Mechanical problems |
Impairment of child development | Enteral feedings and tube interfere with feeding skill
development and normal activity | Develop feeding schedule so that child learns association
between oral activity and satiety. Establish a nonnutritive program.
If possible offer small amounts of food from spoon and fluids from
a cup. These offerings should be before enteral feedings. |
Instruct family to secure tube and place child on
abdomen to promote upper body development and encourage crawling. |
Encourage normal clothing. |
Consider skin-level device as early as possible. |
If oral food refusal results, consult an occupational
and speech pathologist. |
Leaking of gastric contents onto the abdomen | Balloon or bulb of tube has slipped away from the stomach | Check marking on tube and gently pull back on catheter/tube
to assure that balloon is snug against stomach wall. |
Balloon has deflated | Add water to the balloon or change tube. |
Child has increased pressure in stomach from air, delayed gastric emptying, coughing, causing formula to leak | Vent tube before or after feeding. Protect skin with barrier creams. |
Tube is too small for size of stoma | Placing a larger tube is usually not recommended.
Take tube out to allow stoma to shrink down. Check stoma diameter
every half hour. |
Frequent positioning of child onto the left side. | Limit the time spent on the left side after feeding. |
Frequent pulling at tube | Use restraints or one-piece T-shirts as needed. |
Tube’s valve is defective | Change tube. |
Redness or drainage around tube/stoma | Some redness and drainage are normal | Assess area more frequently. |
Skin irritation results from dampness and/or leaking around tube | Keep skin dry. Antacids or barrier creams may be necessary to protect skin. |
Ineffective cleaning | Clean area with mild soap and water. Avoid routine use of hydrogen peroxide. |
Tube has not been rotated | Rotate tube once a day. |
Securing device is too tight | Loosen securing device and assess daily for ability to move slightly. (Area between the abdomen and securing device should be about the depth of a dime.) |
Peristomal wound infection | Antibiotic ointments or antifungals should be used only with signs of infection. |
Clogged tube | Lack of routine flushing | Flush tube before feedings and medications. Use warm water with a syringe and slight pulsating pressure every 10 minutes for 1 hour. |
Inability to irrigate tube | Aspirating gastric contents frequently |
Increased formula in reflux bag | Medication-formula interaction | Irrigate the tube before and after residual checks. |
Feedings will not flow | Inadequately crushed medications through the tube | Assess medication-formula compatibility. |
Gastric reflux | Crush medications finely. Use liquid when possible. |
Formula to viscous | Consider intestinal feedings. |
User formula designed for tub diameter and change
formula to one with a lower viscosity. |
Consider milking the tube to alleviate the obstruction. |
Nasal/pharyngeal/esophageal irritation and erosion | 1. Prolonged intubation with nasogastric tube | Use the softest/smallest-caliber feeding tube when possible. |
Perform regular assessment of nares. Moisten and clean nares every 8 hours. Lubricate lips. |
Secure tube properly. |
Consider gastrostomy and jejunostomy tubes for long-term feeding (> 3 months) |
Granulation tissue buildup around gastrostomy
tube | Small amount of epithelial tissue is
normal and not painful | Skin care prevents irritation. |
Secure tub to minimize movement. |
Tissue may increase with increased
movement | Apply silver nitrate to the tissue every other day
for 1 week. |
Cauterization may be necessary. |
Some children are more prone than others | |
Bleeding | May occur with tube change | Lubricate the new tube well before insertion. |
Excessive tension on the tube | Allow slight movement in tube between the gastric
and abdominal wall. |
Movement of tube against mucosa | Secure the tube. |
Gastric ulcers or pressure necrosis | Acid inhibition, endoscopy. |
Migration of tube | Movement or migration of tube | Secure tube and monitor length of external tube. |
Stomach to intestines (increase in stools) | Restrain as necessary. |
Antiemetic as necessary. |
Stomach to esophagus (retching, vomiting, coughing) | Stop feeding if tube position is unknown. |
Reposition the tube. |
Tube into the tract (pain) | May need to verify the tube position with x-ray. |
Accidental removal of tube | Child pulls on tube | Secure tube as instructed. |
Balloon deflated | Restraints may be necessary. |
Tube not secured | Cover the area with a small dressing and cover with tape. |
Replacement should occur within 4 hours. |
Damaged tubes should always be replaced. |
If possible, consider skin-level devices. |
Replacement of jejunostomy tubes needs to be confirmed by x-ray |
Aspiration | Delayed gastric emptying | Stop feeding immediately if aspiration is suspected. |
Gastroesophageal reflux | Never feed if child feels full or is sick or vomiting. |
Gastroparesis | Check placement of tube. |
Poor gag reflex | Check aspirates. |
Vomiting | Never feed child flat. Place on right side, sit up,
or raise head of bed 30–45°. |
Use continuous feeding rather than bolus. |
Consider antireflux medication. |
Gastrointestinal problems |
Nausea and vomiting | Rapid formula administration | For continuous feedings, reduce rate
of administration. For bolus feedings, increase length of time for
feedings. Offer smaller and more frequent feedings. |
High osmolality |
Gastric retention |
Air in stomach | Select isotonic or dilute formula. Gradually increase
to full-strength formula. |
Tube migration from stomach to small intestine | Avoid adding other food to formula
(ie, strained or dehydrated baby food). Consider gastric stimulant
to promote gastric emptying, continuous feedings, or postpyloric
feedings. |
Medications given with feeding |
Child’s position | Burp child during feedings or allow for short breaks.
Elevate child’s head during feeding and for 30 minutes
after meals. Decompress routinely. |
Stop feeding and reposition tube against stomach wall. |
Change times of medication if possible. Check contents
of medications. |
Keep head of child elevated when feeding. |
Diarrhea | Rapid formula administration | Reduce rate of administration or initiate feedings at low rate. |
Hyperosmolar or low-residue formulas | Rule out formula related causes. Select isotonic or
fiber-supplemented formula. Consider diluting formula concentration
and gradually increase the strength. |
Intolerance of formula (allergy/lactose intolerance) | Use formula lacking intolerance component (ie, lactose free). |
Malabsorption | Consider use of elemental or semielemental formula, medium-chain triglyceride. |
Hypoalbuminemia | If absorptive capacity of the small
intestine is compromised, consider use of hydrolyzed, peptide based
formulas or parenteral nutrition. |
Bacterial contamination |
Rapid gastrointestinal transit time | Use commercially prepared sterile formulas.
Use aseptic techniques in handling and administering feedings. Avoid
hanging feedings over a prolonged time. Do not use a delivery set
for over 24 hours. Throw away any opened formula refrigerated over
48 hours. |
Prolonged antibiotic therapy or other medications |
Select formula with fiber supplement. |
Send stool for C. difficile toxin
and culture. Monitor medications (? sorbitol content) and eliminate
causative medication if possible. Check time medications are given. |
If diarrhea persists, measure stool electrolytes and
osmolality. Consider holding feedings for 24 hours and monitor effect
on stool output. |
If osmotic diarrhea persists or if secretory diarrhea
is diagnosed, begin parenteral nutrition. |
Cramping, gas, abdominal distention | Rapid administration of formula | Reduce rate of formula administration and deliver according to patient tolerance. |
Administration of cold formula | Administer formula at room temperature. |
Malabsorption of formula | Select hydrolyzed formula. |
Constipation | Inadequate fluid | Monitor and increase fluids. |
Inadequate fiber | Consider formula with fiber or add fiber supplement. Try prune juice. |
Inadequate activity | Encourage activity. |
Fecal impaction | Disimpact and add stool softeners. |
Obstruction | Stop feedings. |