Nutrition Tube Research Articles

Tube Feeding and Advanced Progressive Dementia

Tube feeding is often presented as a nearly risk free and beneficial treatment for patients with dementia. But evidence shows that its benefits are illusory, while its risks are greater than many realize. Assisted oral feeding and good hospice care are better options. The syndrome of advanced, progressive, and irreversible dementia can be caused by a number of diseases associated with aging. Because Alzheimer disease is the most common cause of such dementia, however, it provides a useful point of focus for thinking about the problems of caring for persons with dementia. Approximately 60 percent of cases of dementia the American elderly are secondary to Alzheimer's,[1] and an estimated 47 percent of persons eighty-five years and older (the old-old) have probable Alzheimer's.[2] It is thought that between 637,600 and 922,500 nursing home residents have dementia; the number of residents with Alzheimer's lies somewhere between 382,500 and 553,500,[3] about half of whom are the advanced stage.[4] Most persons with Alzheimer's are likely to be institutionalized four to six years after symptom onset; they spend an average of three to four years the nursing home before death.[5] One of the pre-eminent problems caring for persons with dementia is deciding whether and how to provide food and water. It is unclear how many persons with advanced dementia are provided with artificial nutrition and hydration through long-term tube feeding, almost always the form of percutaneous endoscopic gastrostomy (PEG), but the practice is common. In 1991, 59,669 Medicare beneficiaries (who are sixty-five years of age and older) were hospitalized for PEG placement, many of whom were then discharged to skilled nursing facilities or to home care. This represents a steep rise from 1985 levels.[6] Of those who undergo PEG placement, how many have dementia is unknown, since this secondary diagnosis is not well reported relevant databases. Among Orthodox Jews, implementing tube feedings for a family member with progressive dementia is standard.[7] Influential spokespersons for Catholicism, however, do not conclude that a person with advanced dementia should be supported by tube feeding, so long as nothing is done to hasten death.[8] In some cases, patients with Alzheimer's will live long enough with PEG tube feeding that they progress to a persistent vegetative state.[9] Such troubling scenarios are peculiarly contemporary. Gastrostomy tube feeding became common the context of advanced dementia and elderly patients more generally after 1981, secondary to the development of the PEG procedure. Initially developed by Michael Gauderer and his colleagues at Rainbow Babies and Children's Hospital Cleveland for use young children with swallowing difficulties, PEG placement requires only local anesthesia, eliminating the significant surgical risks of general anesthesia and infection. Yet there is increasing concern about the proliferation of the procedure. In his recent review of the history of PEG use, for example, Gauderer has written that while PEG use has benefited countless patients, in part because of its simplicity and low complication rate, this minimally invasive procedure also lends itself to over-utilization, and he calls for more attention to the ethics of PEG use.[10] There seems to be no ethical question about PEG use patients who have some chance of recovering from an acute event, such as stroke, but for those dying of progressive dementia, the evidence is growing that PEG feeding provides no benefit.[11] The mounting literature was well summarized recently by Finucane and colleagues, who found no published evidence that PEG feeding prevents aspiration pneumonia, prolongs survival, reduces risks of pressure sores or infections, improves function, or provides palliation this population.[12] Also, older adults are apparently over-whelmingly opposed to PEG placement. In a recent study based on personal interviews with eighty-four cognitively normal men and women aged sixty-five years and older from a variety of urban and suburban settings (including private homes, assisted-living apartments, transitional care facilities, and nursing homes), three-fourths of the participants declared that they would not want cardiopulmonary resuscitation, use of a respirator, or parenteral or enteral tube nutrition with the milder forms of dementia, and a full 95 percent or more would not want any of these procedures with severe dementia. …

Nutritional supplements and tube feeds: what is available?

Gillian White presents information on a wide range of specialized nutritional feeding products that are now available on the market.

A staufen-like RNA-binding protein in translocation channels linking nurse cells to oocytes in Notonecta shows nucleotide-dependent attachment to microtubules.

In Drosophila melanogaster the staufen gene encodes an RNA-binding protein that is essential for the correct localization of certain nurse cell-derived transcripts in oocytes. Although the mechanism underlying mRNA localization is unknown, mRNA-staufen complexes have been shown to move in a microtubule-dependent manner, and it has been suggested that staufen associates with a motor protein which generates the movement. We have investigated this possibility using Notonecta glauca in which nurse cells also supply the oocytes with mRNA, but via greatly extended nutritive tubes comprised of large aggregates of parallel microtubules. Using a staufen peptide antibody and RNA probes we have identified a staufen-like protein, which specifically binds double-stranded RNA, in the nutritive tubes of Notonecta. We show that while the staufen-like protein does not co-purify with microtubules from ovaries using standard procedures it does so under conditions of motor-entrapment, specifically in the presence of AMP-PNP. We also show that the staufen-like protein is subsequently removed by ATP and GTP, but not ADP. Nucleotide-dependent binding to microtubules is typical of a motor-mediated interaction and the pattern of attachment and detachment of the staufen-like protein correlates with that of a kinesin protein within the ovaries. Our findings indicate that the staufen-like RNA-binding protein attaches to, and is transported along, Notonecta ovarian microtubules by a kinesin motor.

Older persons' opinions about life-sustaining procedures in the face of dementia.

To investigate the attitudes of cognitively normal older adults toward various life-sustaining procedures in the face of dementia. Participants were 84 cognitively normal men and women (70% response rate), 65 years and older, from a variety of urban and suburban settings, including private homes, assisted-living apartments, transitional care facilities, and nursing homes. In-person interviews were conducted with each participant to obtain information about demographic characteristics, life and health, and desire for various life-sustaining procedures for 4 hypothesized levels of dementia. Approximately three fourths of participants said they would not want cardiopulmonary resuscitation, use of a respirator, or parenteral or enteral tube nutrition with the milder forms of dementia, and 95% or more of participants would not want these procedures with severe dementia. In addition, only one third or fewer participants thought they would want to be hospitalized or given antibiotics if they were severely demented. Logistic regression analysis showed a relationship between participants' desire for life-sustaining procedures and having less education, greater independence, and a higher perceived quality of life. Most surveyed individuals did not desire life-sustaining treatments with any degree of dementia, and the proportion of individuals not desiring such treatments increased with the projected severity of dementia. These findings indicate a need for including dementia in advance directives planning.

Recent advances in the placement of tubes for enteral nutrition.

Enteral nutrition is the preferred route for nutritional support compared with parenteral nutrition if the gastrointestinal tract is functionally preserved. Long-standing nasogastric or nasoenteric feeding tubes are not well tolerated. Alternative routes are gastrostomy and jejunostomy. Percutaneous endoscopic gastrostomy/jejunostomy or those guided by fluoroscopy, sonography or tomography should be the first choices. Laparoscopy or laparotomy gastrostomy/jejunostomy routes should be reserved for specific situations. Insufflation of the stomach with air or saline solution facilitates the placement of nasoenteric feeding tubes or percutaneous sonographic-guided gastrostomy. The gastrostomy button is a safe and aesthetic alternative, at least in children. Comparison between percutaneous endoscopic gastrostomy and surgical gastrostomy performed either via laparotomy or laparoscopy favours the first in terms of costs and risks. Whenever associated intra-abdominal procedures or anatomic difficulties arise, a laparoscopic or an open access becomes necessary. Complications with feeding tubes are not uncommon and should be promptly recognized and treated.

Poly(A) mRNA is attached to insect ovarian microtubules in vivo in a nucleotide-sensitive manner

In ovarioles of hemipteran insects, RNA passes from anteriorly positioned nurse cells to the chain of developing oocytes via extended nutritive tubes. These intercellular connections may reach several millimeters in length. Each nutritive tube is comprised of many thousands of parallel microtubules. We have extracted microtubule bundles from isolated nutritive tubes of Notonecta glauca and, using hybridization techniques, provide evidence of poly(A) mRNA attachment to microtubules in vivo. We also show this attachment to be nucleotide-sensitive, which is typical of a motor protein-mediated interaction. The pattern of nucleotide sensistivity is indicative of a kinesin motor mechanism. We provide evidence that a kinesin is present in the nutritive tube translocation channels and is a component of the mRNA/microtubule bundles isolated and extracted from them. Our findings are consistent with kinesin-driven transport of mRNA along the nutritive tube microtubules.

Pediatric experience with intradialytic parenteral nutrition and supplemental tube feeding.

Good nutrition is necessary to maximize the potential for growth and development in the pediatric age-group, but children, like adults with chronic renal failure and end-stage renal disease, may be anorectic and eat poorly. Infants and adolescents are at special risk because of the intense demands of growth during the first 2 years of life and again during puberty. Neurodevelopment is also adversely affected by poor nutrition, especially in infants. Approximately two-thirds of pediatric dialysis patients are treated with chronic peritoneal dialysis, which results in significant protein losses in the dialysis effluent that can contribute to protein-calorie malnutrition. Meeting the nutritional needs of pediatric patients usually requires supplemental sources, such as intradialytic parenteral nutrition (IDPN) or tube feeding. Little is known about the effectiveness or desirability of IDPN in pediatric patients. More studies, especially of amino acid-based dialysis fluids for chronic peritoneal dialysis, need to be done before making IDPN a standard for pediatrics. Supplemental nasogastric or gastrostomy tube feedings have been very successful in maintaining and improving growth in infants, but no studies are available to evaluate their success in older children and adolescents. Recombinant growth hormone therapy, in addition to good nutrition and control of other growth factors such as acidosis, renal osteodystrophy, and chronic volume depletion, may be necessary for most growth-retarded children with chronic renal failure to achieve normal adult height.

Nutritional supplements and tube feeds: what is available?

A wide range of specialized nutritional feeding products are now available. One condition for which nutritional feeding products are commonly prescribed is disease-related malnutrition. Nutritional support for poorly nourished clients consists of more than simply prescribing a specialized product. Key nutrition messages need to be applied to individual situations to promote optimal nutritional intake. However, in many situations clients are unable to meet their nutritional requirements by food alone and nutritional supplement products are then extremely useful. The nutritional status of all those receiving nutritional support should be monitored regularly; as the client’s nutritional status improves, his/her intake of these products may need to be reduced or stopped. If clients are unable to maintain or improve their nutritional status despite the use of nutritional supplements, additional help from an alternative feeding product may be required.

Pollination in Arabidopsis Thaliana

Abstract In flowering plants, pollination and the process of fertilization are complex processes involving a series of cell-to-cell communication events. Though details of the progression of the pollen tube through the pistil, beginning with germination of the pollen grain on the stigma and culminating with delivery of the sperm cells to the embryo sac, are well established for several higher plant species, the mechanisms involved have yet to be elucidated. It has been shown that the transmitting tissue, which coincides with the path of pollen tubes in the gynoecium, is composed of highly secretory cells characterized by an extensive extracellular matrix (ECM). The actual roles that this ECM plays in pollination are currently unknown, although functions proposed include mechanical and/or chemotropic pollen tube guidance as well as pollen tube nutrition.

Percutaneous sonographic gastrostomy: method, indications, and problems

Objectives: This study evaluated the application of ultrasound (US) guidance in the percutaneous placement of gastric feeding tubes in patients in whom endoscopic placement of a nutrition tube is not possible. Methods: Thirty-eight patients with upper gastrointestinal obstruction were entered in a prospective study with US-guided nutrition tube application. Feasibility of placement, side effects, and nutritional states were monitored for a mean follow-up of 4 months. Results: Ultrasound allowed rapid puncture after filling of the stomach with water through a nasal tube in 34/38 cases. In four cases a total upper gastrointestinal obstruction required an initial stomach insufflation through a direct puncture. Puncture-related major complications were not observed. Minor complications during the observation time were one late dislocation, five cases with broken material after about 6 months (four could be changed by using the Seldinger technique), and two minor local infections. The nutrition through feeding tubes stabilized body weight and body composition parameters. Conclusion: The percutaneous sonographic gastrostomy (PSG) is a safe and minimally invasive procedure for enteral nutrition in all cases with upper gastrointestinal obstruction when endoscopic placement of a feeding tube is not possible. Percutaneous sonographic gastrostomy may help to stabilize the nutritional parameters and general condition in patients with malignant diseases.

Percutaneous sonographic gastrostomy: method, indications, and problems.

This study evaluated the application of ultrasound (US) guidance in the percutaneous placement of gastric feeding tubes in patients in whom endoscopic placement of a nutrition tube is not possible. Thirty-eight patients with upper gastrointestinal obstruction were entered in a prospective study with US-guided nutrition tube application. Feasibility of placement, side effects, and nutritional states were monitored for a mean follow-up of 4 months. Ultrasound allowed rapid puncture after filling of the stomach with water through a nasal tube in 34/38 cases. In four cases a total upper gastrointestinal obstruction required an initial stomach insufflation through a direct puncture. Puncture-related major complications were not observed. Minor complications during the observation time were one late dislocation, five cases with broken material after about 6 months (four could be changed by using the Seldinger technique), and two minor local infections. The nutrition through feeding tubes stabilized body weight and body composition parameters. The percutaneous sonographic gastrostomy (PSG) is a safe and minimally invasive procedure for enteral nutrition in all cases with upper gastrointestinal obstruction when endoscopic placement of a feeding tube is not possible. Percutaneous sonographic gastrostomy may help to stabilize the nutritional parameters and general condition in patients with malignant diseases.

Nutritional supplements and tube feeds: what is available?

A wide range of specialized nutritional feeding products are now available. One condition for which nutritional feeding products are commonly prescribed is disease-related malnutrition. Nutritional support for poorly nourished clients consists of more than simply prescribing a specialized product. Key nutrition messages need to be applied to individual situations to promote optimal nutritional intake. However, in many situations clients are unable to meet their nutritional requirements by food alone and nutritional supplement products are then extremely useful. The nutritional status of all those receiving nutritional support should be monitored regularly; as the client's nutritional status improves, his/her intake of these products may need to be reduced or stopped. If clients are unable to maintain or improve their nutritional status despite the use of nutritional supplements, additional help from an alternative feeding product may be required.

Phosphorylation of microtubule-associated proteins from the ovaries of hemipteran insects by MPF and MAP kinase: possible roles in the regulation of microtubules during oogenesis.

Nutritive tubes that link the developing oocytes to the nurse cells in ovarioles of hemipteran insects contain extensive arrays of microtubules. These are established, then later depolymerised, by developmentally regulated processes. Breakdown of the microtubules corresponds with the activation of M-phase promoting factor (MPF) and mitogen-activated protein kinase (MAP kinase), later in oogenesis, as the oocytes proceed to arrest at the first meiotic metaphase [Lane and Stebbings, Roux's Arch Dev Biol 205:150-159 (1995)]. The mechanisms that lead to the breakdown of nutritive tube microtubules are unknown. Here, we have investigated the possibility that the insect ovarian microtubules are regulated by MPF- or MAP kinase-dependent phosphorylation, focusing upon the prominent high molecular weight microtubule-associated protein (HMW MAP) enriched in this system, which is a potential target for protein kinase activity in vivo. We have purified the prominent HMW MAPs from the ovaries of two species of hemipterans, and have shown them to be substrates in vitro for the activities of MPF and MAP kinase. However, although the catalytic component of MPF (p34cdc2) is present within microtubule-rich portions of hemipteran ovarioles, we have found that neither this protein nor its regulatory partner (cyclin B) co-purify with microtubules during taxol-mediated microtubule isolation.

老年入院患者における血清コレステロールおよびその他の脂質の著減

In this study 112 elderly inpatients (55 men, 57 women) were recruited. 1. Twelve elderly inpatients (5 men, 7 women) aged 82.5 +/- 7.4 years (M +/- SD) were investigated during 3 periods of dietary intake: good intake (period I), tube nutrition (period II) and fasting with intravenous fluid infusion (period III). Calorie, protein, carbohydrate, fat and cholesterol intakes were greater in period I than in periods II and III. Serum total and LDL cholesterols were lowest in period III, when serum HDL cholesterol, triglyceride and total protein were lower in period III than in period I. 2. One hundred elderly inpatients (50 men, 50 women) were divided into 4 groups according to type of decreased serum lipid and a control group. Serum total cholesterol only was decreased in group I, both serum total and HDL cholesterols were decreased in group II, both serum total cholesterol and triglyceride were decreased in group III, all 3 lipids were decreased in group IV and lipid levels did not change in the control group. There were 5 patients in group I, 28 patients in group II, 20 patients in group III, 27 patients in group IV and 20 patients in the control group. The patient's age ranged from 80.3 to 88.4 years and body mass index ranged from 14.7 to 18.4 kg/m2. Serum total protein decreased significantly in groups II-IV, to 5.6 to 5.7 g/dl. Serum total protein, and total cholesterol correlated positively (r = 0.525, p < 0.01), as did Calorie ingestion and serum total cholesterol levels (r = 0.554, p < 0.001). Therefore, severe hypocholesterolemia was accompanied by malnutrition and a decrease in Calorie or cholesterol intake. Serum total cholesterol levels during observation decreased most in group IV, followed by group II similar to serum HDL cholesterol levels. The amount of nutrient intake was smallest in group IV resulting in an extreme lowering of all 3 serum lipid levels.

Direct evidence for the nature of the binding of mitochondria to microtubules in ovarian nutritive tubes of an hemipteran insect.

Interactions between mitochondria and microtubules have been investigated in the nutritive tubes that link the nurse cells to the oocytes in ovarioles of the hemipteran insect, Notonecta. The nutritive tubes comprise large numbers of microtubules, which can be dissected manually from ovarioles. This approach, which retains the intrinsic components of the system, has allowed the in vivo interactions between the microtubules and mitochondria, which are also present in the nutritive tubes, to be studied directly. Static binding occurred between mitochondria and microtubules, and investigations of its nucleotide and salt-sensitivities have indicated its microtubule-associated protein (MAP)-dependency.

Subcutaneously implanted enteral nutrition port.

Patients who have undergone esophagectomy with extensive lymph node dissection under thoracolapalotomy for advanced esophageal carcinomas frequently need long-term nutrition support because of their inadequate oral intake. We have used tube enterostomy feeding for these patients not only immediately after the operations but also at home to prevent the development of malnutrition. Patients who receive long-term tube enterostomy feeding often suffer from skin problems around the enteral nutrition catheters. Once the catheter is removed, the patient with anticipated malnutrition is subsequently unable to receive beneficial enteral nutrition. We have developed a new enteral access system that is placed subcutaneously. This subcutaneously implanted enteral nutrition port makes possible intermittent and long-term enteral nutrition support not only for the postoperative period but also for home care. This system consists of the port (Infuse-a-Port, SMAP15 Snaplock Macro-Port Venous Access System; Strato Medical Co) and the enteral nutrition tube (Enteral Tube 8F, 75 cm; Zeon Co). This system was applied to seven patients who had undergone esophagectomy. The port was placed on the lower chest subcutaneously, and the catheter was placed through the gastric tube and duodenum up to the jejunum. After the operation, a 20-gauge port needle was placed, and enteral nutrition formula (Enterued; Termo Co) was started with the enteral nutrition pump. No complications (eg, infection of skin, obstruction of tube) were observed from the postoperative period through the home care stage. The observation period for this implanted system ranged from 2 to 12 months. The patients were able to avoid the malnutrition anticipated after the extensive operations and continued to receive nutrition support safely and effectively at home. This new nutrition support system is safe and efficient for patients who anticipate long-term enteral nutrition support. A subcutaneously implanted enteral nutrition port makes possible intermittent and long-term nutrition support without patient discomfort and inconvenience.

Long-term total parenteral nutrition and cholecystostomy tube in a rabbit model surgical procedure: management and preliminary results.

A rabbit model for long-term total parenteral nutrition (TPN), specially provided with cholecystostomy tube, was designed to investigate further aspects of TPN-associated cholestasis (TPN-AC). Modified surgical procedures concerning vascular access, cholecystostomy tube implantation and authors' original modalities for prolonged infusion management in the rabbit were used. Continuous TPN was performed in 30 young rabbits. Five animals died during the experiment (16.6%) and were excluded from final evaluation. Twenty-five rabbits were successfully maintained on continuous TPN for 28 days without restraint, having a cholecystostomy tube implanted 1 week after initiation of TPN. The collection of blood samples and daily parenteral administration of drugs were simply accomplished via a central venous catheter. At the same time the cholecystostomy tube enabled us to perform daily bile sampling. Saline irrigation of the biliary tree could be carried out in conscious animals maintained on TPN. A 4-week duration of TPN in this rabbit model made it possible for the first time to accomplish serial liver biopsies in order to verify the evolution of histologic changes in TPN-related hepatic dysfunction and possible effects of surgical and medical treatment. A preliminary analysis of operative findings and histology was carried out. An enlarged gallbladder containing hyperviscous bile was found in 80% of the animals 1 week after initiation of TPN. At this time it was possible to observe the first histologic changes consistent with TPN-associated hepatic disease, such as moderate to severe hepatocyte degeneration and portal inflammation. Biliary sludge was seen after 3 weeks of TPN in 70% of the rabbits, as well as a subsequent progression of TPN-associated histologic findings. Portal fibrosis and fatty liver degeneration occurred in 50% of the rabbits and bile duct proliferation in all animals. After 4 weeks of TPN (at autopsy) gallstones were found in 20% of TPN animals, as well as further progression of bile duct proliferation and fibrosis. Our first experiences with this model and preliminary results suggest that this concept offers new possibilities for further elucidation of TPN-associated hepatic dysfunction.

At Law: Still Troubled: In re Martin

After many years of discussion and debate, decisions on life-sustaining treatment for incompetent patients continue to pose profound ethical and policy questions. A controversial Michigan Supreme Court decision issued last August highlights four major unresolved issues. First, how specific must a patient's prior remarks be to provide and convincing of the individual's preferences on a current treatment question? Second, should competent persons be granted full control over their future care as incompetent patients? Third, in what situations does an objective benefit-burden analysis permit treatment to be withheld or withdrawn? And fourth, whose wishes should take priority when close family members disagree about life-sustaining measures for an incompetent relative? In re Martin[1] presents all these issues. In Martin, the Michigan Supreme Court by a vote of six to one refused to authorize removal of an incompetent patient's gastrostomy tube. In February, the U.S. Supreme Court declined to review the decision. The patient, Michael Martin, suffered serious and permanent brain damage in a car accident. Though severely paralyzed and on a gastrostomy tube for nutrition, has no progressive terminal illness and retains some awareness of his environment. At the trial, witnesses gave differing accounts of his cognitive capacities. Although all agreed the patient could no longer make his own medical decisions, one expert testified lacked capacity for any meaningful interaction. Another claimed the patient could engage in limited voluntary movement, could recognize faces, respond emotionally, and communicate with others with head nods. According to this physician, when asked if experienced pain or suffering or did not want to continue living, the patient signaled no. Other testimony, both lay and professional, placed Mr. Martin's abilities somewhere in between. Most believed was able to respond appropriately to commands and to answer simple yes or no questions. His responses were sometimes inconsistent, however, and at times was unresponsive to external stimuli. Besides the patient's current capacities, court proceedings focused on his prior statements as a competent individual. His wife, who was also his legal guardian, initiated the request to withdraw the gastrostomy tube. According to Mary Martin, her husband had frequently and emphatically asserted that would not want to live if became incompetent and dependent on people and machines. According to her, he was always bothered by, and intolerant of, people who were disabled and on others. Other witnesses reported conversations in which Mr. Martin said would not want to be maintained in an unconscious state. What Qualifies as Clear and Convincing Evidence? Many courts have ruled that life-sustaining treatment may be forgone if an incompetent patient's previous statements provide clear and convincing evidence of a competent desire to refuse such treatment. Courts have disparate views on what kinds of statements satisfy this evidentiary standard, however. Some courts have accepted relatively general statements; others have demanded that the patient's prior refusal expressly encompass his or her current condition, current treatment intervention, or both. In Martin, the Michigan Supreme Court adopted the latter approach. Although a hospital ethics committee and two lower courts found and convincing that this patient sought to refuse treatment in his current circumstances, the higher court disagreed. The supreme court noted that most of the witnesses referred to Mr. Martin's prior remarks on coma or unconsciousness, which was not his current condition. The judges also were unpersuaded by Mrs. Martin's account of numerous conversations in which her husband asserted that life would be unacceptable if became on other people and machines to perform basic functions such as eating and dressing. …

Reorganisation of microtubule arrays in the telotrophic ovaries of hemipteran insects: Correlation with meiotic reinitiation.

We have shown that, in the ovaries of hemipteran insects, microtubule reorganisation and depolymerisation in the oocytes, and in the nutritive tubes supplying them, correlate with the activation of M-phase promoting factor (MPF) and mitogen-activated protein kinase (MAP kinase) as the oocytes proceed to arrest at the first meiotic metaphase. The application, however, of Xenopus egg extracts with high MPF activities to isolated nutritive tube microtubules failed to result in their depolymerisation, suggesting that a novel factor may be required for the breakdown of these highly stable microtubule arrays in vivo.

Enteral nutritional support by gastrostomy tube in children with cancer

We examined the use of gastrostomy tubes in malnourished children with cancer as part of our ongoing efforts to improve their supportive care. Patients were examined on the basis of percentage of weight loss and percentage of desirable body weight. Twenty-five patients underwent gastrostomy tube placement followed by aggressive enteral nutritional support. Gastrostomy tubes were placed at a mean of 3.5 months (range, 0.3 to 8 months) after diagnosis; mean weight loss had been 10.1% (range, to 21%) of desirable body weight. There were no immediate postoperative complications. Gastrostomy tube feedings were well tolerated by all patients. All children gained or maintained weight, and 60% of the severely malnourished children returned to a desirable body weight after an average of 4.9 months (range, 1 to 13 months). Weight gain averaged 12.9% (range, to 45.4%) of desirable body weight. The most common complications were 38 episodes of inflammation at the gastrostomy tube site during periods of severe neutropenia, which were treated successfully with topically or orally administered antibiotics, and 13 episodes of cellulitis, which required intravenously administered antibiotics. The infection rate was 1.58 episodes per 1000 days of use compared with a rate of 5.0 per 1000 days previously reported with total parenteral nutrition. The monthly costs of gastrostomy tube nutrition support were 9% of those associated with use of total parenteral nutrition. Gastrostomy tube use in children with cancer is a safe, effective, and cost-effective method of reversing malnutrition. Further investigation with larger numbers of patients is warranted. (J P EDIATR 1995;127:58-62)