1. health and fitness
2. nutrition

Caring for your child
with a feeding tube…
Contents
Introduction
The digestive tract
What is tube feeding?
Why your child needs a feeding tube
Types of gastrostomy tubes
What formula will you feed your child?
Preparing the formula
Storing the formula
Types of feeding methods
Checking tube position
Flushing the feeding tube
Clearing a blocked gastrostomy tube
Feeding your child
Venting the stomach
Giving medication through the feeding tube
Measuring for gastric residual
What is aspiration?
Stoma care
Tube care
Testing for balloon inflation
Replacing the gastrostomy tube
Cleaning the feeding equipment
Your child’s daily activities
Before your child goes home
Buying formula and feeding equipment
Your child’s feeding plan
Your child’s feeding schedule
Information to remember
Troubleshooting
Skin-level feeding tubes
Helpful Resources
Glossary
Notes
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Introduction
This booklet is for families of children with feeding tubes. Your child may need a feeding
tube because of a medical condition that makes him/her:
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Unable to eat enough to grow
Unable to chew or swallow food
Unable to digest regular food
Unable to swallow medicine
At risk for choking or aspiration
Sometimes tube feeding is only a temporary measure that is intended to give your child
extra nutrition if he or she cannot eat enough. In some cases, the feeding tube is
permanent.
Tube feeding provides your child with the nutrients to maintain their health. No one
knows your child as well as you do. You play an important role in your child’s tube
feeding. This booklet is yours and serves as a guide to teach you, step by step, how to
provide tube feeding for your child.
This booklet helps you understand your child’s care. You may find some words that are
new to you. The definitions in the Glossary tell you what they mean.
There is space for you to write notes and questions on page 39.
The digestive tract
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The digestive tract begins at the mouth where food is chewed and broken down. When
swallowed, the food passes down the esophagus and enters the stomach. The acids
and enzymes in the stomach break down the food. The food matter then enters the
bowel.
The bowel, also known as intestine, is a tube-like structure that is divided into two main
parts: small bowel and large bowel. The small bowel absorbs the vitamins and minerals
necessary for good nutrition. The small bowel has 3 parts: duodenum, jejunum and
ileum.
The large bowel removes water and salts that the body needs from the waste. Muscles
in the colon contract and relax to propel the stool along the length of the bowel. The
rectum stores the waste (stool) until the rectum is full. The muscles at the anus relax to
allow for the elimination of stool. This is referred to as a bowel movement.
What is tube feeding?
Tube feeding is the delivery of liquid nutrients, also known as formula, through a narrow
tube into the digestive tract. Feeding tubes are soft, have rounded tips on one end and
have one or two ports on the opposite end that are used to connect to the feeding
system. There may be a bumper that will hold the tube in place at the level of the
abdomen.
There are different types of feeding tubes, depending on where the tube enters the body
and the part of the digestive tract where the formula is delivered. The doctor will discuss
with you what type of feeding tube your child will have. Often the choice of feeding tube
depends on your child’s anatomy and medical condition.
The most common types of feeding tubes are:

Gastrostomy (G-tube) - from an opening in the abdominal wall and directly into
the stomach
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Gastro-jejunostomy (GJ-tube) – from an opening in the abdominal wall and into
the stomach, then into the jejunum. GJ-tubes are placed when there is a high
risk of aspiration or when gastrostomy feedings are not tolerated
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Why your child needs tube feedings
Good nutrition maintains health, growth and development. Tube feeding is a way to give
fluid, calories and medications to your child. Many children receive tube feedings for
various medical conditions that may include:
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Prematurity
Cerebral palsy
Burns
Birth defects
Cystic fibrosis
Head trauma
Inherited metabolic disorders
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Diseases of the digestive tract
Gastroesophageal reflux
Failure to thrive
Severe food allergy
Cleft lip/palate
Cancer
Eating disorders
Types of gastrostomy tubes
There are several types of feeding tubes. The most common type is the gastrostomy
tube. Your child’s doctor will recommend the best type for your child and discuss this
with you. Depending on the type of procedure for the insertion of the tube, there are
three types of gastrostomy tubes:
The percutaneous endoscopic gastrostomy (PEG) tube has a shaped end and a
cross-piece called a “bumper” to hold the tube in the stomach. This tube is often used
as the first placement tube to establish the tract between the stomach and abdominal
wall. The tract generally takes 6 weeks to heal, although the time may vary.
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PEG gastrostomy tube
The balloon-type gastrostomy tube has a balloon at the end of the tube that is inflated
with water to hold the tube in the stomach. There may also be a skin stitch to hold the
tube in place. This tube is often used as a replacement tube and is often inserted once
the tract is healed.
Stomach
Balloon-type gastrostomy tube
The PEG tube and balloon-type gastrostomy tubes are inserted by a surgeon. The
procedure is carried out in the operating room. Your child is given a general anesthetic
so that he/she is asleep. After the operation, your child goes to the recovery room for
close monitoring. Your child then returns to the pediatric unit.
The coiled-end gastrostomy tube is a thin straight tube with a coil at the end. The coil
keeps the tube in the stomach. There is a skin stitch to secure the tube after it is
inserted. The nurse cuts away this stitch after 10 days.
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Coiled-end gastrostomy tube
The coiled-end gastrostomy tube is inserted by a doctor in the Interventional Radiology
department. Prior to the procedure, your child is given sedation so that he/she will not
feel pain. A small tube is inserted through the nose and into the stomach. This tube
allows the doctor to put air into the stomach. The gastrostomy tube is then inserted into
the stomach. The air in the stomach will pass through the tube.
After the procedure, your child will go to a step-down unit for close monitoring. Your
child then returns to the pediatric unit.
What formula do you feed your child?
There are many types of formula products available. The dietician will recommend the
best type of formula for your child. Your dietitian will also give you a feeding plan that
tells you:
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What formula to feed your child
When to feed your child
How much formula to feed your child
Your child’s feeding plan and schedule are on pages 25 and 26.
Preparing the formula
Most formulas come in cans and are ready-to-use. Some formulas, such as powdered
or liquid concentrate, need to be mixed.
For ready-to-use formula:
1. Check the expiry date on the formula. Do not use formula that is past its
expiry date.
2. Wash your hands with soap and warm water
3. Shake the can well.
4. Rinse the top of the can and the can opener with hot water.
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5. Dry the top of the can with a clean cloth and open the can.
For mixed formula:
1. Check the expiry date on the formula. Do not use formula that is past its
expiry date.
2. Wash your hands with soap and warm water
3. Make sure all the equipment that you use is clean.
4. Mix the formula. The dietitian will tell you how.
Storing the formula
Ready-to-use formula that is unopened can be stored in a cool dry place at room
temperature. Once opened, the can must be covered, dated and stored in the
refrigerator. Discard any unused formula after 48 hours.
Powdered formula that is unopened should be stored in a cool dry place at room
temperature. Once opened, the container of powdered formula should be covered and
stored in a dry place for up to one month. Any unused powdered formula that has been
mixed must be covered, dated and stored in the refrigerator. Discard any unused mixed
formula after 24 hours unless otherwise instructed.
Liquid concentrate that is unopened should be stored in a cool dry place at room
temperature. Once opened, the liquid concentrate should be covered, dated and stored
in the refrigerator for up to 24 hours. Discard any formula after 24 hours.
Types of feeding methods
Tube feedings usually begin with frequent small amounts of formula. Children have
small stomachs but develop the capacity to hold larger feedings in their stomachs as
they grow. The dietitian talks to you about your child’s feeding needs and tells you
which way is best to feed your child. The dietitian also helps you develop a feeding plan
for your child. This plan is checked regularly and often changes as your child grows.
There are 3 different ways to feed your child through the gastrostomy tube:
1. Continuous feeding is given at a constant, steady rate over 24 hours. The
formula is fed into the stomach with a feeding pump to control the steady rate of
the feeding. When the feeding tube is first put in, it is common to start with
continuous feeding to help the body get used to the formula. A feeding into the
jejunum is always given as a continuous feeding since the small bowel is not able
to hold a large amount of formula.
2. Intermittent feeding is given at specific times over the day. The formula is fed
into the stomach with a feeding pump or by way of gravity feeding every 4 to 6
hours. This allows the stomach to empty between feedings. The feedings are
small and take only 30 to 60 minutes to give.
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3. Bolus feeding is given over 10 to 30 minutes, much like a normal pattern of
eating and digestion. The formula is fed into the stomach by syringe or gravity
feeding 2 to 6 times per day. Some children may have difficulty tolerating bolus
feedings. Bolus feeding should only be given when instructed by the dietitian or
doctor.
Checking tube position
Before beginning any feeding or giving medication, you must check that the feeding tube
is in the correct position. This must also be done after the replacement of a tube.
Follow these steps:
1. Attach a 30 ml syringe to the end of the tube. Pull gently on the plunger until you
can see some stomach content in the syringe. The content appears similar to
the most recent feeding or other gastric contents such as saliva or water. This
tells you that the end of the tube is in the stomach.
2. Push the stomach contents back into the stomach.
3. Flush the tube with 30 ml of water.
4. Remove the syringe and insert plug.
Note: Do not feed through the feeding tube if there is any question that the tube may
not be inside the stomach.
Flushing the feeding tube
It is important to clear the feeding tube by flushing water through it. The dietitian tells
you how much water to give to meet your child’s fluid needs. Use any drinkable water to
flush your child’s tube. If your child is less than 6 months old, use sterile water. The
water should be at room temperature. Do not use excessive force to flush the tube.
When to flush the feeding tube:
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Before and after each feeding for intermittent or bolus feeding
After measuring for gastric residual
Every 4 to 6 hours during continuous feeding, according to your child’s feeding
schedule
Before and after each medication given through the tube
Twice a day if the feeding tube is not used
Steps to flush the feeding tube for continuous feedings:
1.
2.
3.
4.
5.
6.
Close the clamp and disconnect the tubing from the feeding tube.
Draw the water into a 30 – 60 ml catheter tip syringe.
Attach the syringe to the feeding port of the tube.
Flush the water through the tube into the stomach. This clears the tube.
Reconnect the tubing to the feeding tube.
Open the clamp to restart the feeding.
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Steps to flush the feeding tube for bolus/intermittent feedings:
1.
2.
3.
4.
5.
Before the feeding, draw the water into a 30-60 ml catheter tip syringe.
Attach the syringe to the feeding port of the tube.
Flush the water through the tube into the stomach. This clears the tube.
Connect the tubing to the feeding tube and start the feeding.
Flush with water after the feeding is complete.
Clearing a blocked gastrostomy tube
The feeding tube can become blocked when:
 The tube is not flushed before and after feedings
 The tube is not flushed after measuring for gastric residuals
 The formula or medications are too thick
 The pill fragments are too large
 The formula becomes contaminated
If the feeding tube is blocked above the level of the skin, you can massage or milk the
tube between your fingers to help clear it. Never try to clear the blockage by
inserting objects into the tube. If the tube remains blocked, follow these steps:
1. Attach an empty 60 ml syringe to the feeding port of the gastrostomy tube.
2. Gently pull back the syringe plunger.
3. If the tube does not clear, remove the syringe and gently push in 10 ml of warm
water. Use sterile water if the child is less than 6 months old. Note: Avoid using
acidic juices or carbonated drinks to flush the feeding tube as these may
combine with the proteins in the formula and cause further clogging.
4. Gently pull the plunger to draw the water back into the syringe. Repeat several
times. Note: Excessive force may cause the tube to rupture.
5. If this does not work, try to instill a solution of 2 ml (½ tsp.) baking soda and 15
ml (1 Tbsp.) of water into the feeding tube. Clamp tube for 15 minutes. Massage
the tube between your fingers to get the solution as close as possible to the
blocked area. Try the push-pull technique again.
6. If the tube will not clear after two attempts, it will need to be changed. See
section Replacing the gastrostomy tube.
Feeding your child
Usually you start to feed your child through the feeding tube 24 to 48 hours after the tube
has been inserted. The doctor will tell you when you may start feeding your child. At
first, your child will receive frequent feedings with small amounts of formula. When your
child tolerates this well, your child can follow the feeding schedule that the dietitian gives
you.
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Feeding your child through a feeding tube may be new to you. The nurse and dietitian
teach you how and what to feed your child and care for the equipment. You will be able
to practice feeding your child and cleaning the equipment before your child leaves the
hospital. You may wish to have another family member or friend with you to learn these
activities.
Adjusting to tube feeding takes time. If you feel uncertain about any part of your child’s
care, talk to a member of the health care team. Tube feeding is easy to learn and will
become more familiar to you with practice. In a short time, you will be able to tube feed
your child with ease and confidence.
There are two methods of feeding your child: gravity feeding and pump infusion feeding.
The dietitian tells you which method is best for your child. The method often depends on
the type of feeding your child needs.
Gravity feeding
Gravity feeding is usually employed for bolus feedings since this method allows a larger
amount of formula to be given in a shorter period of time, The equipment required for the
gravity method is a 60-ml syringe and a feeding bag (or container). The formula is
poured into the syringe or feeding bag and held up approximately 61 cm (2 feet) above
the level of the feeding tube. The feeding is given over 10 to 30 minutes. It may also be
pushed in with the syringe, if tolerated. Bolus feedings are given 2 to 6 times per day, as
directed by the dietitian.
Gravity feeding equipment
Pump infusion feeding
The pump infusion method is the best way to provide continuous or intermittent
feedings since the pump evenly controls the flow of formula over a longer period of time.
The formula is poured into a feeding bag (or container) that is attached to tubing. This
tubing is then threaded in the pump’s roller mechanism. The settings of the pump can
be adjusted to provide the prescribed flow rate and volume. The pumps have a number
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of alarms to alert you when there are problems with the feeding. The nursing staff will
show you how to set up the pump.
Pump infusion feeding equipment
Positioning
Place your child’s head higher than his body, at a 30 to 45 degree angle during and for 1
hour after feeding. Always hold and cuddle your baby during feedings. An older child
can sit in a high chair, car seat or other comfortable chair and be with the rest of the
family at the meal table. Your child should not lie flat during the feeding or for 60
minutes after the tube feeding is finished.
If your child goes to bed after the feeding, place him or her on the right side. This
position uses gravity to help the formula follow the digestive tract. The head of the bed
should also be raised by placing pillows under the mattress.
Setting up the feeding
1. Gather clean supplies and equipment.
2. Wash your hands well with soap and water.
3. Check the expiry date on the formula. Do not use formula that is past its
expiry date.
4. Shake the formula before using.
5. Wash the top of the can with soap and water. Dry with a clean cloth before
opening with a clean can opener.
6. Take out any refrigerated formula ½ hour before using. This helps prevent
cramps. Never heat formula.
7. In order to reduce bacterial growth, do not allow the formula to hang any longer
than recommended in the feeding plan. Do not add a new supply of formula
to old formula in the feeding bag.
Note: All formula should be examined carefully for thickening, lumps or
separation. Ready-to-use formula may be hung for 8 hours whereas mixed
formula can only be hung for 2 to 4 hours.
Giving bolus feedings:
1. If using a feeding bag, close the roller clamp and fill the feeding bag with
formula. Remove the air from the tubing by opening the roller clamp and allowing
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2. If using a syringe, draw up the formula by pulling gently on the plunger of the
syringe. Hold the syringe upright and push the plunger to allow the formula to
reach the tip. This removes the air from the syringe.
3. Remove the plug from the end of the gastrostomy tube.
4. Check the tube position and flush the gastrostomy tube with water.
5. Attach the feeding bag or syringe to the end of the gastrostomy tube.
6. Open the roller clamp or slowly push on the barrel of the syringe until the
prescribed volume of formula is delivered over the recommended time.
7. Disconnect the feeding system. Flush the feeding tube with water and replace
the plug.
Giving intermittent and continuous feedings:
1. Close the roller clamp and fill the feeding bag with formula.
2. Remove the air from of the tubing by opening the roller clamp and allowing the
formula to flow to the tip of the tubing. This is called “priming” the tubing. Close
the roller clamp. Note: Some pumps may prime the tubing automatically.
3. Remove the plug from the end of the gastrostomy tube.
4. Check the tube position and flush the gastrostomy tube with water.
5. Attach the feeding bag to the gastrostomy tube.
6. If using a feeding pump, thread the tubing through the roller mechanism. Open
the roller clamp and set the pump to deliver the prescribed volume of formula
over the recommended time. Start the pump.
7. Disconnect the feeding system when the feeding is complete if your child is on
intermittent feedings. Flush the feeding tube and replace the plug.
8. Flush the feeding tube every 4 to 8 hours if your child is on continuous
feedings, according to your child’s feeding schedule.
Venting the stomach
Gas may build up in your child’s stomach. Signs of gas in the stomach are crying, or
restlessness after feeding. Your child may also act colicky and vomit or burp up formula.
If your child is very small and is being fed intermittently, he or she may need to be
burped. Burping may not be necessary when using the continuous feeding method.
You can also let gas pass out of the stomach through the gastrostomy tube. This is
called venting. Your child’s doctor may recommend that you vent the tube before or
after each feeding.
Steps to vent the stomach:
1. Take the plunger out of a 60 ml syringe.
2. Remove the plug at the end of the feeding tube and attach the syringe.
3. Hold the syringe up higher than the level of the stomach. This prevents stomach
contents from leaking out of the tube.
4. Allow the gastrostomy tube to vent for 5 to 20 minutes. If your child is able to
cough, this will hasten the venting. You will hear air pass out of the stomach
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5. Flush the tube with water and replace the plug.
Giving medication through the feeding tube
Most medications have been formulated to be taken by mouth. If your child is able to
take medications by mouth, it is better to use this route.
However, if your child is unable to take medications by mouth, the feeding tube can be
used. It is preferable if the medication is available in the liquid form to avoid blocking the
feeding tube. If liquid medication is not available, consult the pharmacist. Pills or tablets
may be crushed into a fine powder and dissolved in 10 to 15 ml of warm water. Do not
crush enteric-coated or timed-release tablets or capsules since particles of pills that do
not dissolve may cause blockage of the feeding tube. Crushing timed-release pills can
also result in an overdose of medication.
Do not add medications to the formula unless you are instructed to do so by your child’s
doctor or pharmacist. Also, give the medication at the appropriate time in relation to the
feeding. Some medications should be given with the feeding, while some should be
given on an empty stomach. Check with the pharmacist to find out if the feeding must
be held for a prescribed time interval before and after the medication is given. For
proper action, some medications must be delivered to the stomach. If your child has a
GJ-tube, check with the pharmacist.
Do not mix medications, especially with antacids or vitamins containing iron, calcium or
magnesium. Give each medication separately with water flushed between each
medication. To give more than one medication, put each medication into a separate
syringe. Dilute thick liquid medications with 5 to 10 ml of water to make it easier to give.
Steps to give medication through the feeding tube:
1. Wash your hands with soap and warm water.
2. Draw the medication into a clean syringe.
3. Draw 60 ml of tap water into another syringe. Use sterile water if the infant is
under 6 months old. Use this to flush the tube after you give the medication.
4. Remove the plug from the end of the feeding tube. Check tube position.
5. Attach the syringe with water to the feeding tube and instill 30 ml of water.
6. Attach the syringe with the medication and instill the medication.
7. Flush 5 ml of water through the feeding tube between each medication. Do not
mix medications together.
8. Give the tube a final flush with 30 ml of water so that the medication does not
block the tube.
9. Replace the plug at the end of the feeding tube.
Note: The amount of water used for flushes add up quickly if your child is taking several
medications. This is important to discuss with the dietitian if your child is a small baby or
has fluid restrictions.
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Measuring for gastric residual
The gastrlc residual is the amount of formula left in the stomach hours after a feeding
has been given. Measuring the gastric residual may tell you if your child is tolerating the
formula. Measure your child’s gastric residual when your child’s dietitian or doctor tells
you to and whenever:
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The formula backs up into the feeding tube.
Your child feels nauseated.
Your child’s abdomen is bloated.
Note: Gastric residuals cannot be measured when your child has a GJ-tube (gastrojejunostomy) feeding tube.
Steps to check gastric residual for continuous feedings:
1. Stop the feeding.
2. Draw 3 to 5 ml of air into a 60 ml syringe. Attach the syringe to the end of the
feeding tube. Inject the air into the gastrostomy tube until you hear a bubbling
sound. This clears the fluid in the tube.
3. Gently draw back on the plunger. This pulls the fluid out of the stomach. Keep
pulling the plunger until no more fluid comes out of the stomach. Stop pulling the
plunger if it is hard to pull or if nothing comes out of the stomach. This means
that the gastrostomy tube is against the stomach wall. Note: You may not
obtain any residual if the stomach is empty.
4. Measure the amount of residual fluid.
5. Push the residual fluid back into the stomach. This fluid has important nutrients
that your child needs. Do not push back any air that may have come out with the
residual fluid. Follow with a flush of 30 ml of water.
6. Continue with the feeding if the residual volume is less than 2 times the hourly
volume.
7. Hold the next feeding if the residual volume is more than 2 times the hourly
volume. For example, hold the feeding if your child’s feeding rate is 50 ml per
hour and the residual volume is more than 100 ml. Wait 1 hour and repeat steps
4, 5, 6 and 7.
Steps to check gastric residual for bolus and intermittent feedings:
1. Check gastric residual before scheduled feeds.
2. Attach a 60 ml syringe to the feeding port of the gastrostomy tube.
3. Pull the plunger back gently. This pulls the fluid out of the stomach. Keep pulling
the plunger until no more fluid comes out of the stomach. Stop pulling the
plunger if it is hard to pull or if nothing comes out of the stomach. This means
that the gastrostomy tube is against the stomach wall.
4. Measure the amount of residual fluid.
5. Push the residual fluid back into the stomach. The residual fluid has important
nutrients that your child needs. Do not push back any air that may have come
out with the residual fluid. Follow with a flush of 30 ml of water.
6. Go ahead with the next feeding if the residual volume is less than half the
amount of formula that you fed your child during the last feeding.
7. Hold the next feeding if the amount is more than half the amount of formula that
you fed your child during the last feeding. For example, hold the feeding if your
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The amount of residual depends on such things as the amount and timing of the last
feeding or dose of medication. Your child’s activity and positioning may also influence
how quickly the feeding leaves the stomach. The residual fluid may be clear, indicating
the presence of gastric juices or it may contain partially digested formula.
Note: If the gastric residual is high for two or more consecutive measurements
and your child feels unusually full or sick to the stomach, call your child’s doctor.
What is aspiration?
Aspiration occurs when formula or stomach contents have accidentally entered the wind
pipe and/or lungs. It can result in breathing problems and infection.
Signs of aspiration include:
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Coughing and/or choking during the feeding
A change in the sound of breathing to difficult, noisy or rapid, shallow breathing
Wet, gurgling voice
Pale or bluish lips
Aspiration can be prevented by making sure that your child is sitting upright or lying with
the head of the bed raised 30 to 45 degrees during each feed and for 30 to 60 minutes
after the feeding is finished.
If you think that aspiration has occurred:
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Stop the feeding right away
Put your baby in a lying position with the head and neck in a neutral position or
ensure that your child is sitting upright and that the airway is clear.
If your child’s breathing does not improve after taking these steps, call an
ambulance (911) right away.
Stoma care
Special care must be given daily to the site where the feeding tube exits the abdomen.
This site is called the stoma. Some of the most common problems with feeding tubes
are related to the stoma.
Kingston General Hospital has an Enterostomal Therapy nurse (ET nurse) who helps
you learn about your child’s stoma and tube care.
After the feeding tube is inserted, there may be a small amount of bleeding. A small
gauze dressing covers the stoma. The next day, the dressing is removed for stoma
care.
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A small amount of pale discharge is normal. It is therefore important to keep the stoma
and the surrounding skin clean and dry. Wash your hands with soap and water before
caring for your child’s stoma. Care to the stoma can also be done when you are bathing
your child. Wait one week after the insertion of the tube before you bathe your child in
the tub.
Follow these steps daily:
1. Gently lift the bumper, if present, and wash the stoma and surrounding skin using
a soft washcloth with mild soap and water, moving from the tube outward.
2. Use a soft cotton swab, if needed, to clean under the bumper and around the
base of the tube. This area may be tender until it has healed completely.
3. Rinse well and gently pat dry. There is no need for any cream or dressing unless
directed by your nurse or doctor. Leaving the stoma open to air is the best way
to keep it healthy.
Check the stoma and skin area for any redness, tenderness, swelling, drainage or
irritation. A small amount of yellow discharge is normal. The stoma area may
sometimes become reddened, firm and tender. Thick, cream-colored drainage may be
noted. Report this to your child’s doctor as these are signs of infection.
Note: Beefy red, moist tissue may grow at the stoma site. This may bleed easily and
cause skin irritation. Report this to your child’s doctor for treatment.
Tube care
It is important to keep the feeding tube clean. Cleaning the feeding tube daily removes
skin oils, lint, adhesive residue and build-up of formula on the tube surface.
Wash your hands with soap and water before caring for the tube. The easiest time to
clean the gastrostomy tube is when you are bathing your child.
Follow these steps daily:
1. Using a soft washcloth, wash the full length of the tube with mild soap and water.
Gently lift the bumper or base of the tube, if present, from the stoma and use a
soft swab to clean the skin area. Clean all the ports of the tube with a swab to
clear all formula that can dry inside the valve and stem openings.
2. Rotate the tube and bumper 360º plus a quarter turn while cleaning to free the
tube from the skin. Note: Do not rotate GJ-tubes.
3. If the bumper is leaving any marks on the skin, it needs to be loosened. Wet the
tube with water and ease the bumper 1/8 inch (2 mm) away from the abdomen.
This is close to the thickness of a dime.
4. Rinse and pat dry. Make sure the skin is dry before putting on clothes. Do not
allow a tight waistband or belt to be placed over the tube site.
5. Check the placement of the tube by gently pulling on the tube until it is snug
against the stomach wall. Avoid using too much force since this can damage the
stomach wall.
6. Measure the exterior length of the tube from the exit site on the abdomen to the
end of the tube with a measuring tape. Make sure that the length is the same
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Testing for balloon inflation
Balloon-type gastrostomy tubes often last several months. Over time, the balloon may
rupture or develop a leak. It is necessary to check that the balloon is fully inflated to
ensure that the tube is in the correct position. Follow these steps weekly:
1. Attach an empty 10 ml syringe to the balloon port.
2. Withdraw the water in the balloon. Check the volume of water in the syringe. If
there is less than 5 ml of water, the balloon may be leaking or was not properly
inflated. Discard the water.
3. Draw 5 ml of fresh water in the syringe and refill the balloon.
4. Withdraw the water again. If the volume is 5 ml, there is no leak. Re-inflate the
balloon and repeat the test for balloon inflation in one week. If the volume is less
than 5 ml, the balloon is leaking. See section Replacing the gastrostomy tube.
Note: It is important to inflate the balloon with water. Saline can form crystals that can
clog the balloon valve. Air tends to seep out and cause the balloon to deflate. Be sure to
use the recommended amount of water. Over-inflation can block the lumen and underinflation will cause the tube to leak.
Replacing the gastrostomy tube
All feeding tubes have a limited life span. Tube breakdown may be due to: normal wear
and tear, type of formula, medications, infection, tube abuse, and stomach acids. The
water in a balloon-type gastrostomy tube may sometimes leak out, causing the formula
to leak out from the stoma or causing the tube to slip out. The tube can also sometimes
be pulled out accidentally. The tube needs to be replaced as soon as possible since the
stomal opening begins to tighten and close over within 2 to 4 hours, making it difficult to
replace the gastrostomy tube.
Keep an emergency kit of supplies on hand at all times in the event that the tube has to
be replaced. The kit should have the following:
 A balloon-type tube
 Tape measure
 10 ml and 60 ml syringes
 Tape
 Water-based lubricant
 Plug
 Washcloth
 Emergency phone numbers
 Small cup for clean tap water
Note: If the child has recently had a G-tube (gastrostomy tube) inserted (within 6
weeks) or has a GJ-tube (gastro-jejunostomy tube), do not attempt to replace the
tube. The tract between the stomach and the abdominal wall may not be completely
healed. Instead, place a clean cloth or gauze pad over the stoma. Phone your doctor or
go to the nearest Emergency Department. Remember to bring the emergency kit with
you.
17
If you are replacing a balloon-type gastrostomy tube that has fallen out but is still
functional, it may be reinserted. Prior to reinsertion, wash the tube with soap and water,
rinse and dry. Follow the steps for Testing for balloon inflation. If the balloon is intact,
remove the water from the balloon and follow the following steps:
1. Wash hands well.
2. Draw 5 ml of water into the syringe
3. Check the balloon outside of the body by instilling 5 ml of water from the
syringe. Make sure that there are no leaks in the balloon.
4. Deflate the balloon, leaving the water in the syringe.
5. Apply a small amount of water-soluble lubricant to the tip of the tube.
Note: Do not use oil or petroleum jelly as these will damage the tube.
6. Insert the tube about 2 inches (5 cm) into the stoma. Inflate the balloon
with the 5 ml of water in the syringe.
7. Remove the empty syringe from the balloon port and gently pull the tube
so that it is snug against the stomach wall.
8. Attach the 60 ml syringe to the end of the tube. Pull gently on the plunger
until you can see some stomach contents in the syringe. This tells you
that the tube is in the stomach. Push the stomach contents back into the
stomach. Flush with 30 ml water. Remove the syringe. Measure and
record the exterior length of the tube.
9. Clean the skin and secure the tube with tape.
10. Check the tube position.
Inserting a new tube may be stressful because your child may be upset and may cry.
There may also be a small amount of bleeding. If you are unable to withdraw any
stomach contents, wait for 30 minutes and try again. Do not use the tube if you are
not sure that the tube is in the stomach. If you are unable to insert the tube, place a
clean cloth or gauze pad over the stoma. Phone your doctor or go to the nearest
Emergency Department. Remember to bring the emergency kit with you.
Note: When the spare tube is used, make sure that you buy another one to
replace it.
Cleaning the feeding equipment
It is important to keep the feeding equipment clean. Each piece of equipment can be
reused may times. Discard the feeding equipment every 3 days or sooner if residue
remains in the feeding container or drip chamber. If the feeding bag has an odor, is
cloudy or has a different colour, replace it with a new one.
After each feeding:
1. Rinse all equipment thoroughly with clean, cool water. No trace of formula
should remain.
2. Fill the equipment with warm water and a few drops of liquid dish soap. Let them
soak for a few minutes.
3. Connect the tubing pieces to a syringe and push soapy water through them to
clean the inside.
4. Use a bottlebrush to clean the inside of the feeding bag/bottle and syringe.
5. Rinse the equipment with the hottest water you can handle.
18
6. Hang or set on a clean towel to dry.
At the end of the day:
1. Clean the equipment as you would after each feeding.
2. After rinsing, soak the equipment in a solution of equal parts white vinegar and
water. Allow to soak for 5 minutes.
3. Rinse with clean water and allow to dry.
4. Wrap and store the feeding equipment in a clean towel or hang in a clean dry
place. Do not allow the end of the tubing to come in contact with the sink or the
floor.
Note: Do not use any household cleaners or bleach to clean the equipment.
Your child’s daily activities
Once the stoma has healed, your child can resume normal activities.
Eating by mouth
Your child may be able to eat by mouth if his/her medical condition and swallowing
ability allows it. The doctor discusses this with you. If allowed to eat, there is no
problem with eating while the tube is in place. It gives your child an opportunity to touch
and taste food.
The need to suck is present despite the fact that your child may not be able to eat or
drink by mouth. In order for your child to associate oral gratification with a full stomach,
encourage your child to suck on a pacifier or fingers as the feeding is administered.
Oral care
Your child’s mouth needs care at least twice a day even if your child is not eating. For
babies, use a wet baby washcloth to gently wipe lips, gums and tongue. Use a soft baby
toothbrush to clean your child’s first teeth. To help make saliva flow and keep the mouth
clean and moist, a pacifier may be used. For toddlers, use a soft toothbrush and
toothpaste to clean teeth. Use dilute mouthwash or a mild salt solution as needed to
freshen the mouth and breath. If the mouth and lips are dry, moisten lips with a wet
cloth. Petroleum jelly can be used on the lips to keep them soft and prevent cracking.
Bathing
Your child may have a tub bath one week after the insertion of the feeding tube. This is
a good time to care for the skin and tube. Make sure that the skin is dried well before
putting on clothing.
Clothing
No special clothes are required when your child has a feeding tube. One-piece outfits
with front buttons or snaps give you easy access to the tube. Overalls and shirts that
snap between the legs will help to protect the tube. Avoid clothing with a tight waistband
or belt that could pull on the tube. Children are naturally curious. Mittens or socks on
19
their hands may help prevent the infant from pulling on the tube. Wearing an undershirt
keeps the tube from being visible. Skin-level feeding tubes also decrease the incidence
of accidental removal.
Activities
A feeding tube does not change your child’s growth and development needs. It is
important for babies to roll over onto their tummies. It helps them learn to raise their
heads and push up onto their hands and knees to crawl. If your child seems uneasy in
the tummy position, tape a gauze pad over the tube site. Tuck the feeding tube inside
clothing to prevent accidental removal.
Swimming is allowed after the tube site has healed and is healthy. Swimming in a
properly treated swimming pool, where no pets are allowed, is safe. Swimming is
normally safe in the ocean, whereas lakes and ponds are not a good choice. Hot tubs
and public swimming pools may be hazardous because of the level of bacteria in warmer
water.
Your child may participate in sport activities once the stoma is no longer tender. Taking
part in aggressive sports should be discussed with your doctor. If there is a blow to the
abdomen, there may be some pain, but it is not usually an emergency. If the pain
persists, or if there is any bleeding or bruising around the stoma, contact your doctor.
Your child may be fed while doing homework, watching TV or doing any other quiet
activity.
Travel
Traveling with your child requires careful planning. It is important to store the formula
correctly so that it will not spoil. It is better to use bottled water if the safety of the water
is in doubt. It is important to have the child’s emergency kit available at all times.
If you are traveling to a distant destination, it is wise to discuss this with the doctor. Ask
your doctor to write a letter explaining your child’s need for feeding supplies and
medications. Have a plan of action in the event of an emergency. Know where the
nearest medical centre or community hospital is located.
If you are travelling by airplane, find out the airline’s policy regarding transportation of
formula and medical equipment.
Prepare a list of supplies well in advance to avoid overlooking any items at departure
time. Pack extra supplies in case of loss or damage. For more information, see Helpful
Resources.
Social
All children need to feel loved and secure. You may hold, cuddle and comfort your child.
Your baby may have a pacifier during feedings to stimulate the lips, gums and tongue.
Allow your child to chew or suck on appropriate toys that will give him/her a sense of
different shapes, surfaces and texture.
An older child may be able to help with the tube feeding or even carry it out
independently.
20
Try to make tube feeding a routine part of family life by feeding your child during family
mealtime. Allowing your child to sit at the table for meals allows time to socialize with
family and friends while they are eating. It allows your child to feel just like everyone
else.
Ask about portable equipment that would allow your child to move about freely. Treat
your child as normally as possible. Try not to interrupt family trips and vacations
because of the tube feeding.
Before your child goes home
A Community Care Case Manager visits you while your child is in the hospital to:



Talk to you about your child’s home care needs
Arrange for a nurse to help you with your child’s feeds and care for the
equipment
Arrange for a dietitian to adjust your child’s feeding schedule as needed
The Ontario government pays for Community Care. It is a service for Ontario residents
who have a valid Ontario Health Insurance number.
Your child will receive an appointment for follow-up with the surgeon 4 to 6 weeks after
hospital discharge. Your child may then be referred to the Nutrition Support Clinic for
long-term follow-up by a team of healthcare professionals that includes a pediatrician, an
ET nurse and a dietitian.
Buying formula and feeding equipment
The dietitian talks to you about where to buy the formula before you take your child
home from the hospital. Most drug stores can order the formula that you need. Call
your drug store at least 2 business days before you leave the hospital. The doctor will
write out a prescription for the formula. Take the prescription to the drug store in order
to pick up the formula.
The cost of formula may be covered under the Ontario Drug Benefit (ODB) program if
the formula is the only source of nutrition and has been prescribed by a physician. The
doctor will complete a Nutrition Products ODB form for your child.
The ET nurse provides you with a list of vendors that sell equipment and supplies in your
area. You may purchase from any supplier you choose. You are encouraged to shop
around as prices may vary.
There is funding available from the Ministry of Health and Long Term Care (MHLTC) to
cover the cost of feeding bags and container, feeding tubes and accessories if the
following criteria is met:

child is a resident of Ontario
21
 child has a valid Ontario Health Insurance number
 child requires enteral feeds for 6 months or more
The Assistive Devices Program (ADP) provides a yearly grant of $1,500.00. If your child
is a recipient of the Ontario Disability Support Program (ODSP), Ontario Works (OW) or
Assistance to Children with Severe Disabilities Program (ACSD), the yearly grant is
$2,000.00. The total grant amount is sent in four equal installments, four times a year.
The money may be sent directly to you as a cheque or may be deposited directly into
your bank account. As a client of the ADP program, you may be subjected to audit. You
must retain the original receipts or all your enteral feeding supplies for a minimum of two
years after the purchase date. ADP covers the cost of a feeding pump only for children
who are on continuous feeding for 6 or more hours per day. Your child’s doctor will
complete an Application for Funding Enteral Feeding Pump and Supplies form. It is
your responsibility to keep all your contact information with ADP current and up to date.
Failure to notify ADP of a change of address may result in a missed payment and in
cancellation of the grant until the contact information is updated. For more information,
contact the ADP office:
Ministry of Health and Long-Term Care
Assistive Devices Program
5700 Yonge Street, 7th Floor
Toronto, ON
M2M 4K5
Toll-free 1-800-268-6021
TDD (for deaf people) 1-800-387-5559
www.health.gov.on.ca
If you have private medical insurance, contact your agent. Many private insurance
plans will reimburse you for costs that exceed the ADP grant.
Vendors of feeding supplies and equipment include:
Medigas
125 Church St. South
Belleville, ON
K8N 5E8
Ph: (613) 969-4450
Medigas
2B-460 Gardiners Rd.
Kingston, ON
K7M 7W8
Ph: (613) 546-5529
Medigas
14-333 California Ave.
Brockville, ON
K6V 5Y6
Ph: (613) 498-3057
Motion Specialties
2293 Princess St.
Kingston, ON
K7M 3G1
Ph: (613) 384-0400
Medigas
1 Strathy Rd.
Cobourg, ON
K9A 5J6
Ph: (905) 373-4303
22
Your child’s feeding plan
The dietitian works with you to develop a feeding plan that is best for your child. The
feeding plan is guided by your child’s weight and height. The feeding plan is reviewed
regularly in order to determine what type of formula and how much formula your child
needs
Date: ________________________________________________________________
Height: ___________________________
Weight:
_______________________
Type of feeding:
____________________________________________________
Formula name:
____________________________________________________
Number of cans of formula per day: _________________________________________
Pleasure feeds:
____________________________________________________
Your child’s formula can hang for a maximum of ______ hours. You may need to
shorten the time in hot and humid weather.
Estimated nutritional requirements:
Calories per day:
____________________________________________________
Grams of protein per day:
Total fluid per day:
_______________________________________________
____________________________________________________
Tube feeding provides:
Calories per day:
____________________________________________________
Grams of protein per day:
_______________________________________________
Fluid per day: _________________ from feeds, ______________from water flushes
Your child’s feeding schedule
□
Continuous feeding




Pour _____ ml of formula into feeding bag every _____ hours.
Set feeding pump rate at _____ ml per hour.
Flush feeding tube with _____ ml water every _____ hours.
Add _____ ml water to feeding container, if prescribed.
23
□
Intermittent feeding




□
Pour _____ ml of formula into feeding bag for each feeding.
Set feeding pump rate at _____ ml for _____ hours.
Flush feeding tube with _____ ml water after each feeding.
Schedule for feeding times: ______, _____, _____, _____, _____, _____.
Bolus feeding




Pour _____ ml of formula into feeding bag or draw up formula into syringe.
Adjust rate of flow by opening or closing clamp or by pushing on plunger of
syringe to give the feeding over _____ minutes.
Flush feeding tube with _____ ml water after each feeding.
Schedule for feeding times: _____, _____, _____, _____, _____, _____, _____.
Information to remember
Surgeon:
________________________ Phone:
_______________________
Dietitian:
________________________ Phone:
_______________________
Enterostomal Therapy Nurse: _______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Phone:
Community Care Case Manager:
(613) 549-6666 Ext. 2828
_________________________________________
Phone: _________________________________________
Hotel Dieu Hospital Children’s Outpatient Centre:
Phone: _______________________
Pharmacy:
___________________________ Phone: _______________________
Supplier:
__________________________ Phone:
Type of tube: __________________________ Fr. size:
_______________________
_______________________
Date of tube insertion:____________________________________________________
Exterior length:
____________________________________________________
Tube replacements:
Date
_____________________________
_____________________________
Type/size of tube
___________________________________
___________________________________
24
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Troubleshooting
What can happen?
Aspiration
-accidentally taking in
formula into the windpipe
and/or lungs
-signs: coughing or choking
during the feeding, noisy or
rapid, shallow breathing,
wet, gurgling voice, pale or
bluish lips
Why does it happen?

Often caused by
vomiting
What you should do:
See section What is
aspiration?
Vent the stomach.
Ensure your child’s head is
30 to 45 degrees higher
than the body or is sitting
up during and for 1 hour
after feeding.
Do not allow your child to
lie flat during a feeding.
Check the gastric residual
as directed by the dietitian.
Never try to give a feeding
if your child feels full or sick
to the stomach or is
vomiting.
Bleeding from the stoma

The tissue is fragile
and bleeds easily
Pinpoint bleeding from the
stoma is normal, especially
with tube changes.
Call your doctor if there is a
large amount of bleeding or
if there is blood mixed with
the stomach contents.
Bloating
-stomach fullness causing
abdominal pain or


Feeding is given too
quickly
Child is swallowing
Follow the feeding
guidelines for the type of
formula, rate and schedule.
25
discomfort
-child may be restless and
cry
-child may vomit or burp
Vent the stomach before
feeding.

Child may be
constipated
Decrease the feeding rate.
Stop the feeding for 1 to 2
hours. Restart the feeding
at a slower rater. Continue
to slowly increase the rate
as long as the child remains
comfortable.
Blocked feeding tube
-clogged tube can occur
with any kind of feeding
tube, though less common
with a skin-level feeding
device








Clamp is closed
Tube not flushed as
directed
Tube not flushed
after measurement
of gastric residual
Medicine mixing
with formula
Formula
contamination
Thick formula or
liquid medication
Improper pill
crushing
Backup of gastric
content into tube
causes curdling with
formula
Ensure the clamp is open.
If the blockage is above the
stoma, massage the tube
between your fingers.
Flush tube after each
medication and after
measuring for gastric
residual.
Use liquid medication or
very finely crushed tablets
dissolved in warm water.
Give only one medication at
a time and flush with 5 ml of
water after each
medication.
Dilute formula or liquid
medication with water.
Measure for gastric
residuals only when
required.
Do not mix anything with
the formula without
checking with your doctor
and/or pharmacist.
Do not allow the feeding
bags to run dry.
Follow steps in “Clearing a
blocked feeding tube”.
If unable to clear the
blocked tube, see steps for
26
“Replacing the feeding
tube”.
Constipation
-fewer than normal bowel
movements where the stool
may be hard and painful to
pass




low water intake
low fibre intake
low activity level
changes in formula,
medication or
routine
Talk with the dietitian who
may suggest::
 increase water
intake
 a fibre-containing
formula
 as much exercise
and activity as
possible
If child is bloated and has
no stool for 3-4 days, call
the doctor.
Cramping



Dehydration
-the body needs more
water as seen with thirst,
weakness, dry mouth/ lips
and decrease in urine

Formula is too cold
Feeding given too
quickly
Intolerance to
formula
Bring formula to room
temperature.
May be the result of
vomiting, diarrhea,
fever, not receiving
enough water
especially in hot
weather
Watch for thirst, dry lips
and mouth, dry and warm
skin, weakness, irritability,
small amounts of dark
urine.
Reduce feeding rate.
Contact the dietitian.
Give the prescribed
amount of formula and
water.
Contact the doctor if
vomiting, diarrhea or fever
persists.
Diarrhea
-frequent, loose, watery
bowel movements






Feeding is given too
quickly
Type of formula is
not tolerated
Tube is in wrong
place
Spoiled formula
Equipment not
cleaned
Changes in formula,
medications or
Check the tube position.
Formula that enters the
small bowel rather than the
stomach may cause
diarrhea.
Check for signs of
dehydration.
Ensure opened cans of
formula are covered and
kept in the fridge.
27
Give feeding more slowly.
Throw out any unused
formula after 24 hours.
Keep feeding sets clean.
If the child has diarrhea for
3 days, blood in the stool,
or is unwell, call the doctor.
Hypergranulation
-pink or red tissue, moist
scar tissue that grows
above the stoma
-the body is reacting to the
feeding tube as a “foreign
body”
-tissue often leaks a sticky
yellow fluid
-tissue may bleed easily







Tube dangling
Tube migration
Trapped moisture
around the tube
Repeated infections
Long-term use of
dressings
Poor fitting of skinlevel tube
Use of disinfectants
for stoma care
Ensure the tube is fastened
to reduce dangling.
Complete stoma care daily.
Ensure the skin around the
stoma is clean and dry,
especially after
bathing/showering,
swimming or other water
activities.
Do not apply creams or
dressing to the stoma
unless directed by your
doctor or ET nurse.
If a dressing is required, a
polyurethane foam dressing
is best for controlling
moisture.
Call your doctor or ET
nurse.
Infection
-pain, swelling, redness and
warmth at the stoma and
surrounding skin
-there may be a thick,
cloudy yellow or greenish
discharge that smells bad
-child may have a fever
-the skin may be itchy






Child may be feeling
unwell from teething
or from a cold or flu
Child may be
receiving
chemotherapy or
may be taking
steroid medication
Excessive handling
of tube
Lack of daily stoma
and tube care
Improper hand
washing
Long-term use of
Wash your hands before
you care for the stoma or
tube.
Soak the stoma 4 times a
day for 5 to 10 minutes
using a clean gauze pad
soaked in a warm saline
solution (2 ml (1/2 tsp.) salt
in 250 ml (1 cup) of boiled
water).
Avoid using dressings over
the stoma. Leave the
stoma open to air. If
28


Leakage of fluid from the
stoma








Chronic leakage
from around the
tube
Swimming in unsafe
water
Improper tube
position
Improper balloon
inflation
Poor tube fit
Presence of
hypergranulation
Infusing feeds too
fast
Child may be
bloated or
constipated
Excess coughing or
increased spasticity
Presence of
hypergranulation
moisture is excessive, a
dressing may be used, but
should be changed on a
frequent basis.
Call the doctor if the red
area is larger than a
quarter, if your child has a
fever and there is an odor
from the stoma.
Check tube position before
any feeding or giving
medication.
Test for balloon inflation
weekly. Ensure that the
balloon has the correct
amount of water.
Check the placement of the
tube while performing daily
tube care. Measure the
exterior length of the tube.
Ensure that the tube is
snug against the stomach
wall. Adjust the bumper 1/8
inch (2mm) away from the
abdomen.
Keep skin clean, dry and
free of drainage. If a
dressing is used, change it
when wet or soiled.
Contact the ET nurse for
advice on the use of skin
barriers.
Slow down the feeding rate
and increase the number of
feedings. If your child is
very ill and unable to
tolerate the usual rate and
volume of feedings, change
to continuous feedings.
Nausea


Air in stomach
Feeding tube may
have migrated into
the small bowel
Vent tube.
Keep head raised during
and after feeding.
29
Wait 1 to 2 hours before
feeding.
Feed slowly.
Check for tube placement
daily.
Check the exterior length of
the tube.
Red skin
-skin around the stoma is
red and raw looking
-there may be a watery
discharge
-skin becomes sore





Gastric leakage
around the tube
Moisture trapped
under the bumper or
base
Irritation from the
tube dangling
Long-term use of
dressing
Pressure
Cleanse the stoma and
surrounding skin 3 to 4
times each day and pat
dry.
Avoid using dressings over
the stoma. Leave the
stoma open to air.
Test for balloon inflation.
Ensure the balloon has the
correct amount of water.
Check tube position.
Ensure the tube is fastened
to reduce dangling.
Ensure there is 2 mm of
spacing between the
bumper and the abdomen.
Call your doctor or ET
nurse if there is no
improvement after 3 days.
Retching
-the first movement of
formula through the feeding
tube can cause gagging or
retching


Feed is started too
quickly
Volume of feed is
too large for
stomach size
Start feeding very slowly.
After several minutes,
slowly increase the speed
of the feeding.
Vent tube.
Flush tube slowly.
Give smaller, more frequent
feedings.
Tube breakdown
-all tubes and their parts

Wear and tear,
medications,
Examine tube daily for
abnormalities such as
30
have a limited life span
cracking and damage.
Test for balloon inflation
weekly.
Replace the gastrostomy
tube whenever indicated.
Tube falls out
-tube loss must be
managed as quickly as
possible to prevent tract
closure





Tube migration
-tube looks shorter than
when it was first put in
-may result in vomiting and
diarrhea
-child may be agitated and
irritable

Water in the balloon
leaks out over time
Saline in the balloon
can clog the balloon
valve
Air in the balloon will
leak out the balloon
and cause early
deflation
Balloon may be
underinflated
Balloon may be
overinflated
Complete balloon checks
weekly.
Tube may migrate
or move into the
small bowel and
block it off
Check tube position every
day.
Instill the correct amount of
water in the balloon.
See section Replacing the
gastrostomy tube.
Always check the exterior
length of the tube and
secure the tube with tape.
Try pulling the tube back
into position. If this does
not work, deflate the
balloon before
repositioning.
Tube slippage
-tube looks longer than
when it was first put in

Tube balloon may
be leaking or is
ruptured, allowing
the tube to slip out
Check tube position every
day.
Check for balloon inflation.
Check the exterior length of
the tube.
Replace tube as necessary.
Vomiting
-varies from child to child
and day to day
-stomach may be too full
-may be due to illness


Feeding is given too
quickly
Volume of feeding is
too large for
Check tube position.
Vent the stomach.
Give feeding more slowly.
31




Formula intolerance
Tube migration
Constipation
There may be a
feeding time when
your child is more
likely to vomit
Give smaller, more
frequent feedings.
Ensure child is in a sitting
position or with the head of
the bed elevated.
Burp the child before,
during and/or after the
feeding.
Flush the tube slowly.
Allow a quiet time after
feeds.
At a problem feeding, make
that feeding smaller. Add
the missed amount of
formula to the next few
feedings.
If vomiting occurs during
the feeding, stop the
feeding. If the child is lying
down, turn the head to the
side or have the child sit up
to prevent aspiration.
If child is vomiting for 2
days, or is feeling unwell,
contact your doctor.
Skin-level feeding tubes
About 6 to 8 weeks after the insertion of your child’s feeding tube, the surgeon will
assess the site. If the stoma and skin are healthy, the surgeon talks to you about the
option of changing the tube to a skin-level feeding tube.
A skin-level gastrostomy tube is a small, flexible tube that is made of medical grade
silicone. The base of the tube rests close to the body, just above the abdomen. There
is either a balloon or internal bumper that keeps the tube in place in the stomach. These
tubes are ideal for active children and those that are prone to pulling on their feeding
tubes.
This type of tube has several additional advantages:
 easy care and use
 greater freedom
 less bulk
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



more comfort
easy replacement
fewer stoma and skin problems with less migration of the tube
fewer spills from the tube with an anti-reflux valve
Skin-level tube with balloon
The ET nurse shows you the types of balloon-type skin-level tubes that are available.
The skin-level feeding tube and other supplies come in a kit along with an instruction
booklet. Because the tube is short and designed with a tapered tip, it is easy to replace.
The ET nurse shows you and your child how it is inserted and replaced. These tubes
generally last between 4 and 6 months, although they can last longer in some cases.
They are available in a variety of sizes and lengths, to allow your child to have a good fit
as he/she grows. The cost of the skin level feeding tube is covered by the ADP program
and by private medical insurance.
Each balloon-type skin-level feeding tube has a separate feeding attachment, called an
extension tube, which is only used when giving a feeding or a medication or venting the
stomach. The extension tube locks into the skin-level feeding device so it cannot detach
accidentally. The extension sets are reusable and must be cleaned along with all the
other parts of the feeding equipment.
Skin-level tube with internal bolster
Another type of skin-level feeding tube is designed with an internal bolster instead of a
balloon to hold it in place in the stomach. These devices are generally flatter or lower
profile than the balloon-type devices and last longer because there is no balloon that can
break. They are a good option for teenagers who want to hide their tube as much as
possible. They are also a good choice for children who tend to pull at their tube. The
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flatter design makes it difficult to grab. Since these tubes are more difficult to insert and
replace, this procedure is arranged by your child’s surgeon. These tubes are only
available in limited lengths and sizes, therefore, spacers are sometimes required around
the outside of the tube to prevent movement in the tract. The extension sets for some of
the skin-level devices with internal bolsters do not lock in place and can become
detached during the feeding. This is a hazard for children who receive nighttime
feedings and move a lot in their sleep. Feeding pumps do not alarm for disconnected
tubing, therefore, the problem may go undetected for several hours.
The surgeon tells you about the procedure for converting to a skin-level feeding tube.
Your child will be scheduled to go to the Same Day Admission Centre for this procedure.
Your child will be given sedation and the feeding tube will be removed. The surgeon
measures your child with a stoma measuring device to determine the tube length
required. A temporary balloon-type feeding tube will be inserted.
If you choose to purchase a balloon-type skin-level feeding tube, the ET nurse meets
with you to show you how it is inserted and how to care for it. If you choose to purchase
a skin level feeding tube with an internal bolster, the surgeon will make arrangements for
insertion.
Helpful Resources
Abbott Nutrition
Ph: 1 (800) 227-5767
www.abbottnutrition.com
Covidien
Ph: 1-800-962-9888
www.covidien.com
American Society for Parenteral
and Enteral Nutrition
Ph: 1 (800) 727-8972
www.nutritioncare.org
Kimberly-Clark Health Care
Ph: 1 (800) 524-3577
www.kchealthcare.com
Bard Access Systems
Ph: 1 (800) 632-2109
www.bardamless.com
Mead Johnson Nutrition
Ph: 1 ( 847) 832-2420
www.meadjohnson.com
Cook Medical
Ph: 1 (800) 554-8335
www.cookmedical.com
Nestle Nutrition Institute
Ph: 1 (800) 387-5536
www.nestle.ca
Corpak Medsystems
Ph: 1 (800) 323-6305
www.corpakmedsystems.com
The Oley Foundation
Ph: 1 (800) 776- 6539
www.oley.org
Glossary
Aspiration
Accidentally taking in formula or stomach contents into the
windpipe and/or lungs
34
Bolus feeding
Method of feeding in which a large volume of formula is given in a
short period of time, usually through a large syringe or feeding bag
Constipation
Fewer than normal bowel movements where the stool may be
hard and painful to pass
Continuous feeding Method of feeding in which the formula is given at a constant rate
without interruption throughout the day and/or night, usually using
a feeding pump
Diarrhea
Frequent, loose, watery bowel movements
Duodenum
First part of the small intestine, into which the stomach empties
Feeding pump
A small machine, plug-in or battery-powered, that automatically
controls the amount of formula going into the feeding tube
Feeding set
Feeding container or bag and tubing through which the formula
flows into the feeding tube
Feeding tube
Tube through which formula flows into the stomach or small bowel
Flushing
Pushing water through the feeding tube in order to clear it of
formula or medication
Formula
Liquid feeding solution that contain nutrients for a complete diet
G-tube
Gastrostomy tube; a tube that passes through the abdomen into
the stomach; also called feeding tube
G-J tube
Gastro-jejunostomy tube; a tube that passes through the abdomen
and into the jejunum by way of the stomach
Gastric
Relating to the stomach
Gastrostomy
A surgical opening, called a stoma, through the skin into the
stomach
Granulation tissue
Naturally occurring scar tissue that forms around the tube; also
known as proud flesh
Gravity feeding
Method of giving formula with the assistance of gravity and not
with the use of a pump, often used with intermittent feeding
Intermittent feeding A method of feeding specific amounts of formula over 30 to 60
minutes at scheduled times during the day (stop-and-start feeding)
Jejunum
Second part of the small bowel after the duodenum
Nutrient
Parts of food that nourish the body such as protein, carbohydrate,
fat, vitamins, minerals and water that promote growth and repair of
body tissues
35
Reflux
Backing up of formula or gastric juice from the stomach into the
esophagus
Residual
Amount of formula remaining in the stomach when measured just
before the next feeding is to be given
Stoma
Surgical opening through which a feeding tube can enter the body
Tube feeding
Nourishment in the form of liquid formula that enters the stomach
or jejunum through a tube, also known as enteral feeding
Venting
Removal of gas from the stomach; also called gastric
decompression
Notes
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