Helpful Position Paper: Percutaneous Endoscopic Gastrostomy in Children

A recent European Society for Pediatric Gastroenterology Hepatology and Nutrtition (ESPGHAN) position paper provides some useful advice regarding the management of percutaneous endoscopic gastrostomy (PEG) in children and adolescents (JPGN 2015; 60: 131-41).

Table 1 provides a succinct description of the potential benefits of PEG compared with nasogastric tube including less dislodgement, reduces risk of aspiration, better appearance, safer/more reliable enteral access, optimizes development of oral skills, less blockage/clogging, cost-effective, less interference with daily activities, avoids nasal irritation/trauma, reduced anxiety at mealtimes, and shorter meal times.

Table 2 provides a good summary of clinical indications including optimizing nutritional status, maintaining hydration, supporting unpalatable diet, decompressing stomach, improving medication adherence, ensuring safe feedings/prevent aspiration, and improving quality of life.

The position paper reviews relative and absolute contraindications (uncorrectable coagulopathy, interposition of enlarged organs, frank peritonitis); I did not see any mention of high dose steroids as a relative contraindication.  Given high dose steroids’ impact on healing, PEG needs to be avoided if possible in this setting (in my opinion).

The authors provide extensive information on potential complications (table 6 and table 7).

Other key points:

  • “In the United Kingdom, it is accepted by the National Institute of Clinical Effectiveness that expectation of continuous NGT use for a minimum of 4 weeks (www.nice.org.uk/CG032 –this reference provided by authors focuses on NGT in adults), or even 2 to 3 weeks, should prompt consideration of PEG insertion.”
  • “The use of a routine preoperative upper GI contrast study is NOT advised to rule out malrotation.”
  • “Asymptomatic children do not require investigation for GERD before PEG insertion.” However, the authors note that in the presence of significant symptomatic reflux, or reflux in the presence of an unsafe swallow/progressive neurologic disease, or chronic respiratory disease, this should prompt discussion around the need for a surgical antireflux procedure.
  • The authors suggest that PEG change to a button can occur “after a period of 2 months or more.” Our institution generally does not change prior to 3 months.
  • The authors state that formula (rather than clears) can be started within 4 to 6 hours of PEG insertion.
  • One aspect of their recommendations that I disagreed with was their advice on preventing a ‘buried bumper.’  “To prevent a ‘buried bumper,’ the PEG should be carefully pushed into the stomach by 1 to 2 cm and then rotated once a week from day 7 postinsertion.”
  • Perhaps this advice is offered as the guideline also suggests that patients do not need much follow-up: “The child will require follow-up, typically provided by nurse specialists 3 months after placement of the gastrostomy.  Thereafter, annual review of the device is usually adequate…between routine appointments caregivers should have access to appropriately trained professionals.”  In my view, if the tube is appropriately sized (checked early on) and patients are followed (for excessive weight gain), then pushing in the tube should be unnecessary.

Take-home message: Overall, this is a useful reference/summary for PEG tube management, though some recommendations are based on practice patterns rather than high-quality data.

Are there others who would like to relay their experience and advice?

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