Gastrostomy Tube Recommendations in Pediatrics

L Berman et al. Pediatrics 2022; 149 (6): e2021055213. Gastrostomy Tube Use in Pediatrics: A Systematic Review

This lengthy review (27 pages) authored by a multispecialty team makes 17 graded recommendations regarding gastrostomy tubes/gastrostomy tube (GT) placement. The authors state that this review was based on nearly 900 publications with 58 influencing final recommendations.

Here are several of them:

Trial of home nasogastric feeding is safe and should be strongly considered before GT placement, especially for patients who are likely to learn to eat by mouth
Routine contrast studies are not indicated before gastrostomy placement
Laparoscopic placement is associated with the best safety profile
For most patients, a low-profile balloon GT is preferred

Elaborating on these recommendations::

Home NG: The authors note that Lagatta et al found that infants sent home with NG from nursery had shorter length of stay and fewer readmissions/emergency encounters than patient sent home with GT. However, this statement ignores the significant differences in the patient characteristics in the two groups noted in this article (see related blog post: Impact of NG Feeding Program for NICU Graduates). Interestingly, many of the return visits are due to dislodgements of button GTs.

Preoperative workup: While the authors discourage use of preoperative UGI and except in patients not achieving adequate enteral nutrition due to emesis, they also recommend “GT should only be pursued after appropriate workup has been performed to investigate the underlying medical diagnosis.” I find this vague recommendation to be problematic. Shortly before making this recommendation, the authors state “proper identification and management of the underlying diagnosis (eg. diet modification for eosinophilic esophagitis) may obviate the need for GT placement.” So, do the authors want every child who may need a GT to undergo an EGD? Or perhaps even more, such as an MRI or full exome sequencing? Also, which diet trial do they recommend for potential eosinophilic esophagitis -does this mean an amino acid based formula or is a hydrolysate sufficient?

GT technique: The review of the techniques of GT placement cite data comparing the techniques and complication rates (though noting critical risk of bias in these studies):

open gastrostomy (n=1471) vs PEG (n=679): 3.2% vs 4.1% (P=.35)
laparoscopic gastrostomy (n=787) vs PEG (n=1321) 1.2% vs 5.4% (P<.0001)
IR placement (n=321) vs PEG (n=417): 3.7% vs 1.9% (P=.04)
the authors note the decision needs to consider specific patient characteristics and institutional factors
related post: Is a Laparoscopic Gastrostomy Better Than a Percutaneous Endoscopic Gastrostomy?

My take: This article’s recommendations need to be carefully considered by pediatric gastroenterologists along with pediatric surgeons and interventional radiologists.

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