Updated ESPGHAN Percutaneous Endoscopic Gastrostomy Position Paper

M Homan et al. JPGN 2021; 73: 415-426. Open Access: Percutaneous Endoscopic Gastrostomy in Children: An Update to the ESPGHAN Position Paper

A couple of interesting recommendations in this updated position paper on the use of percutaneous endoscopic gastrostomy (PEG) include the following:

  • Feeding can be initiated as early as 3 hours post-procedure in a stable child with no complications.
  • Iso-osmolar feeds of the standard polymeric formula are the best type of food to start with after the PEG insertion” and ” bolus feeding is more physiological and should be the first choice… in some children, small boluses during the day could be combined with the overnight continuous feeding via enteral pump.”
  • Replacing the initial tube with a gastric balloon/button should be recommended to the families/children who will need long term enteral nutrition to improve quality of life.”
  • Gastric balloons should be replaced every 6 months, but non-balloon PEGs can be replaced annually.”

The full article provides a rationale/nuance for these recommendations. Use of feeds starting at 3 hrs post-op has been found to be safe. And, there is no evidence available that suggests routine use of a clear fluid test or dilute or hypotonic feed after the procedure. In fact, it has been suggested that these measures delay the time to full enteral intake and prolong hospital stay.

With regard to balloon button Gtube changes, the authors note that while manufacturers recommend changing every 3 months, “in the majority, these are safe to replace less frequently.”

The authors clearly favor low-profile buttons and state that changing to them earlier after initial Gtube placement (after 1 month) under general anesthesia should be safe (if no issues with healing like diabetes, and systemic corticosteroids); “however, the physician should give the parents/child the possibility of choice whether to perform the replacement or not.” Also, “the primary device can stay in place for one year or even more. In a German study, 85% of parents answered that the GB is advantageous over primary gastrostomy tube due to mobility, patient comfort at physiotherapy, swimming or night-time sleep, and higher parent satisfaction.”

My take: This article provides a good summary of PEG indications/contraindications, complications, and advise for clinicians

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Resource:

www.feedingtubeawareness.com  This site contains a terrific PDF download which explains enteral tubes in an easy to understand style along with good graphics. “What You Need to Know Now, A Parent’s Introduction to Tube Feeding is the guidebook that every parent wished they had when they were first introduced to feeding tubes.”

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PEG Placement in Cystic Fibrosis

A small retrospective study (RT Khalaf et al.NCP 2018; LINK: doi.org/10.1002/ncp.10219) showed that PEG placement was associated with a trend (not statistically significant) towards improved lung function in children with cystic fibrosis (CF). Reference from Kipp Ellsworth twitter feed.  There were 20 patients who had PEG placed compared to 40 patients who did not.

Findings:

  • BMI percentile increased per month for those with PEG (0.51, 95% confidence interval (CI) = −0.05–1.08, P = .08), but decreased for those without PEG (−0.03, 95% CI = −0.33–0.28, P = .86); however, the difference (0.54; 95% CI = −0.10–1.18, P = .10) was not statistically significant.
  • FEV1 change with time showed a decrease for patients with PEG (−0.04; 95% CI = −0.30–0.22, P = .74) and those without PEG (−.22; 95% CI = −0.45–0.01, P = .06). Although the FEVdecrease for those without PEG was higher than those with PEG, the difference between the groups was not statistically significant (0.18; 95% CI = −0.17–0.52, P = .32)

My take: While the differences are not statistically-significant, this study indicates that PEG placement is NOT detrimental to lung function in CF and may be beneficial.

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