Clinical management of post-pyloric enteral feeding in children

Feeding jejunostomy in children: safety, effectiveness and perspectives

PURPOSE

Jejunal feeding (JF) indications in children have recently increased. However, surgical jejunostomy (SJ) is reported to be subjected to a high complication rate. The aim of the study is to focus on safety, effectiveness, and complications of SJ and to identify those categories of patients who could most benefit from it.

METHODS

A retrospective analysis of all SJ performed at Giannina Gaslini Children's Hospital between 2014 and 2022 was performed. Data were collected regarding demographics characteristics, past medical history, surgical indications, surgical technique (Roux-en-y (REYJ), omega jejunostomy (OJ)), complications and nutritional outcomes.

RESULTS

Fourteen patients were included. Nine (64%) had severe neurological impairment. The most frequent indication for SJ was gastroesophageal reflux. REYJ was performed in five (36%) patients, OJ in nine (64%); no technique appears to be superior. One patient experienced a major long-term complication. After a follow-up of 40 months (range: 1-152), five (36%) patients discontinued JF: three (21%) successfully completed JF cessation, and two (14%) had their jejunostomy closed due to JF intolerance.

CONCLUSIONS

Based on our experience and on data available in the literature, SJ should be recommended in selected patients as temporary procedure or as bridge treatment to prevent or at least delay more invasive surgeries.

Postoperative management of pediatric patients undergoing single-stage laryngotracheal reconstruction in the United States: A survey of ASPO members

INTRODUCTION

The postoperative management of single-stage laryngotracheal reconstruction (ssLTR) plays a significant role in the surgery's outcomes. The relatively prolonged period in which the child remains intubated and sedated to allow graft healing may be complicated by pulmonary sequelae, airway obstruction, withdrawal symptoms, and eventually failed extubation. This study aims to assess post-ssLTR practices among pediatric otolaryngologists.

METHOD

An electronic cross-sectional survey was distributed to the American Society of Pediatric Otolaryngology (ASPO) members to elucidate current protocols in post-ssLTR practice in the United States.

RESULTS

Eighty-six responses were recorded. A majority (60 %; n = 50) reported performing fewer than five ssLTRs per year. The mean time to bronchoscopy following ssLTR was postoperative day 8±3 for ssLTR with a posterior graft and postoperative day 7±3 without a posterior graft. Most practitioners reported avoiding paralytics (61 %, n = 44) unless the desired level of sedation could not be achieved. Most providers utilized pre-pyloric feeding via a nasogastric or gastrostomy tube (n = 50, 72 %). A total of 70 % (n = 49) of respondents use a single medication for acid suppression, whereas 21 % (n = 15) reported dual-acid suppression whether the patient was diagnosed with gastroesophageal reflux prior to surgery or not, regardless of feeding route. Nebulized agents were routinely used, with normal saline (43 %; n = 36) being the most reported agent.

CONCLUSION

The postoperative management after ssLTR varies greatly among pediatric otolaryngologists due to a lack of evidence-based data to support one protocol over the other. Multi-institutional studies should be considered to evaluate current protocols and improve postoperative care.

Procedures for a Transpyloric Feeding Tube Inserted Into Newborns and Infants: A Systematic Review

BACKGROUND

Enteral feeding by a transpyloric tube in critically ill infants is indicated when there is a failure in gastric feeding. However, there is a wide variability regarding the insertion technique.

PURPOSE

To perform a systematic review of the methods for inserting a transpyloric feeding tube in newborns and infants.

DATA SOURCES

Nine databases, without date or language restrictions, accessed in September 2021.

STUDY SELECTION

A systematic review of experimental and nonexperimental studies, according to the "Patient/problem; Intervention; Comparison; Outcome" strategy and the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" guidelines. The clinical question was about the measurement and insertion techniques, as well as the success rates of properly placing a transpyloric tube in newborns and infants.

DATA EXTRACTION

Two authors (N.M.Q. and J.F.S.) analyzed 6 observational descriptive prospective studies, all of them published in peer-reviewed indexed medical journals and one in the official journal of the National Association of Neonatal Nurses.

RESULTS

The success rate varied between 70% and 100%. There was an important variability in the type of tube, measurement method, and insertion techniques. It was found that the most common strategies to achieve proper positioning were glabella-calcaneal measurements, gastric air insufflation, and right lateral decubitus.

IMPLICATIONS FOR PRACTICE

A transpyloric catheter insertion protocol needs to be established in each neonatal unit, according to the literature findings.

IMPLICATIONS FOR RESEARCH

Randomized controlled studies that evaluate the gastric air insufflation technique and other adjuvant measures could elucidate the knowledge gap concerning the correct positioning of transpyloric tubing in newborns and infants.

Postpyloric Feeding Access in Infants and Children: A State of the Art Review

Achieving postpyloric feeding access is a clinical challenge faced by the pediatric gastroenterologist in everyday practice. Currently, there is limited literature published on the topic. This article provides a practical summary of the literature on the different methods utilized to achieve postpyloric feeding access including bedside, fluoroscopic, endoscopic and surgical options. Indications and complications of these methods are discussed as well as a general approach to infants and children that require intestinal feeding.

Enough is enough: Radiation doses in children with gastrojejunal tubes

INTRODUCTION

Many children with gastric feeding intolerance require postpyloric tube feeding via a gastrojejunal (GJ) tube. Placement or positioning of these tubes is typically a procedure with a low dose of radiation. Although the risk of developing cancer from radiation exposure owing to computed tomography scans is well-documented in children, the risk of cumulative radiation exposure owing to frequent GJ tube replacement often goes unnoticed in the clinical decision-making process. We sought to define the frequency and cost of GJ tube replacement, quantify the radiation doses associated with the initial placement and replacements, and assess the number of conversions to surgical jejunostomies.

METHODS

All pediatric patients who underwent GJ tube placement or replacement by Interventional Radiology (IR), surgery, and gastroenterology between 2010 and 2018 at a single center were reviewed. We evaluated the total cost of the initial placement and replacement of each GJ tube, the total number of replacements, and the cumulative radiation dose (mGy).

RESULTS

We identified 203 patients who underwent GJ tube placement and/or replacement, of which 150 had radiation data available. Patients underwent a median of five GJ tube replacement procedures, and there was a wide range in the number of replacements per patient, from zero to 88. Patients were exposed to a median cumulative dose of 6.0 mGy (IQR: 2.2, 22.6). Nine percent of patients with available radiation data were exposed to more than 50 mGy, solely from GJ tube replacements. The median cost per replacement was $1170. The sum of the cost of the replacements for dislodged GJs translated to more than $1.4 million during the study period.

CONCLUSIONS

Overall, the average dose per GJ replacement was 3.50 mGy among all patients with available data. Nine percent of patients (14/150) were exposed to greater than 50 mGy cumulative radiation solely from GJ replacements. Patients who receive more than 50 mGy of cumulative radiation dose, who undergo seven GJ tube replacements in one year, or two consecutive GJ tube replacement procedures with radiation doses exceeding 10 mGy (per replacement) should be considered for a surgical jejunostomy.

LEVEL OF EVIDENCE

IV TYPE OF STUDY: Treatment study.

Percutaneous endoscopic gastrojejunostomy in pediatric intestinal pseudo-obstruction

Pediatric intestinal pseudoobstruction (PIPO) is the "tip of the iceberg" of the most severe gut motility disorders. In patients with PIPO, the impairment of gastrointestinal propulsive patterns is such as to result in progressive obstructive symptoms without evidence of mechanical causes. PIPO is an important cause of intestinal failure and affects growth and pubertal development. Bowel loop and abdominal distension represent one of the main features of intestinal pseudo-obstruction syndromes, hence intestinal decompression is a mainstay in the management of PIPO. So far, pharmacologic, endoscopic, and surgical treatments failed to achieve long-term relief of bowel distension and related symptoms, including pain. Recent data, however, indicated that percutaneous endoscopic gastrojejunostomy (PEG-J) might be a minimally invasive approach for intestinal decompression, thereby improving abdominal symptoms and nutritional status in adult patients with chronic intestinal pseudo-obstruction. Based on these promising results, we treated for the first time a 12-y-old patient affected by PIPO refractory to any therapeutic options to obtain intestinal decompression by PEG-J. We showed that PEG-J yielded sustained small bowel decompression in the reported PIPO patient with considerable improvement of both abdominal symptoms and nutritional status. The positive outcome of the present case provides a basis to test the actual efficacy PEG-J versus other therapeutic approaches to intestinal decompression in patients with PIPO.

The Use of Jejunal Tube Feeding in Children: A Position Paper by the Gastroenterology and Nutrition Committees of the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition 2019

OBJECTIVES

Jejunal tube feeding (JTF) is increasingly becoming the standard of care for children in whom gastric tube feeding is insufficient to achieve caloric needs. Given a lack of a systematic approach to the care of JTF in paediatric patients, the aim of this position paper is to provide expert guidance regarding the indications for its use and practical considerations to optimize its utility and safety.

METHODS

A group of members of the Gastroenterology and Nutrition Committees of the European Society of Paediatric Gastroenterology Hepatology and Nutrition and of invited experts in the field was formed in September 2016 to produce this clinical guide. Seventeen clinical questions treating indications and contraindications, investigations before placement, techniques of placement, suitable feeds and feeding regimen, weaning from JTF, complications, long-term care, and ethical considerations were addressed.A systematic literature search was performed from 1982 to November 2018 using PubMed, the MEDLINE, and Cochrane Database of Systematic Reviews. Grading of Recommendations, Assessment, Development, and Evaluation was applied to evaluate the outcomes.During a consensus meeting, all recommendations were discussed and finalized. In the absence of evidence from randomized controlled trials, recommendations reflect the expert opinion of the authors.

RESULTS

A total of 33 recommendations were voted on using the nominal voting technique.

CONCLUSIONS

JTF is a safe and effective means of enteral feeding when gastric feeding is insufficient to meet caloric needs or is not possible. The decision to place a jejunal tube has to be made by close cooperation of a multidisciplinary team providing active follow-up and care.

Success of Bolus Gastric Feeding After Fundoplication Among Children Who Require Preoperative Jejunal Feeding

PURPOSE

Management of complicated reflux in infants and children is controversial. Jejunal feedings are used when reflux complications occur with gastric feeds. We sought to determine how successful fundoplication is to allow for return of physiologic gastric feeds in patients requiring jejunal feeds preoperatively.

METHODS

A retrospective review of patients requiring jejunal feeds before fundoplication between 2010 and 2015 was conducted.

RESULTS

Two hundred thirteen children underwent fundoplication during the study period. One hundred fourteen (49%) children required preoperative jejunal feeds. Median preoperative jejunal feeding trial was 15 days (interquartile range [IQR] 8-36). After fundoplication, gastric feeds were attempted in all patients. Ninety-one (80%) patients tolerated feeds postoperatively without return of preoperative symptoms. Twenty-one (18%) children developed gastric feeding intolerance and were treated with jejunal feeds at a mean of 8 months postoperatively (range 3-17). Ten (9%) children eventually tolerated intragastric bolus feeds, requiring jejunal feeds for a median duration of 2.3 months (IQR 1-5). There were no differences seen in those who were able to tolerate gastric early after the operation and those who did not. Of the patients who were unable to tolerate bolus gastric feeds during the study, a higher proportion had neurologic impairment and were on jejunal feeds for a longer period of time before fundoplication.

CONCLUSION

In the majority of patients requiring continuous jejunal feeds to manage complications of reflux, fundoplication allows for transition to gastric bolus feeding.

Enteral Protein Supplementation in Critically Ill Children: A Randomized Controlled Pilot and Feasibility Study

BACKGROUND

Loss of muscle mass in critically ill children can negatively impact outcomes. The aims of this study were to conduct a pilot randomized control trial (RCT) to examine the difference in protein delivery and nitrogen balance in critically ill children with enteral protein supplementation vs controls. We also aimed to assess the feasibility, safety, and tolerance of the pilot trial.

METHODS

This is a 3-arm RCT in critically ill children eligible for enteral nutrition (EN) therapy. Patients were randomized to 1 of the 3 groups: (1) control (routine EN), (2) polymeric protein module added to EN to reach protein goal by day 4, or (3) oligomeric protein supplementation. Demographics, clinical characteristics, nutrition status, and daily nutrition intake variables were recorded. Protein delivery, nitrogen balance, feasibility variables, and rate of adverse events were the outcomes.

RESULTS

After screening 286 consecutive patients admitted to the pediatric intensive care unit over 11 months, we enrolled and randomized 25 patients. Twenty-two patients (88% of the enrolled) completed the study procedures. Significantly higher protein prescription and actual protein intake within the first 5 days was achieved in the intervention groups, compared with the control group. Nitrogen balance was obtained in 15 patients. There was no significant difference between the groups for the rate of adverse effects and clinical outcomes.

CONCLUSION

In our pilot trial, protein supplementation was safe and well tolerated. Our preliminary results suggest that a larger RCT is potentially feasible, with some modifications of the entry criteria. Trial enrollment was low, likely due to restrictive entry criteria.

Assessment of the safety and efficacy of percutaneous laparoscopic endoscopic jejunostomy (PLEJ)

INTRODUCTION AND AIMS

Gastric feeding may not be possible in the neurologically impaired child with foregut dysmotility. Post-duodenal feeding can be crucial, thereby avoiding the need for parenteral nutrition. The aim of this study is to evaluate the technical success, complication and clinical outcome of our institution's technique in creating a jejunostomy using the percutaneous laparoscopic-endoscopic jejunostomy (PLEJ) technique.

METHODS

Retrospective review of all paediatric patients (<18) with PLEJ between January 2008 and April 2015 was conducted. Patients were identified using the electronic procedure code and clinic letters. Data were collected in regard to the procedure technical success, short and long-term complications and clinical outcomes.

RESULTS

Sixteen patients (age range, 2-17years) were identified. The procedure was successful in all cases. At a median follow up of 25months, eleven patients (68%) had significant improvement of their symptoms of feeding intolerance/aspirations and are permanently PLEJ fed and two (13%) were regraded to gastric feeds. Two patients moved from total parenteral nutrition to partial parenteral nutrition while on PLEJ feeds. All patients had experienced weight gain and either went up or maintained their weight centile. The only major complication was small bowel volvulus encountered in two patients with abnormal gastrointestinal anatomy requiring surgical intervention.

CONCLUSIONS

In our small case series, PLEJ placement was safe as it provides valuable visualization of the bowel loops intraabdominally. It is a technically feasible and successful approach for children requiring long-term jejunal feeding especially those with foregut dysmotility.