

Glossary …………………………………………………………………….…………

References …………………………..…………………………………………………

Parent Notes...................................................................................................................

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Guide to Gastrostomy Tubes | Page i

Dear Parents and Caregivers,

As your child prepares for gastrostomy tube (also called g-tube) surgery, we realize that you will have many questions regarding the procedure and how it will impact your child’s life. This journal will give you access to important facts regarding your child’s g-tube and fundoplication surgery. The journal also reviews the aspects of care your child will need following a g-tube placement. We believe your child deserves personalized care. Therefore, you may find that some of your child’s care will differ from what is indicated in this journal. Be sure to always follow the individualized recommendations of your child’s physicians and surgeons.

Although we hope this journal addresses the majority of your questions and concerns, we want you to know that our nurses, doctors, occupational therapists and all specialty teams are available to answer additional questions you have. Do not hesitate to seek further information at any time!

When your child is discharged from the hospital, our Home Care team will help you learn to care for your child at home. There may be a few differences between your hospital routine and your home routine. There may also be some differences between supplies you will use while in the hospital and at home. Your Home Care team will be there to support, guide and instruct you in all areas.

At Rady Children’s Hospital, our goal is to work as a unified team of surgical, medical, nursing, specialty groups and - most importantly - parents and children. We are here to provide you with the highest level of care for your child and ensure that you are fully informed and involved with all aspects of care.

Sincerely,

Linda Black, RNC-NICU, CLE

Gail Knight, MD, Division Chief of Neonatology

Mary Hilfiker, MD, PhD, MMM, Division Chief of Pediatric Surgery

Guide to Gastrostomy Tubes | Page 1

Important Contact Information

If your child’s tube falls out on the weekend or outside of office hours, call Rady Children’s Hospital at (858) 966-1700. Please ask to speak with your child’s physician, surgeon or

on-call gastroenterology (GI) specialist.

Rady Children’s Hospital–San Diego3020 Children’s Way. San Diego, CA 92123

Emergency Department Number: (858) 966-8005Rady Children’s Gastroentrology (GI) Clinic: (858) 966-4003Rady Children’s Hospital - Main Number: (858) 966-1700Rady Children’s Occupational/Physical Therapy: (858) 966-5829Rady Children’s Referral Service: (800) 788-9029 or (858) 966-4096Rady Children’s Outpatient Pharmacy: (858) 966-4060Rady Children’s Home Care: (858) 966-4941Rady Children’s Hospital Website: www.RCHSD.org

Surgeon’s Name: _____________________________________________

Surgeon Phone: _______________________________________________

GI Specialist’s Name: ________________________________________

GI Clinic: _________________________________________________

Occupational Therapy: _______________________________________

Physical Therapy:_____________________________________________

Nutrition Clinic: ___________________________________________

Primary Care Physician (PCP):_____________________________

PCP Phone:__________________________________________________

Home Pharmacy:___________________________________________

Home Care:__________________________________________________

Insurance:__________________________________________________

Notes


Personal G-Tube & Feeding Information

Under certain circumstances your surgeon may instruct you to insert a red robin or g-tube at an earlier date than listed below. Always confirm with your surgeon before you insert any replacement tubes earlier than listed below.

Date of surgery or g-tube placement: ____________________________________________

Date after which red robin tube can be placed: ____________________________________________

Date after which mic-key low profile g-tube button can be placed: ________________________________

Type and brand of g-tube: ________________________________________________________________________________

Size of low profile mic-key g-tube: ______________ French ______________ cm

Size of g-tube: ______________ French

Length of g-tube: ______________ cm

Size of red robin tube: ______________ French

Balloon volume: ____________ ml

Day of week to check balloon volume: ____________________________

Day of week to change extension tube: ____________________________

Length red robin tube to be inserted: ____________ inches

Feeding Pump: ______________________________________

Notes


My Child’s Feeding Schedule

Only liquid feeding and medications can be given via a g-tube.

Type of feed: __________________________________________________________________________________________________

Special formula preparation: _______________________________________________________________________________

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Day-time feeding schedule: _______________________________________________________________________________

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Night-time feeding schedule: _____________________________________________________________________________

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Continuous Feeding Pump program: _____________________________________________________________________

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Daytime: _____________ ml per hour Overnight: ____________ ml per hour


Important Gastrostomy Facts

If your child develops breathing difficulties during or immediately after feeding, 1. stop the feeding immediately. Attach a 60 ml syringe to the extension or g-tube and place lower than stomach to allow gravity to empty stomach content (see Pg. 19). Call 9-1-1 immediately if breathing difficulties persist.

2. Always bring a travel kit with you and make sure to carry a red robin tube and a new mic-key button tube.

If the original tube falls out during the first 3 weeks after surgery, cover the stoma with gauze and call 3. your child’s physician or surgeon. Take your child to the Emergency Department (remember to take your travel kit and new g-tube with you).

You can insert a red robin tube 3 weeks after surgery if original tube falls out. Do not force the 4. tube in. Once tube is inserted, call your child’s physician or surgeon for follow-up instructions. Important: Never give any feeds/medications via red robin tube. If you have difficulty inserting the new tube, cover the stoma (hole) with gauze and call your child’s surgeon for instruction. Then, go straight to the Emergency Department (take your child’s travel kit and new g-tube with you).

You can insert a new mic-key low profile g-tube 6 weeks after surgery if the original tube falls out. Call 5. your child’s surgeon for follow up instructions once a new tube inserted. Important: Do not force the new tube in. Never feed your child through the new g-tube unless instructed by your child’s physician. If you have difficulty inserting the g-tube, try inserting a red robin tube or place a gauze swab over the stoma before calling your child’s physician or surgeon and going to the Emergency Department (take your travel kit and new g-tube with you).

The balloon volume should be checked weekly. Also check the balloon volume if the g-tube becomes 6. loose or leaky. Only use sterile water (see Pg. 16) or distilled water to inflate the balloon.

7. Only liquid feeds and medications should be given through g-tubes. Any change in thickness of feeds should be discussed with your child’s physician, dietician or feeding specialist.

Rotate the mic-key button tube once per day if you were instructed to do so by hospital staff. 8. Important: Never rotate a Gastro-Jejunal (G-J) tube. Important: Never rotate a tube that has sutures inserted to hold it in place.

Remove the extension tube from the mic-key button after every feed and clean it thoroughly.9.

If the tube falls out your child’s g-tube stoma, the stoma will start to reduce in size between 1 to 4 hours. It is 10. important that your child receives medical attention as soon as possible if the tube falls out.


When to Call Your Child’s Doctor

1. If the skin around the g-tube site feels excessively warm or tender, or looks bright red. 2. If there is continual bleeding or excess puffy red tissue around your child’s g-tube site. 3. If there is excessive leaking around the g-tube site. 4. If there is yellow or green drainage from the g-tube site that has a foul odor. 5. If your child has persistent vomiting, wrenching or diarrhea. 6. If the feeding tube becomes blocked and you cannot remove the blockage. 7. If your child has a fever over 101 degrees Farenheit. 8. If there is any bloody residual (blood in your child’s stomach contents). 9. If your child’s stomach remains full and enlarged after venting for an hour, and your child appears in obvious discomfort. 10. Any time your child’s g-tube falls out!

Parent Learning

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Anatomy of the Digestive System

Esophagus

Diaphragm

Stomach

Duodenum

Jejunum

Ileum Large Intestines

Appendix Rectum

Anus

Esophagus carries food from the mouth to the stomach.

Diaphragm separates the lungs and heart from the abdominal area.

Stomach is where food begins the process of digesting.

Duodenum lies just after the stomach and is the first part of small intestines.

Jejunun is the middle of the small intestines.

Ileum is the last part of the small intestines.

Appendix is located near the junction of the small and large intestines.

Large Intestines are the final part of intestines, removing nutrition from food before passing waste products out of body.

Rectum and Anus are where the waste products from the body are excreted.


Nissen Fundoplication

A Nissen Fundoplication is normally carried out if a child has severe Gastric Esophageal Reflux Disease (GERD). During the surgery, the upper portion of the stomach (the fundus) is brought around your child’s esophagus from behind and sutured to create a wrap (similar to the way a collar fits around a neck). The wrap acts like a one way valve, allowing food into the stomach and keeping food from returning up the esophagus. A g-tube is normally placed at the same time as the Nissen Fundoplication to allow for feeding, burping and dispensing of medication.

Your child will either have a single incision line across his or her abdomen, or 3 to 5 small incision holes depending on your surgeon’s preference for this procedure. Your surgeon will discuss all aspects of this operation with you prior to surgery.

Normal Stomach Nissen Fundoplication


Gastrostomy Tube (G-Tube) Placement

Gastrostomy tubes are inserted while your child is sedated under general anesthesia. A small incision is made through the abdominal wall directly into your child’s stomach. A tube is then inserted and held in place by inflating a balloon or, in some cases, sutures. There are a few different types of tubes used and your surgeon will discuss what type they will be using for your child’s surgery.

This type of tube has the extension tubing attached which cannot be removed between feeds. It is essential that this type of tube is flushed with water (5 – 10 ml) after each feeding session to avoid blockage. You must be aware of the depth your child’s tube needs to be inserted. Ask your child’s nurse to show you the markings on the side of the tube to ensure the tube remains in the same position.

These tubes are normally sutured in and should not be rotated unless instructed by your child’s physician or surgeon.

skin

Esophagus

Stomach

G-Tube

G-Tube

Balloon

Feeding Port

Medication Port

Bolster

Balloon Port


Mic-Key Low Profile Gastrostomy Tube

Mic-Key Button Tube: Is small and easily hidden under clothing once the extension tube is removed between feeds. It lies flat against the skin and is held in place with an inflated balloon inside the stomach.

Mic-Key Button Extension Tube: Is a detachable tube which attaches to the mic-key button for feeding, medications and venting. It can be removed from the mic-key button base when not in use. This tube should be removed and cleaned after each feed.

Mic-Key Button Bolus Extension Tube: Is a detachable tube that attaches to the mic-key button for bolus feeds and venting. This tube should be removed and cleaned after each feed.

Feeding port cover

Balloon port

Balloon

Feeding port Extension tube attaches here

Clamp

Secur-lok connector attaches to mic-key button feeding port

Feeding port

Feeding port cover

Feeding portMedication port

Clamp

Secur-lok connectorAttaches to mic-key button feeding port.


Gastro-Jejunal (G-J) Tube Placement

The G-J tube is normally inserted when a child has difficulty tolerating feeding into the stomach. For example, a child may have problems with chronic vomiting and severe reflux resulting in lack of weight gain, low motility (causing the stomach to be extremely slow at emptying), or stomach abnormalities. This tube is inserted in the same way as a g-tube, through a small hole in the abdomen, directly into the stomach. The tube is then threaded down into the jejunum.

The G-J tube is narrower and longer than a regular g-tube and it is mostly used to give feeds slowly over longer pe-riods of time. Continual feeds are normally given with this type of tube. While most of the care for this tube is the same as any gastric tube there are a few differences. Important:

The G-J tube needs to be flushed at regular intervals to 1. prevent blockage (pg. 13).

The G-J tube empties directly into the intestine and, 2. therefore, certain medications will not be tolerated in the jenunal port. In this case, medications may need to be given via the gastric feeding port. Check with your child’s physician or surgeon on how to give medications.

When a blockage occurs, your child’s physician or 3. surgeon may advise you to utilize a small amount of fizzy (carbonated) fluid via the jejunal port to help remove the blockage. Always follow your physician’s or surgeon’s instructions regarding any change in your child’s care.

Never rotate your child’s G-J tube!!4.

Esophagus

Stomach

skinJejunum

G-J Tube

Gastric Feeding port

Jejunal Feeding port

Balloon

Bolster

Balloon Port


Tubes, Tube Parts and Their Uses!

Feeding port: Where the feeding tube or extension tube will attach to give liquid feeds. Feeding port cover: Stops feeds from escaping once the feeding or extension tube is removed. Balloon port: Allows the balloon to be inflated and deflated, which is completed when checking the balloon for volume or changing the mic-key button tube if it falls out.

Silicon balloon: Holds the tube in place when it is inflated with sterile water.

Mic-key extension tube: Attached to the mic-key button by the secur-lok connector. The extension tube can be used for venting, checking tube placement and feeding (when the main feeding tube is attached).

Mic-key bolus extension tube: Attached to the mic-key button by the secur-lok connector. The mic-key bolus extension tube may also be used for venting, checking tube placement and bolus feeding (when the feeding syringe is attached).

Secur-lok connector: Fits into the feeding port of a mic-key button tube. Clamp: Closes the extension tube when not in use.

Medicine port: A port for giving liquid medications.

Bolster: A round plastic disk next to your child’s abdomen, which holds the g-tube securely in place.

Jejunal port: Where main feeding tube attaches to a G-J tube for jejunal feeding.

Gastric port: Where main feeding tube attaches to a G-J tube for gastric feeding. This port can also be used for venting.


Care of Equipment

Formula Container and Syringes:

After each use, wash well with warm water and a little dish soap.1. Rinse well with clear warm water to ensure all soap is removed.2. Air dry on a clean towel.3. When the container and syringe are completely dry, store them in a clean and covered container.4.

Feeding Bag and Tubing:

After each use, wash with warm water.1. You may need to squeeze the tubing and bag to clear out all the milk.2. Rinse thoroughly with clean warm water.3. Air dry and store in a clean covered container.4.

How frequently to change equipment:

Your medical insurance coverage will determine how frequently you will change out your feeding bags and extension tubes. Please check with your Home Care team and your insurance provider to determine what supplies will be available to you.

Feeding bags can be used for 24 hours, or sometimes longer. It is important that your feeding bags are kept as clean as possible; therefore, thorough cleaning between feeds is advised. Many insurance companies will allow these bags to be discarded and changed every day.

The extension tubes can be used for a week, or sometimes longer. It is important that you remove your child’s extension tube and clean it thoroughly between feeds. Your insurance company will determine how frequently you will be able to change them. However, if at any point in time the tube starts to leak or the tube becomes difficult to clean, it is advisable that you discard and change it.


Preventing Tube Blockage

Remember: Your child’s tubes need to be flushed with water at regular intervals to keep them in good working order.

It is important that you flush your child’s tube with water after every bolus feeding, as well as before and after every medication. If your child is on a continual feeding program, then flush the tube at least every 4 to 6 hours during the day (normally while changing your child’s milk).

In infants, 1 to 5 ml of water should be used to flush the tubes clear. In children, 5 to 10 ml of water should be used to flush the tubes clear.

Check with your child’s nurse how much water is needed to flush your child’s tube.

A 12 inch mic-key extension tube requires approximately 3 ml to clear.A 24 inch mic-key extension tube requires approximately 5 ml to clear.A g-tube feeding port requires approximately 3 ml to clear.

Mic-Key Low Profile Gastrostomy Tube:Flush water via extension tube after every bolus feeding.Flush water via extension tube every 4 to 6 hours if continual feeding (when changing milk).

G-Tube: Flush water via feeding port after every bolus feeding. Flush water via feeding port every 4 to 6 hours if continual feeding (when changing milk).

Gastro-Jejunal (G-J) Tube:1 to 5 ml water via Gastric Port every 4 to 6 hours.3 to 10 ml water via Jejunal Port every 4 to 6 hours (when changing milk).

ImportantNever• give solid foods through a g-tube, G-J tube or mic-key button tube.

Helpful TipsOnly give formula and milk preparations that have been prescribed by your child’s physician, dietician • or feeding specialist.Only give medications that have been cleared by your child’s physician. Make sure the medication is • given in the form that was prescribed by your child’s physician.The water you use to prepare your child’s formula can also be used to flush the tube.•


Daily Skin Care

ImportantAlways wash your hands before touching your child’s g-tube!• All tube sites should be cleaned at least once per day. If the tube is not sutured in and is not a G-J tube, • then it should be gently rotated once per day to prevent sticking.Immediately after surgery, the area around the tube should be cleaned with normal saline (Pg. 26). Once • the wound has healed, soap and water can be used.

1. Soap and warm water may be used to clean the area, but be sure that soap residual is removed with fresh water to avoid drying out your child’s skin. Gently pat the area around tube dry with gauze.

Cotton tip applicators (i.e., Q-Tips) may be used to allow better access around and under the g-tube.

2. The g-tube and mic-key button port should be cleaned with warm water. Cotton tip applicators may be used to give better access while cleaning the mic-key button.

3. If the tube remains slightly loose or the site is showing signs of irritation from rubbing, then a 2 x 2 inch piece of gauze can be placed between the tube and the skin to prevent rubbing.


Skin Care Problems

It is important that you check your child’s g-tube site daily for any changes including redness, puffiness, breaks in skin, bleeding or any discharge that has a foul odor.

Redness or Irritation Around Stoma:This can be caused by infection, leakage, tape irritation or the tube being repeatedly pulled on by your child.

• Keep skin around stoma clean and dry.

• Change any dressings with every diaper change or as soon as they become damp.

• Leave as much of the site exposed to air as possible.

• Take care not to over clean site and damage the fragile skin (once or twice a day is enough).

• Call your doctor if there is any unusual redness, warmth or foul smelling discharge. These could be signs of infection.

Leaking around G-tubeTake care not to pull on the tube too much around the stoma site. Constant pulling on the tube during feeding or by your child during play can cause the stoma to become bigger which can create leakage.

• A one piece outfit such as a “onesie” can help protect the tube from constant pulling by your child (hide thetube under the outfit.

• Remove the extension tube after each feed. This will reduce pressure placed on the stoma site.

• Vent your child’s tube anytime their tummy appears full. This will reduce excess pressure around g-tube site.

• Check the balloon volume. A reduction in volume can cause leakage.

Excess skin growth around G-Tube site (granulation)Some children are more prone to this than others. It can be caused by moisture and recurrent movement.

• Contact your doctor for further advice on treatment.and care.


Checking the Balloon

The mic-key low profile g-tube and G-J tube balloon should be checked once a week to ensure proper inflation. On average, infants have 3 to 5 ml inserted into the balloon and children have 5 to 10 ml inserted. Ask your child’s physician or surgeon for the correct amount to be inserted. The amount of water in the balloon should also be checked if any leakage of milk is noted around the tube or if the tube starts to feel less stable. As your child grows, you may need to increase the amount of water in his or her balloon. Your child’s physician or surgeon will advise you when and how much to increase.

Important: Only use sterile or distilled water to inflate balloon (See Pg. 26).

1. With the plug in g-tube or G-J tube, attach an empty 5 or 10 ml syringe into the balloon port. A slight twist is needed to secure the syringe.

2. Securely hold the base of the button between your fingers. Use the syringe to gently with-draw all the fluid from your child’s balloon.

3. Check how much water is in syringe without removing the syringe. Immediately replace water into your child’s balloon, and then remove the syringe. Remember to hold the syringe plunger down as you remove the syringe.

4. If the water in your child’s balloon is not at the correct level (recommended by your physician or surgeon) draw extra sterile water into the syringe and reattach the syringe to your child’s balloon port. Push the additional water in gently.

5. Remove syringe. Remember to hold the sy-ringe plunger down as you remove the syringe from your child’s balloon port. This will keep water from leaking out of the balloon!

Important: If you have to add extra water into the balloon, recheck the ballon volume within two to

three hours to ensure there is not a slow leak.

My Child’s Balloon Volume: ____________ml


Attaching & Removing the Extention Tube

The extension tube should be removed and cleaned after every bolus feed, or every 4 to 6 hours if your child is on continuous feeds. Remember: Always wash your hands before touching your child’s g-tube!

3. Gently turn the extension tube in a clockwise direction until resistance is met.

3. Gently pull the tube up and out. Slight resistance may be felt.

4. Replace plug into mic-key button.

To Attach the Extension Tube: 1. Expose your child’s abdomen and tube. Remove the plug from the button.

2. Align both markers and press the tube plug into the hole until a slight ‘pop’ is felt.

To Remove: 1. Gently turn extension tube in a counter-clockwise direction.

2. Align both markers.


Checking Tube Placement

Important: Check the placement of all g-tubes before you begin feeds or give medication. Always check the placement of a newly inserted g-tube before giving feeds or medication.

Mic-Key Low Profile Gastrostomy Tube and G-TubeThere are a two different ways to check placement of g-tube:

G-J Tube

You do not need to check the gastric aspirate on G-J tubes, but you do need to check the centimeter markings on the tube at the entry point of the stoma. If this number has changed from previous recorded

measurements, call your child’s physician before you begin feeds or give medications.

Parent Learning

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Gravity:1. Remove the plunger from a 60 ml slip-tip syringe. Attach the syringe to your child’s decompression/extension tube. Attach the tube to your child’s button port and lower the tube below stomach level. Check for gastric (stomach) aspirate.

Aspirate:2. Attach a 30 or 60 ml syringe to the end of your child’s g-tube and pull the plunger back gently for gastric (stomach) aspirate.


Venting via the G-Tube

Children who have a fundoplication cannot burp and need assistance to burp by venting the g-tube. Every child is different and venting should be adjusted to your child’s needs and medical requirements.

1. Attach a 60 ml slip-tip syringe to the g-tube extension or venting tube. Attach the tube to the mic-key button. 2. Place the syringe at a higher level than your child’s stomach. 3. Vent the tube until all gas has been released from your child’s stomach before each feed (about 5 minutes before) and after each feed (up to 30 minutes after). Venting time decreases as your child gets older.

Bolus feed: Vent before and after every bolus feed.

Continuous feeding during the day: Vent every 4 to 6 hours when you change your child’s feed.

Continuous feeding overnight: Collaborate with your Home Care team to create a convenient schedule for venting. If your child shows any signs of discomfort during a feed, or anytime between feeds, try venting the g-tube to ensure they do not have trapped gas in their stomach. Changing your child’s position can also help release trapped gas.

Important: If your child’s stomach suddenly distends (gets bigger) and your child is in obvious distress even after venting, attach the 60 ml slip-tip syringe and empty your child’s stomach contents into a bowl. Place the syringe at a lower level than the stomach and this will allow gravity to take its course. Be sure to call your child’s physician or surgeon as soon as possible!


Types of Feeding

Continual Feeds: Based on your physician’s recommendation, your child may be on continuous feeds for the full 24 hours or strictly overnight. Continuous feeds are always delivered by a pump. Home Care services will deliver and teach you how to use your pump.

Important: It is important to stop continuous feeds every 6 hours during the day to clean the feeding bag and vent the g-tube.

Bolus Feeds: A bolus feed is when your child is given a set amount of feed over a set length of time (usually between 30 to 60 minutes). Your child may be on bolus feeds for a full 24 hours or strictly during the day. Bolus feeds may be given by pump or gravity feeding:

Pump feeding: Your child’s physician may want you to give feeds over the period of an hour. In this case the feeds will need to be delivered by pump. Your nurse will show you how to calculate the amount of milk and time to give the pump before you are discharged to leave the hospital.

Gravity feeding: Your child’s physician may want you to give feeds over a short period of time (between 20 to 30 minutes). Gravity feeding is completed using a 30 or 60 ml syringe that is attached to your child’s extension tube. The speed of the feeding can be adjusted depending on the height that the syringe is placed above the stomach.

Important: Flush your child’s g-tube and extension tube with 5 to 10 ml of water after every bolus feed. Use 1 to 5 ml if your child is on restricted fluids or as directed by your child’s provider.


Feedings

Important: Your child’s head should be elevated above the level of his or her stomach while feeding, and for 30 minutes after feeding.

Continuous FeedingPrime feeding tube and pump.1. Clamp the extension tube shut.2. Attach the extension tube to the feeding port.3. Check placement of tube.4. Attach the main feeding tube to the feeding port of 5. the extension tube.Unclamp extension tube.6. Start feeds at ordered rate.7. Once complete clamp extension tube and remove 8. main feeding tube.Vent the tube while cleaning the bag and adding milk.9. Flush extension tube with water to clear.10. Remove extension tube and clean; then re-prime tube with 11. milk. Repeat all steps.

Gravity FeedingCompleted over 20 to 30 minutes.

Prepare feed.1. Clamp extension tube.2. Attach extension tube to feeding port.3. Check for placement of tube.4. Remove plunger from 60 ml slip-tip syringe5. Attach 60 ml slip-tip syringe to feeding port .6. Unclamp the extension tube and slowly raise the syringe 7. above the level of the stomach. Regulate the flow of milk by raising or lowering the 8. syringe level.Flush with water to clear tube.9. Vent until all stomach gas has been removed (up to 30 minutes).10. Remove extension tube and clean.11. Close feeding port.12.

Remember: The higher you hold the syringe, the faster the feed will flow. If you feed your child too quickly, it may cause your child to vomit or experience discomfort.


Even though your child is being fed by a g-tube or G-J tube, it is important to provide your child with oral stimulation and the social interaction that surrounds mealtime.

Feeding positions for infants under 6 months:It is advised that the infant always have their head elevated higher than their stomach. Suggested Positions

1. Cradle heldBouncy Seat2. Car Seat3. Wedge4. A Boppy5.

Feeding positions for infants 6 months and older:Typically mealtimes become more interactive as your child gets older and they start learning feeding skills. We encourage you to have your child supported in a highchair to give your child opportunities to interact with the family during mealtimes, and start exploring and imitating feeding behaviors.

Positioning: Daytime & Bolus Feeding

Your child may need to have continuous feeds overnight. If this is recommended, be sure that your child’s head is always at a higher level than his or her stomach. Your doctor may suggest that you raise the head of your child’s crib or bed. The recommended position is usually your child laying on his or her side. However, if your child has problems with spit-ups your physician may suggest you lay your child on his or her stomach.

You should only lay your infant on his or her stomach if it is expressly recommended by your doctor.

Positioning: Nighttime Feeding


Giving Your Child Medication

Medications should be given through an extension tube via the gastric port of both the mic-key low profile g-tube and G-J tube. If your child has a regular g-tube, the medications should be given via the medication port. Remember: Always wash your hands before touching the g-tube, and check the placement of the tube before dispensing any medication.

1. Check placement. Clamp extension tube. Draw water into a 5 or 10 ml syringe and attach to medica-tion port. Unclamp extension tube and flush with water to clear. Re-clamp tube and remove syringe.

2. Attach medication syringe to medicine port. Unclamp extension tube. Gently push medication into extension tube. Re-clamp tube and remove syringe.

3. Draw more water into a 10 ml syringe and attach to medication port. Unclamp extension tube and flush with water until the tube is clear. Clamp extension tube and remove syringe.

It is important that you flush the tube completely with water before, between and after giving medications. Use 3 to 5 ml infants, and 5 to 10 ml in children.

Parent Learning

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Important Medication Facts

It is important to understand the different types of medications your child is prescribed. Some medications need to be taken with food while others may not be given with food if the food changes the effect of the medication.

1. Check with your child’s physician regarding special instructions for your child’s medications. 2. Always check with your physician and pharmacist before starting your child on any new medications to ensure there are no potential interactions with current medications or formula. 3. Liquid medication is the only recommended type of medication to be given via g-tubes. However, some children have capsules or tablets prescribed. Check with your physician and pharmacist to ensure that you can alter the way to give these medications.

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Capsule: Slow Release Beads These are not recommended for g-tubes and you should ask your doctor for a liquid form of this medication.

Capsule: Soft Gelatin These are not recommended for g-tubes and you should ask your doctor for a liquid form of this medication.

Capsule: Powder Inside Remove the outer case and empty powder into a small dish. Mix the powder with water until the powder has dissolved (three to five ml water for infants and five to ten ml for child). Draw solution into a syringe and give via extension tube. Flush tubing with water until clear.

Tablet Crush the tablet to a fine powder in a dish. Mix with water until powder has dissolved. (three to five ml water for infants and five to ten ml for child). Draw solution into a syringe and give via extension tube. Flush tubing with water until clear.


Important Medication FactsContinued

4. The following are guidelines to help you when your child needs to be given their medication in a specific way. 5. If your child has a G-J Tube, medication should be given through the gastric port only (unless otherwise instructed by your child’s physician).

6. Flush the tubing with water between each medication you give, making sure the tubing is clear of the previous medication before you give the next. 7. Understanding units of measurements:

To be given with food: The medication can be given at any time during the bolus feeding and continual feeds. Bolus feeds can be adjusted a little to accommodate the times of the medication. Alternatively in an older child adjust the feeding schedule to give a snack between bolus feeds.

To be given on empty stomach: Bolus Feeds:Aspirate stomach contents midway between bolusfeeds. If there is still formula in stomach return it and retry 15 to 20 minutes later . Give medication once stomach is empty.

Continual Feeds:If the child is on continual feeds stop the feeds for 15 to 20 minutes to allow the stomach to empty. Give medications then leave the feeds off for 15 to 20 minutes to allow the medication to be absorbed before you restart feeds. If your child is on a strict intake their feeds can be increased a little over the next hour to balance out the volume.

1cc = 1ml

1 fl. oz = 30ml

1 cup = 8oz = 240ml


Preparing Normal Saline and Sterile Water

Supplies Needed:

Saucepan• Metal tongs• Glass jar with lids• Table salt• Tap water•

Steps to Follow First:

1. Place glass jars, metal tongs and lids in large saucepan. 2. Fill pan with enough water to cover the jars and boil for 20 minutes. 3. Let cool.

Sterile Water:

1. Place 2 cups boiled water in glass jar. 2. Place lid on jar. 3. Discard after 3 days.

Normal Saline: Complete “Steps to Follow First”, then proceed:

1. Fill glass jar with 2 cups boiled water and add 1 teaspoon table salt. 2. Place lid on jar and shake solution to mix thoroughly. 3. Store normal saline in the refrigerator. 4. Discard after 3 days.

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Tube Dislodgement

There may be an occasion where your child’s g-tube falls out. In most cases this happens accidentally while your child is playing; on other occasions it is due to the sutures or balloon becoming dislodged or deflated. A few simple tips will help you to reduce the chances of your child’s tube falling out:

1. Remove the extension tube when your child is not being fed. 2. Keep the tubing secure and away from your child by hiding it under his or her clothing (e.g. onesies). 3. Do not allow your child to pull or play with the tubing. 4. Check the balloon volume every week and keep it filled to the correct amount. 5. Check the balloon volume if there is any leakage around the g-tube or the tube feels loose. 6. Important: Keep your child’s travel kit and new g-tube with you at all times!

In the event that your child’s tube does fall out: 1. Do not panic! The stoma will start to shrink after the tube falls out, but you still have time to get things in place. 2. Check how many weeks after surgery your child is.

If child is • less than 3 weeks after surgery, cover stoma with gauze.If child is • between 3 and 6 after surgery, place a red robin tube.If child is • more than 6 weeks after surgery, place a mic-key g-tube.

3. Follow the instructions to place a red robin tube or g-tube (Pg. 28-29). 4. If you cannot place any tubes due to timing post-surgery or resistance. place gauze over the stoma and call your child’s physician. Immediately go to the Emergency Department with your travel kit.

Important: Never give any feeds or medications through a red robin tube.Never start feeds through a new g-tube unless instructed to do so by your child’s physician.Always call your child’s physician following the insertion of a red robin tube or g-tube.Always take your travel kit, with a new g-tube, to the Emergency Department.

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Inserting an Emergency Red Robin Tube

If the g-tube falls out between 3 and 6 weeks after surgery a red robin tube can be gently inserted. Once the tube is inserted, call your child’s physician for follow up instructions and/or go to the Emergency Department for a new g-tube placement. If you encounter any resistance while trying to insert the red robin tube: stop, remove the tube and place a gauze swab over stoma. Then, immediately call your child’s physician and go to the Emergency Department (remember to take your child’s travel kit and new g-tube).

Important: Never give any feeds or medications through red robin tube!

1. Cover the stoma with gauze until you collect supplies (gauze, tape, lubrication, red robin tube).

2. Measure 1.5 inches for infants, or 2 to 3 inches for children, from the tip of the red robin tube. Run tape around tube to prevent it from slipping in.

3. Fold the open, larger end of the tube back onto itself and tape in position.

4. Lurbricate the tip of the tube and then gently insert the tip into your child’s stoma at a 90 degree angle to your child’s stomach. Stop and remove tube if any resistance is met.

5. Secure the new red robin tube in place by applying tape in a cross-over (chevron) style. Secure with more tape as needed.

6. Check placement of tube by removing tape from open end, and watch for milk return. Place tube at lower level than stomach. Re-tape open end of tube.


Replacing a Mic-Key Low Profile G-Tube

If the g-tube falls out more than 6 weeks after surgery, you can place a new mic-key low profile g-tube. If there is any resistance while trying to place the mic-key low profile g-tube, try a red robin or place gauze over your child’s stoma. Call your child’s surgeon and go to the Emergency Department if you are unable to replace the tube. Be sure to take your travel kit with you, along with a new g-tube!

4. Gently push mic-key button tube into stoma at a 90 degree angle to stomach. Stop and remove if you meet resistance. Slowly inflate baloon with sterile water.

5. Remove syringe and check for placement by visualizing gastric contents from tube.

6. Call your child’s physician for follow up instruction. Never give feed or medication through the new tube until your physician has given you permission.

My Child’s Balloon Volume:

___________ ml

1. Collect all your necessary supplies. Place some gauze swabs over the hole and tape in place. Pull 3 to 5ml of sterile water into 5 ml syringe.

2. Take new mic-key button tube and check the balloon is intact. Place syringe with sterile water onto balloon port. Gently push water until you see balloon inflate. Remove water from balloon.

3. Place some lubrication on a swab and dip the tip of the mic-key button into the lubrication. Place child on their back and expose belly.


Problem Solving

Child has difficulty breathing.

If your child develops difficulty breathing during or immediately following a feeding, STOP THE FEEDING AT ONCE. Empty the stomach contents (Pg. 19) and call your physician immediately. If your child continues to have breathing difficulty, call 911.

Child is vomiting. This can sometimes be caused if the feeding has gone in too fast, if the formula is too cold and if the formula is spoiled. It can also happen if there is a new formula or medication being given and can even be a sign of infection.1. Try giving feed at slower rate.2. Try warming formula up to room temperature. 3. Only keep formula for 24 hours once you have mixed it. 4. Keep all formula in fridge once it has been mixed.5. Always wash hands before touching and preparing

milk formula.6. Call your doctor if the vomiting continues or your child

has any other signs of illness.

Child has diarrhea. Diarrhea can be the result of giving feeds to quickly or from giving spoiled formula or breast milk. Diarrhea can also be caused by a change in formula or medications or even a sign of infection.1. Try giving feed at a slower rate.2. Only keep formula for 24 hours once you have mixed it. 3. Keep all formula in fridge once it has been mixed.4. Always wash hands before touching and preparing

milk formula.5. If diarrhea persists call your doctor.

Child hasconstipation

Constipation can be the result of a change in formula or medications. It can also be caused by a change in the feeding schedule. Notify your doctor if constipation continues.


Tube blocked This can be caused by thick formulas or medications. 1. Try gently flushing with water.2. Call your doctor if you are unable to unblock the tube.

G-Tube falls out If this happens do not panic, cover stoma with gauze and get your travel kit. Follow instructions on handout.

1. Less than 3 weeks after surgery cover stoma with gauze go to Emergency Dept.

2. More than 3 weeks after surgery place red robin tubego to Emergency Dept.

3. More than 6 weeks after surgery place g-tube call doctor for follow up care.

Extension tubingleaks

Sometimes the medication port of the extension tube starts to become loose and pops off. Letting milk leak out. 1. Always make sure you push the plug into the

medicine port after giving medications and before starting feeds.

2. If it continues to leak change out the extension tube.

Leaking around the G-Tube site

Leakage can occasionally occur around the g-tube site and can be caused by feeds being given too fast, too much feed being given, reduced inflation of the balloon and the need for a new larger size g-tube.1. Try giving feed at a slower rate.2. Check the amount of water in the balloon and top up

if needed..3. If your child has suddenly gone through a growth

spurt check with your doctor to see if they require a larger g-tube

4. Keep the tube out of your child’s reach to stop them playing and pulling on it. Secure it under their clothes.

Problem SolvingContinued


Common Questions

Why does my child need a g-tube?

Your child may be unable to tolerate taking feeds orally at this point in time. The g-tube will provide an alternative way for your child to get the nutrition they need to grow and develop properly.

Why does my child need a fundoplication?

This is one of the most common surgicalprocedures to help treat severe gastro-esophageal reflux (GERD).

What is a GERD? GERD is the backup of stomach contents into the esophagus (the tube between the stomach and themouth). This causes your child to have pain and discomfort.

What is the goal of the Nissen FubdoplicationOperation?

A Nissen Fundoplication is performed by wrapping the upper stomach around the lower part of the esophagus to create a one way valve which will stop the GERD symptoms.

How Long will my childhave the G-Tube?

The length of time your child will have the g-tube depends on the specific special needs of your child. Discuss with your doctor you child’s future plans.

How long will the procedure take?

Usually the procedure takes anywhere from 2 hours or longer.

What will my child look like after the procedure?

If your child is an infant and has general anesthetic, he or she may return with a breathing tube attached to a ventilator (breathing machine).This tube will be removed once your child wakes up from the anesthesia and is able to breathe on his or her own. If your child is older, he or she may come back from the procedure awake, but a little sleepy.

Depending on what type of procedure your child has completed, he or she may have no visible wounds except the stoma; or he or she may have 3-5 small wounds or one larger wound. Any incisions will be covered with sterile dressings.


How will a NissenFundoplication benefit my child?

The fundoplication will prevent your child from experiencing severe reflux with feeds. This will in turn reduce the negative feelings that they associated with feeding. The g-tube will allow your child to receive the nutrition and hydration they need to grow and develop. It will also allow them to work on oral feedings at their individual skill level.

When can I hold my child? Your child will be a somewhat sore after surgery and we will ensure that they receive adequate pain medication. It is sometimes best to let them rest and heal. Discuss with your nurse when you will be able to hold your child.

When will my child start receiving formula/breast milk through the g-tube?

Once your child has recovered from the surgery your doctor will decide when to start feeds. Usually we start with a clear liquid called Pedialyte and progress to formula/breast milk over the next few days. We usually start off feeding by continual feeds and increase the amount slowly to ensure your child can tolerate it.

Is it safe for my child to eat food or formula by mouth?

Your child’s doctor and Occupational Therapist will discuss whether it is possible for your child to eat food orally. Your Occupational Therapist will show you some exercises to encourage your child’s development and prepare them for the re-introduction of oral feeds.

Can I give my child a bath with the g-tube?

Your child can have a tub bath once the incision site has healed and all the sutures have been removed. Usually between 7 and 14 days post-op, or when ordered by your surgeon.

Common QuestionsContinued


Going Home

Before your child is discharged home it is advised that you spend as much time as possible at the hospital to become familiar and confident with all aspects of g-tube care.

The bedside nurses will let you practice care on our g-tube doll to ensure that you have adequate training in all areas of care needed for your child’s g-tube. For a few days prior to discharge, the nurses will expect you to carry out the majority of your child’s g-tube care.

Our goal is to ensure that you feel comfortable, and confident with your child and their new g-tube before you take them home.

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Home Care and Equipment:Usually 24 to 48 hours prior to discharge someone from the Home Care team will meet with you to go over all aspects of the care you will receive in the community. They will ensure that you have all the supplies you will need and they will arrange for any feeding pumps and equipment to be delivered to you. Follow up meetings with a Home Care Nurse will also be made to match with your discharge date.

Occupational Therapy:Prior to discharge our Occupational Therapist will meet with you on a regular basis to discuss and practice exercises that you can carry out with your child to help them progress to oral feedings at your child’s skill level. Our Therapists will also make arrangements for you to come back to one of their clinics for follow up and support.

Primary Care and Specialty Clinic Follow-Up Appointments:Prior to discharge, we will ask you to make an appointment with your child’s primary care physician. We strongly suggest that your child’s first follow-up appointment is held within 24 hours from discharge. A copy of your child’s medical record will be given to his or her primary care physician. We will also give you a copy of your child’s discharge record.

Your child’s relevant specialty clinic appointments will be made and the information will be given to your prior to your child’s discharge from the hospital. We want to ensure that all aspects of your child’s care is followed up on.


Parents’ Travel Kit

We have created a small emergency travel kit that should be carried with you at all times. Upon discharge, please ensure a kit is assembled and given to you. When you use an item from your travel kit, be sure to replace that item to ensure your kit is fully stocked at all times.

List of Contents:Gauze sponges Medical tapeLubricating gelBottle sterile water5 ml slip tip syringe30 ml/60 ml slip-tip syringeRed robin Tube (in package)Tape measureNew mic-key button tubeStorage container for mic-key button tubeMic-key extension tube (12 inches)

Parent to supply:Small hand sanitizerSmall supply of wipes or a wash cloth Travel Instruction Cards:Carry the travel instruction cards with you at all times:

Inserting a Red Robin Tube1. Inserting a Mic-Key Button2. Important Contact Information3. Important G-Tube Information4.

Replacement G-Tube:You may also carry the new g-tube in its original packaging along with your travel kit.


Private Insurance

The Member Services number on the back of your insurance card will be helpful for you in determining your benefits for outpatient care, home equipment, supplies and home health (visits from a nurse or shift nursing in which a nurse cares for your child in your home for eight hours or more per day). The amount of benefit coverage will vary from plan-to-plan. Your discharge planner can help you with this information since she has already been discussing your child with a representative from the insurance company. The financial counselors at Rady Children’s can also help you with any questions you may have about insurance and your child’s stay. The medical unit secretary can help you contact your financial counselor.

Medi-Cal

If your family’s income is within certain guidelines you may be eligible for Medi-Cal, which provides families with financial assistance for regular check-ups and special medical care. If you are applying for Medi-Cal, contact a financial counselor at Rady Children’s. The medical unit secretary can help you contact your financial counselor. If your child currently has Medi-Cal, contact your Medi-Cal representative about current eligibility. Your discharge planner will discuss what the Medi-Cal plan will cover for outpatient care, home equipment, supplies and home health (visits in which a nurse cares for your child in your home for eight hours or more per day).

California Children’s Services (CCS)

CCS is a statewide, tax-supported program for specialized medical care and rehabilitation. Children who have a medically eligible diagnosis may receive financial assistance for medical expenses through CCS. A family may be eligible for both Medi-Cal and CCS. A child who is covered by private insurance may also be eligible for CCS for both the inpatient stay and for outpatient care, equipment and supplies. CCS can be helpful when there is need for services that are not covered by your insurance plan. There are financial criteria for the family that your financial counselor can assist you with. Your discharge planner will discuss your child’s eligibility and will make the referral to CCS during the inpatient stay if your child qualifies.

Supplemental Security Income (SSI)

If your child has a disability that will last more that one year, you may receive a monthly income. Both the amount received and eligibility are dependent on family income. Families with a wage earner and private insurance may still be eligible. For more information about SSI, call (800) 772-1213.

Financial Resources

Insurance


Financial Assistance

In Home Support Services (IHSS): Children who require special help for their care at home and who are also receiving SSI may also be eligible for IHSS. You may use the money to help care for your child. For more information, you can call IHSS at (866) 351-7722.

W.I.C. (Women, Infants, Children): This is program that provides food supplements to pregnant and/or breast feeding women and children at nutritional risk under the age of 5. There is an income guideline that must be met. WIC will also cover many specialty formulas that your child may require. To learn more about WIC services, call (800) 500-6411.

Anderson Dental Center Endowment: The endowment is dedicated to enhancing dental care for children with disabilities, special needs and early childhood carries by providing limited funding for children up to age 18. Eligible families are typically uninsured or underinsured and are otherwise unable to obtain dental treatment. Treatment funding is provided at reduced rates. Call Rady Children’s Healthcare Referral at (800) 788-9029 to apply.

SDG&E: Your family may qualify for a discounted energy bill based on your income. See your discharge planner for an application.

Additional Family Resources

San Diego Regional Center: A state-funded program for diagnosing and serving individuals who have developmental disabilities or young children at high risk for developmental disabilities. The Regional Center will provides multiple services including diagnosis, treatment programs, transportation and respite services. For more information, call (858) 576-2996.

Exceptional Family Resource Center (EFRC): EFRC provides families with emotional support, factual information and encouragement in order to help children reach their full potential. Agency services include education and lending library, local, regional and national resources, referral to community-based programs, support groups and disability-specific support groups. For information call (800) 281-8252.

Outreach and Early Intervention Program: This is a family-focused program that provides services to promote optimal development and minimize developmental delays in infancy. One of the services offered is respite care. Ask your discharge planner about a referral for this service.

San Diego Network of Care: A comprehensive resource for services provided in San Diego County. You can access their website at http://sandiego.networkofcare.org.

HowKidsDevelop.com: A collaborative website with information on the Developmental Screening and Enhancement Program (DSEP), Children’s Care Connection (C3), First Five Healthy Development Services Initiative (HDSI) and Rady Children’s Hospital Developmental Services.


Pre-Discharge Quiz

How often do you clean around g-tube? 1. 1 hourly 12 hourly Daily

How often do you change the feeding bag? 2. Daily Weekly Monthly

How often do you change the extension tube?3. Daily Weekly Monthly

How often do you check the balloon? 4. Daily Weekly Monthly

How often do you rotate the tube? 5. Daily Weekly Monthly

How many weeks after surgery can you place red robin tube?6. ____________ Weeks

How far in do you insert your child’s red robin tube? 7. __________________ cm

How many weeks after surgery can you place a new mic- key button? 8. ___________ Weeks

How much water is in your child’s balloon?9. ________________ ml

What type of water do you use for balloon?10. (circle all that apply)

Sterile water Distilled Water Tap water

When do you vent or burp your child?11. (circle all that apply)

After each bolus feed Every 6 hours if on continual feeds Weekly

When should you flush the g-tube and extension tube? 12. (circle all that apply)

After each feed Before and after medications Weekly


Answers: Pre-Discharge Quiz

1. Daily. 2. Daily. 3. Weekly. 4. Weekly. 5. Daily. 6. 3 weeks. 7. Ask your child’s nurse to confirm the correct answer! 8. 6 weeks. 9. Ask your child’s nurse to confirm the correct answer! 10. Sterile or Distilled. 11. After each feed. Every 6 hours. 12. After each feed. Before and after medications.

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Medical Glossary

Esophagus – Tube that carries food from the mouth to the stomach. Fundus – The upper part of the stomach.

Gastric Secretions – Stomach secretions and contents.

Gastro-Esophageal Reflux Disease (GERD) – Excessive reflux of gastric secretions from the stomach into the esophagus.

Gastrostomy – A surgical opening into the stomach.

Gastrostomy Tube (G-Tube) – A tube that is placed into the gastrostomy hole allowing milk feeding to go directly to stomach.

Red Robin Tube – A temporary tube that is placed in a gastrostomy hole when the g-tube falls out.

Jejunum – A tube that lies below the stomach and carries food away.

Gastro-Jejunal Tube (G-J Tube) – A tube that is placed into the gastrostomy hole, into the stomach and then out to the jejunum below.

Fundoplication (also known as Nissen Fundoplication) – A surgical operation that takes the upper portion of the stomach and wraps around esophagus. This helps prevent GERD.

Stoma – A small hole through the abdomen where your child’s g-tube is inserted.

Venting – Burping your child through the g-tube.

Decompressing the Stomach – Emptying the stomach of air and feedings. Decompression is usually necessary if your child becomes ill or has trouble breathing during a feeding.


Recommended Reading

Reckling, A, PsyD. (2007) When Jeremy Jones’ Stomach Stopped Working. Mitochondrial Disease Action Committee. http://www.mitoaction.org/pdf/bookGTube.pdf

Mic-Key Tube Care and Usage (2010). Kimberly-Clark Worldwide, Inc.http://www.mic-key.com/resources/mic-keystar-care--usage-guide.aspx

ReferencesSu W, Berry M, Puligandla PS, Aspirot A, Flageole H, Laberge JM. Predictors of gastroesophageal reflux in neonates with congenital diaphragmatic hernia (2007). http://www.ncbi.nlm.nih.gov/pubmed/17923189

History of the Nissen Fundoplication (2011). TEF/Vater Internatioanl. http://www.tefvater.org/esophageal/fundoplications.html

Cu S, BS; Sidman J, MD. Rates and Risks of Gastrostomy Tubes in Infants With Cleft Palate (2011). http://archotol.ama-assn.org/cgi/content/abstract/137/3/275

Fundoplication - Open Surgery (2005). EBSCO Publishing.http://www.doctorsofusc.com/condition/document/14813

Minard G, MD. The History of Surgically Placed Feeding Tubes (2006).http://ncp.sagepub.com/content/21/6/626.abstract

Gastrostomy Tubes (2011). The Regents of the University of California. http://pedsurg.ucsf.edu/conditions--procedures/gastrostomy-tubes.aspx

Agrawal S. All About NJ, GJ, and J Tubes (2009). Complex Child E-Magazine.http://www.articles.complexchild.com/oct2009/00158.pdf

Sexton E, Holden C. Jejunostomy Tubes (2007). Tracheo-Oesophageal Fistula Support. http://www.tofs.org.uk/index.php/what_is_tof_oa/procedures/jejunostomy_tubes

Enteral Feeding: Enteral Feeding Tubes & Accessories (2009). Kimberly-Clark Worldwice, Inc. http://kchealthcare.or-live.com/digestivehealth/enteralfeeding/product/acc.cfm

Would Ostomy and Continence Nurses Societyhttp://www.wocn.org


My Journal

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08/2011

3020 Children’s WaySan Diego, CA 92123

(858) 966-1700www.RCHSD.org

guide to gastrostomy tubes

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