Placement of a percutaneous endoscopic gastrostomy tube has become an "essential" technique for children and young people with a wide range of problems with feeding and nutrition, according to a position statement in the Journal of Pediatric Gastroenterology and Nutrition, official journal of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.
The new position statement was developed by the ESPGHAN Gastroenterology Committee. "The PEG tube now plays a key role in the management of children and young people with nutritional compromise, providing safe and effective access to the gastrointestinal tract," comments lead author Dr Robert B. Heuschkel of Addenbrookes Hospital, Cambridge, United Kingdom. "This document reviews all the current evidence on this important practice in children and presents it as a practical and accessible guide for all health care professionals involved in the care of these tubes."
PEG is safe and effective for nutritional support in children
Gastrostomy tubes are devices placed into the stomach through an opening in the stomach wall. They are used to provide nutritional support to children (and adults) patients with problems affecting feeding or nutrition -- for example, conditions causing inability to swallow or chronic diseases leading to malnutrition. At one time, open surgery was always required to place gastrostomy tubes.
But in more recent years, the PEG technique -- using an endoscope to guide tube placement in the stomach and to create the opening in the abdominal wall -- has become the standard. "There are very few clinical scenarios which require open, more major, surgery rather than the quicker, less invasive, PEG tube," Dr Heuschkel notes.
The availability of PEG has improved nutritional management of children with many different diseases and conditions. However, they add that the decision to insert a PEG, as well as the procedure itself, should only be performed only by a team experienced in carrying out PEG placement in children, with a pediatric surgeon available to manage possible complications.
Practical guidance on PEG tube placement and care
In addition to medical factors, the decision to perform PEG should consider possible ethical, psychological, and quality of life issues. The patient and parents may need some time and preparation to accept the idea of feeding tube placement. "As a result, the date for gastrostomy insertion may need to be delayed for all parties to be comfortable with the procedure," the Committee writes.
The statement addresses practical considerations and techniques related to PEG tube placement. Concerns that PEG causes gastroesophageal reflux are "misplaced," the Committee writes. They summarize the various techniques for PEG tube placement -- the newer "push" technique may have advantages over the previous "pull" technique.
If the PEG tube is placed for long-term nutritional care, pediatric dietetic expertise is essential. After a few months of healing, the gastrostomy tube can be replaced with a more convenient "button" or "balloon" device.
The statement includes discussions of feeding considerations and supplies, care of the PEG tube after placement, and short- and long-term complications and their management. "Techniques and devices continue to evolve to reduce complications such as infection and displacement," the Committee adds.
The members of the ESPGHAN Gastroenterology Committee hope that their position statement will serve as a useful and practical guide to PEG tube placement, thus helping to optimize nutritional support for the diverse group of children in need. They emphasize, "The decision to place an endoscopic gastrostomy has to be made by an appropriate multi-disciplinary team, which then provides active follow-up and care for the child and device."
- R.B. Heuschkel, F. Gottrand, K. Devarajan, H. Poole, J. Callen, J.A. Dias, S. Karkelis, A. Papadopoulou, S. Husby, F. Ruemmele, M.G. Schδppi, M. Wilschanski, P. Lionetti, R. Orel, J. Tovar, N. Thapar, Y. Vandenplas. ESPGHAN Position Statement on the Management of Percutaneous Endoscopic Gastrostomy (PEG) in Children and Adolescents. Journal of Pediatric Gastroenterology and Nutrition, 2014; 1 DOI: 10.1097/MPG.0000000000000501
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