G-tube Feeding Research Articles

Feeding Methods at Discharge Predict Long-Term Feeding and Neurodevelopmental Outcomes in Preterm Infants Referred for Gastrostomy Evaluation

To test the hypothesis that oral feeding at first neonatal intensive care unit discharge is associated with less neurodevelopmental impairment and better feeding milestones compared with discharge with a gastrostomy tube (G-tube). We studied outcomes for a retrospective cohort of 194 neonates <37 weeks' gestation referred for evaluation and management of feeding difficulties between July 2006 and July 2012. Discharge milestones, length of hospitalization, and Bayley Scales of Infant Development-Third Edition scores at 18-24 months were examined. χ2, Mann-Whitney U, or t tests and multivariable logistic regression models were used. A total of 60% (n = 117) of infants were discharged on oral feedings; of these, 96% remained oral-fed at 1 year. The remaining 40% (n = 77) were discharged on G-tube feedings; of these, 31 (40%) remained G-tube dependent, 17 (22%) became oral-fed, and 29 (38%) were on oral and G-tube feedings at 1 year. Infants discharged on a G-tube had lower cognitive (P <.01), communication (P = .03), and motor (P <.01) composite scores. The presence of a G-tube, younger gestation, bronchopulmonary dysplasia, or intraventricular hemorrhage was associated significantly with neurodevelopmental delay. For infants referred for feeding concerns, G-tube evaluations, and feeding management, the majority did not require a G-tube. Full oral feeding at first neonatal intensive care unit discharge was associated with superior feeding milestones and less long-term neurodevelopmental impairment, relative to full or partial G-tube feeding. Evaluation and feeding management before and after G-tube placement may improve long-term feeding and neurodevelopmental outcomes.

Factors predicting postoperative complications following spinal fusions in children with cerebral palsy scoliosis

The purpose of this study was to review the postoperative complications after posterior spinal fusion (PSF) in cerebral palsy (CP) scoliosis and identify the predictive preoperative risk factors. All PSFs consecutively performed for CP scoliosis between 2004 and 2013 were reviewed. Preoperative risk score (ORS) and postoperative complications score (POCS) were used as measures of all recorded preoperative risk factors and postoperative complications, respectively. The review included 303 children with a mean age of 14.6 ± 3.0 years. Mean hospitalization was 16 days. Dependence on G-tube feeding was associated with higher POCS (P = 0.027). Postoperative fever, seizures, and septicemia were associated with higher ORS (P < 0.01). Specifically, postoperative pancreatitis and deep wound infections were more common in children with G-tube. This study suggests that G-tube dependence is a predictive risk factor of complications after PSF in CP scoliosis. Children with G-tube need special perioperative care. No other specific preoperative risk factor predicted postoperative complications.

Family Experiences With Feeding Tubes in Neurologic Impairment: A Systematic Review.

Gastrostomy tubes (G-tubes) are frequently used to provide enteral nutrition for children who have neurologic impairment. Understanding the impact of G-tubes from the family's perspective will inform decision-making and improve support from health care providers. This study explored the experiences of families after G-tube placement in children with neurologic impairment. We conducted a systematic review of English-language qualitative primary research studies describing family experiences after G-tube placement. Six electronic databases were searched from inception to June 2014. Two authors independently screened and identified relevant studies, evaluated quality of reporting by using the Consolidated Criteria for Reporting Qualitative Research tool, and extracted data. Overarching concepts were developed by using thematic analysis. From 2674 screened abstracts, 84 texts were reviewed, and 13 studies met the inclusion criteria. G-tubes affect the lives of children, parents, and the family unit in many ways, both positive and negative. Improvements and challenges were described for children's health and happiness, for parental caregiving and stress, and for logistics and bonding within the family. G-tube feeding also changed relationships within the family, between the family and the medical system, and between the family and the outside world. Furthermore, experiences varied, with different families framing similar concepts as positive and negative. G-tube placement has diverse effects on daily life for children with neurologic impairment and their families. Clinicians may use the themes identified in this study to guide conversations with families about their values, experiences, and expectations before and after G-tube placement.

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Task shifting in the provision of home and social care in Ontario, Canada: implications for quality of care.

Growing healthcare costs have caused home-care providers to look for more efficient use of healthcare resources. Task shifting is suggested as a strategy to reduce the costs of delivering home-care services. Task shifting refers to the delegation or transfer of tasks from regulated healthcare professionals to home-care workers (HCWs). The purpose of this paper is to explore the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers. This qualitative study was completed in collaboration with a large home and community care organisation in Ontario, Canada, in 2010-2011. Using a purposive sampling strategy, semi-structured telephone interviews were conducted with 46 home healthcare workers including HCWs, home-care worker supervisors, nurses and therapists. Study participants reported that the most common skills transferred or delegated to HCWs were transfers, simple wound care, exercises, catheterisation, colostomies, compression stockings, G-tube feeding and continence care. A thematic analysis of the data revealed mixed opinions on the impacts of task shifting on the quality of care. HCWs and their supervisors, more often than nurses and therapists, felt that task shifting improved the quality of care through the provision of more consistent care; the development of trust-based relationships with clients; and because task shifting reduced the number of care providers entering the client's home. Nurses followed by therapists, as well as some supervisors and HCWs, expressed concerns that task shifting might compromise the quality of care because HCWs lacked the knowledge, training and education necessary for more complex tasks, and that scheduling problems might leave clients with inconsistent care once tasks are delegated or transferred. Policy implications for regulating bodies, employers, unions and educators are discussed.

Variation in Feeding Practices following the Norwood Procedure

To assess variation in feeding practice at hospital discharge after the Norwood procedure, factors associated with tube feeding, and associations among site, feeding mode, and growth before stage II. From May 2005 to July 2008, 555 subjects from 15 centers were enrolled in the Pediatric Heart Network Single Ventricle Reconstruction Trial; 432 survivors with feeding data at hospital discharge after the Norwood procedure were analyzed. Demographic and clinical variables were compared among 4 feeding modes: oral only (n = 140), oral/tube (n = 195), nasogastric tube (N-tube) only (n = 40), and gastrostomy tube (G-tube) only (n = 57). There was significant variation in feeding mode among sites (oral only 0%-81% and G-tube only 0%-56%, P < .01). After adjusting for site, multivariable modeling showed G-tube feeding at discharge was associated with longer hospitalization, and N-tube feeding was associated with greater number of discharge medications (R(2) = 0.65, P < .01). After adjusting for site, mean pre-stage II weight-for-age z-score was significantly higher in the oral-only group (-1.4) vs the N-tube-only (-2.2) and G-tube-only (-2.1) groups (P = .04 and .02, respectively). Feeding mode at hospital discharge after the Norwood procedure varied among sites. Prolonged hospitalization and greater number of medications at the time of discharge were associated with tube feeding. Infants exclusively fed orally had a higher weight-for-age z score pre-stage II than those fed exclusively by tube. Exploring strategies to prevent morbidities and promote oral feeding in this highest risk population is warranted.

Efficacy of permanent gastric electrical stimulation for the treatment of gastroparesis and functional dyspepsia in children and adolescents

PurposePermanent gastric electrical stimulation (GES) has been performed in adults as a treatment for gastroparesis and refractory nausea and vomiting in patients who have failed medical therapy. We assessed the feasibility and clinical outcomes of permanent GES in children. MethodsPermanent GES was performed in 16 children (10 females/6 males), median age 15years (range 4–19years). All patients had chronic nausea and vomiting refractory to medical therapy and met ROME III criteria for functional dyspepsia. Symptoms, route for nutrition, and satisfaction with procedure were recorded before and after permanent GES. Statistical analysis was performed using paired Student's t test. ResultsAfter permanent GES, there was significant improvement in severity of vomiting (p=0.0001), frequency of vomiting (p=0.0003), frequency of nausea (p<0.0001), and severity of nausea (p<0.0001). At the time of follow-up, 13/16 were on oral feeds exclusively, two patients on oral plus G-tube feedings, and one patient on oral plus G-tube plus intermittent TPN. Conclusions1). Permanent GES improved health in children with functional dyspepsia and gastroparesis who fail medical therapy. 2). No serious adverse effects of permanent GES were noted. 3). Long-term efficacy and safety of GES therapy in children need to be established.

Outcomes of surgical management of severe GERD in patients with cystic fibrosis

Patients with cystic fibrosis (CF) are at high risk for gastroesophageal reflux disease (GERD) and medical management of GERD improves pulmonary symptoms. Some patients with worsening CF and GERD symptoms undergo Nissen fundoplication, but the extent to which surgical management of GERD improves respiratory symptoms is not well studied. The purpose of this retrospective study was to evaluate the safety and efficacy of Nissen fundoplication in 48 patients with CF and uncontrolled GERD. Patients exhibited significantly fewer pulmonary exacerbations, increased weight gain and slower decline in % predicted FEV1 at 2 years after the surgery, compared to 2 years before surgery. Mean change in % predicted FEV1 in 2 years before surgery was--13.57% and mean change in % predicted FEV1 in 2 years after the surgery was +1.5% and difference was significant P = 0.001. Better pulmonary and nutritional outcomes were noted among patients with milder lung disease compared to those with severe lung disease, and among patients who received gastrostomy tube feedings for ≥6 months compared to those with no G-tube or tube feedings for <6 months. There was no mortality associated with surgery. In CF patients with worsening lung disease and uncontrolled GERD, Nissen fundoplication not only slows the decline in lung function but leads to significant improvement in weight, and decrease in CF exacerbations. Patients with milder disease and patients receiving G-tube feedings for ≥6 months after surgery benefited the most.

Sp807 Unusual Case of Esophageal Disruption Treated with Self-Expanding Metal Esophageal Stents

A 24-year-old quadriplegic (auto accident) male presented with dysphagia, odynophagia, neck pain, fevers and chills of 4 weeks duration. CT scan showed a cervical para-spinal abscess with a fistulous communication with the esophagus. Neck exploration with abscess drainage and cervical plate removal was performed. Despite two surgical attempts, a persistent defect was present on esophagram. Further surgical intervention was deemed impossible due to infection. Patient was stabilized with conservative management. Two months later, while on G-tube feedings, the patient was referred to GI for any possible intervention so as to allow peroral intake.

Body size in children with chronic kidney disease after gastrostomy tube feeding

Outcome body size of gastrostomy tube (g-tube)-fed children with chronic kidney disease (CKD) was investigated. CKD patients, stages 2-5, who had a g-tube inserted and removed between 1985 and 2007 were retrospectively reviewed (n=20) for anthropometrics, lab values, and steroid use from insertion to latest date. CKD patients never having had a g-tube placed (n=82) acted as the comparison population with similar data collection at start and end of the latest 5-year period. Body mass index (BMI)-for-age, weight (Wt)-for-age, and height (Ht)-for-age z scores were calculated and compared between groups. Median age at insertion and duration of g-tube treatment was 1.7 years (range 0.9-15.6), and 2.9 years (range 0.9-11.8), respectively. There was a significant increase in Wt- (p<0.01), and BMI-for-age (p<0.03) z score, but not for Ht-for-age between insertion and removal for subjects. There were no significant differences in Ht-, Wt-, or BMI-for-age z scores, from removal to 5 years post-removal. In the comparison population, there were no significant differences in Ht-, Wt-, or BMI-for-age z scores over the 5-year period. Approximately 36% of the non-tube-fed comparison population and 50% of the tube-fed subjects were overweight or obese at the most recent evaluation. In both subjects and the comparison group, overweight and obesity is associated with transplant status and steroid use. G-tube feeding is an effective method for achieving catch-up weight and moderate height gain in pediatric CKD patients, and does not apparently predispose patients to obesity after removal; however, overweight and obesity may pose problems to children with CKD whether or not they are tube fed.

The Right to Nutrition and Hydration: A Need for Vigilance

Recent public interest in legal cases related to the withdrawal of artificial nutrition and hydration at the end of life, such as the highly publicized Terri Schiavo case (Quill, 2005), have created a climate in which a potentially life-sustaining intervention, such as gastrostomy tube (G-tube) feeding, might be questioned as futile, and even cruel, when suggested for a person with a severe disability experiencing a health crisis. Lack of understanding exists among some in the health care community and among members of the general public (including some guardians and family members) concerning the distinction between managing medical challenges associated with a chronic disability and providing care at what might be mistakenly perceived to be the end of life (King, 2005). This can have potentially devastating consequences. As suggested by Pugh (2005), the distinction between living with a disability and a terminal illness may be become ‘‘blurred’’ (p. 35), and treatment routinely provided individuals with a disability, such as Gtube feeding, might be denied as futile. The result may be an otherwise preventable death (Turnbull, 2005a).

Prevalence and Risk Factors in Postoperative Pancreatitis After Spine Fusion in Patients With Cerebral Palsy

Postoperative pancreatitis is a recognized complication after spine fusion surgery in scoliosis management. There are established risk factors for the development of postoperative pancreatitis for patients with scoliosis in general, but no such factors have been established in patients with cerebral palsy (CP) who have scoliosis. The aim of this study was to assess the association between preoperative comorbidities and other parameters in the development of pancreatitis after spinal fusion surgery in a sample of children with CP. A retrospective cohort design was used to assess the association between postoperative pancreatitis and preoperative comorbidities and other covariates that might predispose to pancreatitis. The study participants included 355 patients, with a mean age of 13.8 years (range, 5.6-21 years) with CP, who received spine fusion with rod instrumentation. We used the chi statistic, mean, and SD to describe study variables that were categorical and continuous, respectively. To test the null hypothesis of no association between our outcome variable (postoperative pancreatitis) and comorbidities and other covariates as predictors, we used a binomial regression model. To simultaneously adjust for confounding effects in the relationship between our outcome and the independent or predictor variables, we used a multivariable binomial regression model. Of the 355 patients who underwent spine fusion, 109 developed postoperative pancreatitis (prevalence, 30.1%). Patients who developed pancreatitis had prolonged number of fasting days (until oral or G-tube feeding initiated; 7.9 vs 5.2 days) and longer hospital stay (23.1 vs 15.6 days). In the univariable binomial regression model, patients with CP who had gastroesophageal reflux disease (GERD) and feeding difficulty were more likely to develop pancreatitis than those without this condition (risk ratio [RR], 1.57; 95% confidence interval [CI], 1.10-2.28, respectively). Likewise, in this model, gastrointestinal tube and reactive airway disease (RAD) were statistically significantly associated with postoperative pancreatitis. Patients with CP who had gastrointestinal tube were 61% more likely to develop postoperative pancreatitis, whereas those with RAD were 54% (RR, 1.61; 95% CI, 1.01-2.55 and RR, 1.54; 95% CI, 1.13-2.10, respectively). However, there was a clinically relevant but nonstatistically significant association between seizure and postoperative pancreatitis (RR, 1.72; 95% CI, 0.96-3.06). After adjustment for the confounding variables in the multivariable model, GERD with feeding difficulties persisted as a single most significant and potent predictor of postoperative pancreatitis (adjusted RR, 1.52; 95% CI, 1.01-2.29). Consequently, patients with CP who had GERD were 52% more likely to develop postoperative pancreatitis. Likewise, there was a statistically significant 49% increase in the risk of postoperative pancreatitis in patients with CP who had RAD (adjusted RR, 1.49; 95% CI, 1.10-2.04). Pancreatitis is a major cause of morbidity after spinal fusion surgery in patients with CP. Patients with preoperative GERD with feeding difficulties and RAD had a higher risk of developing postoperative pancreatitis. Postoperative pancreatitis causes delays in feeding and increases the duration of hospitalization. Clinicians should be aware of the roles of GERD and RAD, as well as seizure and/or antiepileptics in the development of postoperative pancreatitis in patients with CP undergoing spinal fusion. Level III.

Long-term outcomes with concurrent carboplatin, paclitaxel, and radiation therapy in locally advanced, inoperable head and neck cancer

6032 Background: Our goal was to evaluate long-term outcomes of patients with squamous cell carcinoma of the head and neck (SCCHN) treated with carboplatin, paclitaxel, and radiotherapy. Methods: We conducted a phase II trial in inoperable patients with locally advanced SCCHN. Carboplatin 100 mg/m2 and paclitaxel 40 mg/m2 were administered intravenously once a week during external beam radiotherapy (once daily, 180 cGy/fraction) for 6–7 weeks. Interstitial brachytherapy was used as a boost in selected patients with primary malignancies of the oral cavity and the oropharynx. Results: 55 patients were enrolled. 52 patients (95%) had stage IV and 51 (93%) had technically unresectable disease; 62% had an oropharyngeal primary site. 21 patients underwent brachytherapy boost. Grade 3 or 4 mucositis occurred in 30% of patients. One death occurred during treatment; it was related to complications of gastrostomy tube (G-tube) placement. Forty of 50 evaluable patients (80%) had an objective response, with a complete response rate of 52%. With a median follow-up of 69 months years for surviving patients, the 5-year progression-free survival (PFS) was 36% and the 5-year overall survival (OS) was 35%. Two of the 18 long-term survivors of &gt;50 months were G-tube feeding dependent. Patients undergoing brachytherapy boost (n=21) had similar outcomes compared with the rest of the patients. In multivariate analysis, baseline hemoglobin levels and N stage were predictive of survival. Conclusion: Treatment with concurrent carboplatin, paclitaxel and radiation is safe and offers curative potential for poor prognosis patients with locally advanced SCCHN. No significant financial relationships to disclose.

Lateral esophagostomy: An alternative in the initial management of long gap esophageal atresia without fistula

The authors report an alternative method of cervical esophagostomy that was used in a child with type A esophageal atresia. This method involved performing a lateral esophagostomy in the proximal pouch, preserving its distal end, allowing the child to swallow normally, without choking, while stimulating the spontaneous growth of the proximal esophagus. As a result, the infant could be discharged home on G-tube feedings while waiting for spontaneous growth of the proximal pouch to occur. There were no episodes of aspiration during this period, and definitive reconstruction through end-to-end esophageal anastomosis was accomplished successfully at the age of 18 months. The authors consider that this alternative might increase the possibility of a definitive correction through delayed primary anastomosis of the infant's own esophagus in children with this type of malformation. J Pediatr Surg 35:1827-1829. Copyright © 2000 by W.B. Saunders Company.

Efficacy and safety of radiologically placed gastrostomy tubes in paediatric haematology/oncology patients

The treatment of malnutrition, which is of great concern in paediatric haematology/oncology patients, is fraught with problems. The goals of our study were to document the complications and assess the weight gain with gastrostomy tubes (G-tubes) in this population. Patient data were acquired by retrospective review of all haematology, oncology, and bone marrow transplant (BMT) patients (n = 44) who received radiologically placed G-tubes at our institution over a 4-year period. Forty-four G-tubes were placed (59% peri-BMT). At tube placement, 55% of patients were malnourished and 45% were nourished. Seventy-five percent of patients had the procedure without general anaesthetic. Localized G-tube-site infection was the most common complication (41%). Major complications occurred in 3 patients; 2 patients experienced localized peritonitis, and 1 patient developed a localized collection of pus in the abdominal wall. There were no G-tube-related deaths. At 1 month after the tube insertion, 39% of patients had gained, 54% maintained, and 7% lost weight. At 3 months, 69% had gained, 28% maintained, and 3% lost weight. There was a statistically significant weight gain from the time of the G-tube placement to both 1 month (P < 0.018) and 3 months (P < 0.0001) after G-tube placement. Patients in all diagnosis categories showed improvement from 1 to 3 months. We conclude that retrograde tube placement is safe and can frequently be done without general anaesthetic and that G-tube feeding effectively reverses malnutrition and prevents weight loss in this patient population.

A MODEL FOR THE INPATIENT TREATMENT OF CHILDREN WITH AVERSIVE FEEDING PROBLEMS IN A REGIONAL CARE FACILITY

105 A multidisciplinary approach has been successful in the treatment of children with feeding disorders at tertiary care centers. In this study, we demonstrate the efficacy of an inpatient program to treat children with severe aversive feeding problems in a regional care facility. Methods:(Table) Six subjects underwent treatment for aversive feeding disorder by a team of specialists. A pediatric gastroenterologist and rehabilitation specialist evaluated the child initially and established the diagnosis. A dietitian developed the dietary goals. A child life specialist designed the age appropriate behavioral modification program and assisted in its implementation with emphasis on carry over to the family. A speech therapist fed the child his first few meals and then supervised the caretaker feeding the child at subsequent meals. A social worker integrated the needs of the family with the feeding team. Four of six subjects were receiving caloric supplements prior to admission. Caloric supplements or G-tube feeds were not provided during their hospitalizations. Results: Subjects were hospitalized 2 to 5 days. Prior to discharge, dietary goals were met for each subject. At least one month after discharge, subjects were able to sustain their dietary goals and achieve adequate weight gain. Caloric supplements and G-tube feedings were not resumed in any subjects. Conclusion: Aversive feeding disorders can be managed successfully in a regional care facility utilizing a team of specialty trained individuals, and results appear to be sustainable.TABLE

Efficacy of Gastrostomy Feeding in Infants and Older Children Receiving Chronic Peritoneal Dialysis

To assess the efficacy of supplemental gastrostomy tube (g-tube) feeding in infants and children receiving chronic peritoneal dialysis (CPD). Retrospective observational study. Pediatric nephrology division of tertiary care center. Fifteen patients undergoing g-tube insertion while receiving CPD were included in the study, and were subdivided, on the basis of age, into the following groups: infants (< or = 2.5 years, n = 8); older children (> 2.5 years, n = 7). Assessment of the effect of CPD and g-tube feeding on statural growth assessed by height standard deviation score (SDS) and percentage weight-for-height, and measured anthropometric variables including triceps skinfold thickness (TSF), midarm muscle circumference (MAMC), and midarm mean circumference (MAC). Assessment of the effects of CPD and g-tube feeding on measured biochemical variables including total protein, albumin, cholesterol, triglycerides, and high density lipoprotein. No significant change in height SDS was observed; however, the reported continuing decline in height SDS in infants was arrested. Percentage weight-for-height increased significantly in infants at 6 months (p = 0.008) and 12 months (p = 0.006) following initiation of g-tube feeding. An increase was also observed in the older child group, being significant at 12 months (p = 0.031) following g-tube insertion. Increases in all anthropometric variables occurred in the infant group during CPD and post g-tube insertion, significant only for MAMC at 12 months (p = 0.037) post g-tube insertion. In older children little change occurred during CPD, with all variables increasing post g-tube insertion, significant only for MAMC at 6 months (p = 0.02) and 12 months (p = 0.02). An increase in total protein and albumin was noted; however, no significant changes in any biochemical parameters were observed. Supplemental g-tube feeding facilitates weight gain in infants and older children receiving CPD and arrests the decline in height SDS traditionally observed in infants with end-stage renal disease. No significant alteration was observed in measured biochemical variables, although an increase in total protein and albumin was noted.

Complications of gastrostomy feeding in children receiving peritoneal dialysis.

Gastrostomy tube (g-tube) feeding is recognized to improve the nutritional delivery to children with end-stage renal disease. A retrospective study was undertaken assessing the complications of g-tube feeding in children receiving peritoneal dialysis (PD). Twenty-three patients, mean age 3.8+/-3.2 years received PD and g-tube feeding for 758 patient-months, with 127 patients receiving PD for 1,969 patient-months used as controls. Peritonitis occurred every 18.4 patient-months in controls and 7.8 patient-months in those with a g-tube. Peritonitis occurred every 6.0 patient-months before and 8.1 patient-months after g-tube insertion in those undergoing g-tube insertion on PD. PD catheter exit site infection (PDESI) occurred every 18.7 patient-months in controls and 16.8 patient-months in those with a g-tube. PDESI occurred every 126 patient-months before and 16.2 patient-months following g-tube insertion. PD catheter replacement secondary to infection occurred every 109.4 patient-months in controls and 39.9 patient-months in those with a g-tube. It did not occur before g-tube insertion and occurred every 32.5 patient-months following insertion. Thirty-four episodes of g-tube exit site infection occurred, in 10 the same organism caused concurrent peritonitis. G-tube replacement occurred on 37 occasions. Hemodynamically significant gastrointestinal bleeding occurred in 3 patients, being terminal in 1. We conclude that, although not without risk, g-tube feeding in patients receiving PD is not contraindicated.

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) IN CHILDREN WITHOUT THE USE OF PROPHYLACTIC ANTIBIOTICS

68 PEG is being performed with increasing frequency in children. The placement of PEG is routinely preceded by the administration of I.V. antibiotics. Methods: A total of 29 children underwent PEG placement over a 3 year period without the use of IV antibiotics. 3 children were excluded because they were already on antibiotics for other illnesses. There were 15 males and 11 females, age 1 mo to 19.8 years (mean=7.02years) and weights 2.5 to 70kg (mean=20.75). All children had a CBC and barium upper GI series prior to PEG placement. The procedure was performed under general anesthesia. The two types of PEGs used were the pull type (Bard®) or the push type (Wilson-Cook®). 15 Fr PEG was placed in children ≤15kg and 20 Fr PEG for >15kg. G-tube feeding was started 6hrs after the procedure. All children were examined on the second day after the procedure for G-tube site infections (GTSI) and for feed tolerance. Children were discharged if there were no signs of GTSI and if they tolerated two feeds of Pedialyte and a third feed of a polymeric formula. Parents were advised on the care of the G-tube and G-tube site and were educated to watch for signs of GTSI and asked to call if there were any concerns. There was a follow-up examination within 5 days. Subsequent follow-up period ranged from 2 to 35 months (mean=18.3). Gastrostomy site infection was considered to be present if there was erythema and exudate, with or without tenderness. Treatment of infection was based on clinical signs. GTSI that occurred within 30 days of the procedure were considered early, and those occurring after 30 days as late. Data were collected retrospectively. Results: 6 children had GTSI. Of these, 4 had early infections, all occuring within 8 days of G-tube placement. 2 out of these 4 children were <4mo old. There were 2 late GTSI that occured two and three months post-op. Infections were treated with antibiotics. None had peritonitis or required G-tube removal. Conclusion: Infants less than 4 months may be at risk of early site infection at the G-tube site. In children older than 1 yr, 8.3% (2/24) had G-tube site infection. However, further prospective double blinded studies are required to see if prophylactic antibiotics are required for PEG placement.

Cisapride as a treatment for gastroparesis in traumatic brain injury

Gastroparesis is a well-documented finding among patients with severe traumatic brain injuries. The treatment of choice has been metoclopramide, but it is less than ideal given its central dopaminergic blocking activity. Cisapride is a newer prokinetic agent without side effects on the central nervous system and might be a superior treatment. The case of a healthy 22-year-old man who suffered a severe traumatic brain injury and multiple trauma in a motor vehicle accident is reported. The patient required gastrostomy tube placement but developed recurrent aspiration pneumonia once feedings were initiated. Despite receiving metoclopramide, barium studies revealed gastroparesis, a significant decrease in gastric peristalsis, and reflux. A jejunostomy tube was placed to prevent further aspiration. The administration of cisapride was begun, and 2 days later the patient was changed back to G-tube feedings with no evidence of residual aspirates. Repeat barium study showed definite improvement in peristalsis. This case demonstrates the potential usefulness of cisapride in patients with traumatic brain injury. Although further research is necessary, efficacy without central dopamine blockage may make cisapride the treatment of choice for gastroparesis and reflux in traumatic brain injury.