Mortality After Feeding Tube Placement in Children with Neurologic Impairment

A population-based study (KE Nelson et al. Pediatrics 2019; 143: e20182863) used an administrative data based from Ontario, Canada to examine the mortality rates among children with a diagnosis of neurologic impairment who underwent either gastrostomy placement or gastrojejunal placement between 1993-2015.

Key findings:

  • Two-year survival after feeding tube placement was 87.4% and 5-year survival was 75.8%
  • Unplanned hospital days, emergency room visits and outpatient visits were not significantly different after tube placement compared to pre-tube placement.

The authors interpret their findings as showing a high mortality which is likely due to medical fragility as there was “stability of health care use before and after the procedure.”

In the associated commentary (by KJ Lee and TE Corden, e20183623) the authors note the placement of a Gtube often took place after an increase in health care in the weeks prior.  They recommended engaging in shared-decision making regarding Gtube placement prior to crisis.

My take: There have been a number of studies, particularly in adults, that have shown that Gtubes may not prolong survival in many conditions.  However, they have been shown to improve nutritional status, simplify care, and improve quality of life.

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Gastrostomy Complications

A recent review (RJ Sealock, K Munot. Clin Gastroenterol Hepatol 2018; 16: 1864-69) provides a quick review of some common and rare problems: infection, buried bumper, leakage, bleeding, colonic perforation, tube dislodgment, and nonhealing stoma.

It is a useful reference.  One item (Link to Figure 2) that was interesting was a technique for gastrostomy site closure.  The authors describe passing 2 sutures through a long needle into the stomach around the stoma and using an endoscope/endoscopic biopsy forceps to redirect the sutures back through a catheter to make a loop which can be tied externally.

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#NASPGHAN18 -Our Poster on Antibiotic Stewardship and PEG Placement

Thanks to Chelly Dykes for presenting poster later today and to co-authors for collaborating on this project: Jeffery Lewis, Bonney Reed-Knight and Cate Crenson.

Full abstract below.


 Background: While there is general agreement that antibiotic prophylaxis for percutaneous gastrostomy (PEG) tube insertion reduces the risk of infection at the site of placement (Lipp A, Cochrane Review 2013), optimal antibiotic selection and regimen remain unclear; as a result, there is widespread practice variation.  In addition, in order to limit the development of bacterial resistance and complications from antibiotic use (eg. Clostridium difficile infection), antibiotic stewardship programs have aimed to limit antibiotic usage, particularly broad-spectrum antibiotics.

Methods: From December 1, 2016 through May 1, 2018, the charts of all patients who underwent PEG tube placement in our children’s hospital were reviewed.  This period coincided with an optional practice change in antibiotic prophylaxis.  Prior to the study period, the typical patient received prophylaxis with a three-dose regimen of cefoxitin.  During the study period, at the discretion of the gastroenterologist, patients received either a three-dose regimen of cefoxitin (n=38) or treatment with cefazolin (n=109); 73 patients received a single dose of cefazolin prior to PEG placement and 36 received multiple doses.  The initial dose of either regimen was given within thirty minutes of placement.  All patients were observed for at least 24 hours.  In patients with PEG tube site infections based on clinical assessment, rescue antibiotic treatment was prescribed.

Results: In total, 144 subjects had PEG placement. The main indications for PEG placement were swallow dysfunction (56.2%), poor growth (17.6%), feeding aversions (18.9%) and malignancy (6%).  In the cefoxitin group, clinical infection occurred in 3 of 35 (8.6%).  In the cefazolin group, clinical infection occurred in 20 of 109 (18.3%). In the subset of patients who received multiple doses of cefazolin, the clinical infection rate was 6 of 36 (16.7%). Patients in the cefazolin group had a 2.39 times higher odds (95% CI  0.667-8.612) of infection compared to the cefoxitin group. Although rates of infection were more than twice as high in the cefazolin group compared to the cefoxitin group, this association did not differ statistically using a chi square test (x^2 = 1.89, p = 0.20).

Conclusion: This study highlights the ongoing uncertainty regarding optimal antibiotic prophylaxis for PEG tube placement.  The difference in the clinical infection rate between cefazolin and cefoxitin was not statistically significant; however, the absolute rate of infection in the cefazolin group was more than twice as high as the cefoxitin group and this may influence selection of antibiotic prophylaxis for PEG tube insertion.


Does Gastrostomy Tube Prolong Life in Rett Syndrome?

A recent study (K Wong et al. J Pediatr 2018; 200: 188-95) examined a longitudinal cohort of 323 females in the Australian Rett Syndrome Study.

Key findings:

  • 30.3% of the cohort underwent gastrostomy placement
  • BMI was greater in individuals with gastrostomy placement
  • Median age of gastrostomy placement was 9 years
  • The all-cause mortality rate was greater in those who had gastrostomy placement compared with those who had not (hazard ratio 4.07, CI 1.96-8.45)
  • Survival: 66.1% of the entire cohort was alive at 20 years of age (median survival was 33 years). The survival was 87.3% in those without a gastrostomy.
  • Placement of a gastrostomy tube was not associated with fewer hospitalizations or improvement in parental physical or mental health

While the mortality was higher in those who received a gastrostomy tube, the study’s nonrandomized design does not allow definitive assessment of whether a gastrostomy tube is detrimental to long-term survival.  Children who received gastrostomy tube may have had additional comorbidities.

My take: In adult medicine, it is generally accepted that Gtube placement does not prolong life (Clin Gastro & Hep 2007; 5: 1372).  This study indicates that a Gtube may not improve longevity in many pediatric disorders as well.

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Nutrition Week (Day 5) What a Gastrostomy Tube Means for Cognition

Looking at a retrospective cohort of 194 neonates, a recent study (SR Jadcherla et al. J Pediatr 2017; 181: 125-30) showed that infants discharged with a gastrostomy tube (Gtube) had associated lower cognitive outcomes.

The authors examined discharge milestones along with Bayley Scales of Infant Development (3rd edition) at 18-24 months of age.

Key findings:

  • 60% of infants (n=117) were discharged on oral feedings and 96% remained oral-fed at 1 year.
  • 40% (n=77) were discharged on gastrostomy feedings.31 (40%) remained fully Gtube dependent, 17 (22%) were orally-fed, and 29 (38%) were on oral/gtube combination.
  • Gtube feedings at discharge were a marker for lower cognition (P<0.01), communication (P=0.03) and motor (P<0.01) composite scores at 18-24 months of age.
  • Other factors associated with neurodevelopmental delay included intraventricular hemorrhage, younger gestational age, and bronchopulmonary dysplasia.

My take: This study provides evidence for an expected finding –infants who need gtubes have poorer neurodevelopmental outcomes than infants who do not need gtubes.

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Thanks to an Olive Oyl fan for this picture

Thanks to an Olive Oyl fan for this picture



Nutrition Week (Day 3) Multidisciplinary Feeding Disorders

A recent systematic review/meta-analysis (WG Sharp, VM Volkert, L Scahill, CE McCracken, B McElhanon. J Pediatr 2017; 181: 116-24) by my colleagues at the Marcus Center and Emory indicate that intensive, multidisciplinary treatment for pediatric feeding disorders is a game-changer.

The authors identified 11 studies with 593 patients.

Key finding: After intensive intervention, 71% were successfully weaned off tube feedings at the completion of the intervention and this improved to 80% at last followup. Treatment was also associated with increased oral intake, improved mealtime behaviors, and reduced parenting stress.

Based on the results of their review/meta-analysis, the authors provide a summary of recommendations for “standard of care at intensive day and inpatient programs.”  This lists the professional team which should involve at a minimum: psychology, medicine, nutrition, and speech language/occupational therapy.  Treatment needs active participation of caregivers so that gains will not be lost when intensive treatment is completed. Behavioral intervention is central to success.

In an associated editorial (pg 7-8), the authors (RJ Noel, AH Silverman) explain that the one of the biggest hurdles for intensive treatment is gaining approval from insurance companies. One key point they make: “Their work provides data that will be very useful towards advocacy and improving patient access to such treatment.”

My take: This study provides justification of intensive feeding programs.  That being said, the individuals/programs with the appropriate expertise to achieve these results remain quite limited.

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A few more slides from my recent PNALD/IFLAD lecture:


The other subjects discussed for PNALD treatment included management of bacterial overgrowth, possible role of STEP surgery, and lipid management strategies.



Gastrostomy Tubes: The First 30 Days

A retrospective study (AB Goldin et al. J Pediatric 2016; 174: 139-45) provides a better idea about the likelihood of complications by looking for ED visits and admissions within 30  days of placement.

This study involved 38 Children’s Hospitals and 15,642 patients the Pediatric Health Information System (PHIS) database. Key findings:

  • 8.6% had an ED visit within 30 days
  • 3.9% had an admission within 30 days
  • Common reasons for return visits: infection (27%), mechanical complication (22%) and replacement (19%).

The authors note that risk factors for ED visits and admission were mainly non modifiable like race/ethnicity and medical complexity.  They also note that problems in the early postoperative period are grossly underestimated due to many issues being addressed in the outpatient setting.

This study indicates that there is a tremendous opportunity for improvement.  There is great variation in hospital practices with regard to the type and method of placing gastrostomy tube.  In addition, there is a high variability in the determination of the need for fundoplication which is often undertaken at the time of gastrostomy tube placement.

My take:  Understanding these risks is important to give families accurate information prior to placement of gastrostomy tubes.  In addition, these high rates of complications indicate the need for head-to-head prospective trials comparing types of gastrostomy tube placement and education efforts.

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