GASTROSTOMY: TUBES, FEEDING AND CARE(GAS-STROS-STOW-ME)

CONTENTS

What is a gastrostomy page 3Surgery page 4

Before surgery What surgery is doneAfter surgery

What is a Gastrostomy Tube (G-Tube) page 6Changing the gastrostomy tube

The Button Gastrostomy page 8Advantages of the ButtonDisadvantages of the ButtonInserting the ButtonButton Care

Skin Care page 10General InformationIf you have a G-TubeIf you have a Button

Care of irritated skin page 11Weepy skin #1Weepy skin #2RashGranulation tissue

Dressing Changes page 13StomahesiveD-TAD

Feedings page 15FeedingIncreasing feedingsNipple feedingsOther feeding information

Supplies & Equipment page 19SuppliesCleaning & storing tubes

Helpful Hints page 20MedicinesMouth careBaby carePlayDoctor visits

Call the doctor if….. page 21

Gastrostomy 1

WHAT IS A GASTROSTOMY1. A Gastrostomy is an opening or hole (stoma) directly into your baby’s

stomach. It is a way to feed babies who are not able to suck or swallow well enough for good nutrition.

2. A Gastrostomy Tube (G-Tube) is the tube placed through the stoma (hole) directly into the stomach.

Gastrostomy 2

GastrostomyStoma

Gastrostomy Tubes

Gastrostomy Tubein the stomach

SURGERY

BEFORE SURGERY1. The Neonatologist will talk with you about where the surgery should be done. 2. Surgery may be performed at Cape Fear Valley Medical Center. Occasionally,

babies are transferred to either Duke University Medical Center or The University Hospital at Chapel Hill for the surgery.a. If the decision is made to transfer your baby to another hospital you will be

asked to sign a consent giving Cape Fear Valley Medical Center permission to transfer your baby.

b. If your baby is transferred to another hospital, the doctors there will also talk with you about your baby’s surgery.

3. The surgery is done in the Operating Room and the baby is asleep for the surgery. You will be asked to sign a consent (give permission) for the surgery.

4. Once your baby’s condition is stable and the doctors are happy with the baby’s progress, the baby will be returned to Cape Fear Valley Medical Center’s Neonatal Intensive Care Unit.

WHAT SURGERY IS DONE1. The surgeon makes a small opening or hole in the skin on the baby’s tummy

and into his stomach. 2. He inserts (places) a Gastrostomy tube through the opening on the tummy and

into the stomach.3. Sometimes, a Nissen Fundoplication is done at the same time the

gastrostomy tube is placed. (See picutre)4. This surgical procedure tightens the valve between the esophagus (tube

connecting the mouth and stomach) and your baby’s stomach.5. Part of the baby’s stomach is wrapped around the esophagus, like a scarf is

wrapped around the neck.

6. The Nissan Fundoplication helps stop formula and stomach juices from sloshing up into the esophagus (tube going from the mouth to the stomach). This is called reflux.

7. Reflux can make your baby:a. Spit-up oftenb. Irritate the esophagusc. Have breathing problems (apnea)d. Cause formula and stomach juices to get into the baby’s lungs.

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AFTER SURGERY1. The G-Tube will be hung in the baby’s crib or isolette to “test the stomach” for

about 24 hours. During this time your baby will continue to receive his/her IV fluids.

2. Feedings are usually started through the G-Tube 2-3 days after surgery. When to start the feedings is different for every baby, the doctor will decide when it’s best for your baby to start feedings.

3. Feedings are started very slowly! The baby’s doctor makes feeding changes.4. If your baby was transferred out for the surgery, when doctors and surgeon are

satisfied with how well your baby is doing, they usually transfer the baby back to the Neonatal Intensive Care Unit at Cape Fear Valley Medical Center.

5. Once the baby has returned to our Neonatal Intensive Care Unit, we will continue teaching you how to feed and care for your baby and the G-Tube.

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WHAT IS A GASTROSTOMY TUBE (G-TUBE)1. The G-Tube is a tube placed through the stoma (hole) directly into the

stomach. 2. A G-Tube is used for babies who may not be able to eat well for a long time—

the baby who has a problem with his heart; esophagus; mouth (such as a cleft palate) or may be on a ventilator for a long time;

3. The first G-Tube may be sewn in place until the opening in the skin and stomach heal together. The G-Tube is usually not changed for the 1st 2-4 weeks after surgery.

4. The doctor or nurse practitioner changes the first tube and will probably replace this tube with a Foley Catheter (a tube with a balloon). We still call this a G-Tube.

5. A mark is placed on the G-Tube close to the baby’s skin or the tube length measured. This way we know the correct amount of tube is hanging outside your baby’s stomach. This is to assure the tube has not moved too far into the stomach.

6. A special dressing and the catheter’s balloon that stops the tube from being pulled out keep the G-Tube in place. You will be taught how to care for the G-Tube, the stoma and how to feed your baby before discharge.

CHANGING THE GASTROSTOMY TUBE1. Always wash your hands before changing dressing or tube.2. If the tube comes out, the opening (stoma) may close within 3 hours, so a new

tube needs to be placed as quickly as possible.a. If you are unable to replace the tube you must take a new G-Tube

and the baby to the baby’s doctor.b. If you are unable to reach the doctor or are away from home, take

the baby and the new G-Tube to your nearest hospital emergency room.3. Gather all the supplies together before starting

Stomahesive®or D-TAD 5 cc Syringe

Tape Tap Water

Scissors Hy-Tape (½ inch) (Pink Tape)

Foley Catheter (same size) Cloth to wash skin

Cloth to dry skin

4. Check the Foley catheter by filling the balloon end with 5 cc’s of tap water before inserting tube into baby’s stomach. [this is to make sure the tube & balloon are working correctly.]

5. Remove the water from the tube before inserting tube into stoma. [make sure it’s working correctly first]

6. Wet the tip of the tube in tap water.

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7. Put the tip of the tube into the stomach opening (stoma).8. Pass the tube into the stomach about 1 inch past the balloon.9. Fill the balloon with 5 cc’s tap water.10. Gently pull tube to position balloon against the wall of stomach. Pulling the

tube too tightly will cause the opening to enlarge and formula may leak out around the tube.

11. Clamp tube.12. Apply D-TAD or Stomahesive dressing and tape tube in place.

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THE BUTTON GASTROSTOMY1. The Button gastrostomy is used in babies who have used a regular

gastrostomy tube for a month or more.2. Your baby needs to weigh about 10 pounds to use a Button Gastrostomy. This

is because the part of the button that is inside the baby’s stomach is larger than the tube you have been using.

3. The Button has a one-way valve inside that makes it difficult for milk to come out of the stomach and button. This means that babies who have problems with gas may not do well.

4. A special tube fits in the Button for the feeding. It is removed and the outside flap is closed after each feeding.

ADVANTAGES OF THE BUTTON1. You remove the feeding tube after the feeding.2. It looks better.3. Tube care is easy. You do not need to measure the tube or use special

adhesive dressings. Gastrostomy 7

Button Gastrostomy with feeding tube in place

Button Gastrostomy without the feeding tube and the flap closed

4. You have fewer skin problems.5. It lasts longer. The Button generally lasts 3-4 months before it needs to be

replaced. The one-way valve not working is the most common reason the Button needs to be changed.

DISADVANTAGES OF THE BUTTON1. You must take the baby to the doctor if the tube comes out or use a Foley

Catheter until another Button can be inserted.2. The valve that stops the formula from coming back up in the feeding tube may

get clogged and the tube may stop working.3. The feeding tube may become disconnected if your baby is active during

feeding.

INSERTING THE BUTTON1. The Button may be inserted in the doctor’s (surgeon) office or in the hospital.2. Your baby is given pain medicine before the Button is inserted. It stings when

the stoma is stretched before the Button is inserted.3. The doctor uses a guide to stretch the Button out so it can be inserted through

the stoma and into the stomach.4. Your baby will be fussy several hours after the Button is inserted. The doctor

may have you use Tylenol® or pain medicine to make the baby comfortable. a. Only give the baby the medicine the doctor tells you to.b. The baby will recover by the next day, if he has not; call the baby’s doctor.

5. The stoma may be weepy or bleed slightly the first day or two.6. Turn the Button in a complete circle each time you feed the baby the first 3-4

days after the Button in placed—or—follow the instructions of the doctor.

BUTTON CARE1. Flush the tube and Button with 5 cc’s of tap water after each feeding. This will

stop the Button from getting clogged up as easily.2. Clean the inside of the Button with a Q-Tip® and tap water daily.

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SKIN CARE

GENERAL INFORMATION1. Plan to do the cleaning before feeding the baby.2. Gather all equipment before beginning care:

a. Mild soap (such as Dial® or Ivory or Johnson’s Baby soap)b. Warm waterc. Cloth to wash skind. Cloth to dry skin

3. Wash your hands4. Wash the skin with soap and water 1-2 times a day.5. Rinse well with clear water.6. Pat the skin dry and leave open to air for about 15 minutes.

a. Do not rub the stoma or the skin around it as this may irritate the area and/or make it bleed.

7. Inspect the skin for redness or bleeding. If the skin is weepy or if a rash is present, see the section “care of irritated skin” for more information.

IF YOU HAVE A G-TUBE (FOLEY CATHETER)You will also need the following supplies:ScissorsHy-tape ½ inch (Pink Tape)Stomahesive® or D-TAD

IF YOU HAVE A BUTTON1. Gather all equipment before beginning care.2. Wash your hands.3. Wash the skin with soap and water 1-2 times a day.4. Rinse well with clear water.5. Pat the skin dry and leave open to air for about 15 minutes.

a. Do not rub the stoma or the skin around it as this may irritate the area and/or make it bleed.

6. Inspect the skin for redness or bleeding. If the skin is weepy or if a rash is present, see the section “care of irritated skin” for more information.

7. Turn the Button a quarter (¼) turn 1-2 times a day. This will change the position of the feeding tube each time.

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CARE OF IRRITATED SKIN

WEEPY SKIN METHOD #11. If the skin is weepy or blistered, wash the area with water. Pat dry.2. Apply a thin layer of calamine lotion as follows:

a. Do not shake the bottle.b. Let lotion sit until the water comes to the top of the bottle.c. Pour off the top water and use the thick pink cream that settled to the

bottom d. Apply a THIN layer and let it dry to a pink powder.

3. Place D-TAD or Stomahesive dressing over the dried powder layer.4. Call the doctor if the area is not better in 1 week.

WEEPY SKIN METHOD #21. If the skin is weepy or blistered, wash the area with water. Pat dry.2. Sprinkle Stomahesive powder on weepy skin.3. Dust off extra powder. A cosmetic brush (used only on the baby) works well.4. Apply D-TAD or Stomahesive dressing.5. Repeat every 3-4 days until skin is healed.6. Call the doctor if the area is not better in 1 week.

RASH1. If skin looks like it has “prickly heat” or “diaper rash,” wash the area with

water. Pat dry.2. Apply a THIN coat of Aseptin™ or Micro-Guard™ cream.3. Massage the cream into the skin for at least 2 minutes and let dry.4. Apply the D-TAD or Stomahesive dressing.5. Repeat every 2-3 days until skin is healed.6. Call the doctor if the area is not better in 1 week.

CARE OF GRANULATION TISSUE1. A build-up of red or pink skin around the stoma and tube is called granulation

tissue.2. This tissue may become irritated and bleed.3. The area may become moist and gushy until the granulation tissue is gone and

the area healed.4. Clean the area around the G-Tube or Button 2-3 times a day with a solution

made of half hydrogen peroxide and half water.5. It is helpful to cut a larger hole in the Stomahesive. This lets you clean the

area while it is healing. 6. A tape bridge will keep the tube taped to the Stomahesive and let you clean

without changing the Stomahesive dressing often. (see Dressing Change section)

7. The D-TAD can also be used.8. Call the doctor if the area is not better in 1 week.

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Note: Granulation tissue is usually due to excessive moisture so it is very important to keep the skin around the stoma as dry as possible and to identify the cause of the excessive moisture.

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DRESSING CHANGES

STOMAHESIVE ® DRESSING 1. Change the Stomahesive dressing 2 times a week.

a. Change it immediately and check the site if the area has an odor (smells badly), if you see drainage or if there is redness and/or swelling.

2. Gather all your supplies before you begin. a. Scissorsb. Hy-tape ½ inch (Pink Tape)c. Stomahesive

3. Wash your hands.4. Remove the old dressing.5. Wash skin around the tube. Pat dry.

a. Check for redness and/or bleeding. b. Look for a build-up of red or pink skin around the stoma.

6. Cut a round piece of Stomahesive. Make a slit on one side and cut out a small hole in the center for the tube to fit into.

7. Remove the white paper backing from the Stomahesive wafer.8. Put the wafer over the skin and around the tube. 9. Gently press the Stomahesive down for a minute so it will stick to the skin.10. Make a tape bridge using the pink tape and attach to Stomahesive.

a. This stops the tube from moving into the stomach and prevents its accidental removal when the tube is pulled on.

b. Take care to keep tape off unprotected skin.

11. Check the tube length 2 times a day to make sure it has not moved too far into the stomach.a. If it moves too far into the stomach, gently pull on the tube and re-position

it correctly and re-secure it.b. If you are unable to pull the tube out and re-position it, remove the water

from the balloon and remove the tube completely. Replace the tube and refill the balloon.

12. If the Stomahesive wafer pulls up off the skin or rolls at the edge, place a small piece of pink tape on it to help keep it in place until you can change the dressing.

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D-TAD DRESSING (DRAIN-TUBE ATTACHMENT DEVICE1. Change the D-Tad every 4-5 days.

a. Change it immediately and check the site if the area has an odor (smells badly), if you see drainage or if there is redness and/or swelling.

2. Clean around the clamp every day with a Q-Tip® wet with tap water.3. Gather all your supplies you need before you begin.

a. Scissorsb. Hy-tape ½ inch (Pink Tape)c. D-TAD device

4. Wash your hands.5. Remove the old D-TAD dressing.6. Wash skin around the tube with water. Pat dry.Look at the skin for redness or bleeding. Watch for a build-up of red or pink skin around the stoma .7. Trim D-TAD wafer around plastic clamp and cut the precut hole larger, as

needed.8. Remove paper back from D-TAD.9. Open clamp and place D-TAD around tube and onto skin.10. Close clamp on tube to hold in place.

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FEEDING

1. Gather all your supplies and formula before beginning the feeding:a. Formulab. Pacifierc. Medicine (if ordered)d. 60 cc syringee. Tap water

2. Make your baby comfortable: a. Change his diaperb. Suction if neededc. Offer a pacifierd. Place in an infant seat or on the bed with head elevated.

3. If the baby has a Button Gastrostomy, attach the feeding tube adapter4. Unclamp gastrostomy tube.5. Check for formula left in stomach from last feeding (residuals) by attaching a

syringe to the tube and pulling back on the plunger. a. If you get any residual give it back to your baby. b. DO NOT throw this away. It contains important nutrients. c. If more than 15-20 cc’s of formula (residual) are present, call your doctor or

follow the instructions the doctor has given you before starting the feeding.

6. Clamp the tube7. Remove the syringe from the tube8. Remove the plunger from the syringe and attach syringe barrel to the open

end of the gastrostomy tube.

9. Hold the syringe upright above the baby.10. Pour formula into the syringe and add any medicines.11. Unclamp the tube and let the feeding begin to flow.

a. If the feeding doesn’t flow, a gentle push with the plunger may be needed to start the flow.

b. Feeding should flow by gravity. Do not force the feeding.c. Feeding should run about 2-3 cc’s per minute or be finished in about 20

minutes. Gastrostomy 14

d. If the feeding seems to be running in too fast, lower the syringe a few inches, but keep it above the baby.

12. Add more formula as the syringe begins to empty. a. Do not allow the syringe to empty completely. This will prevent air from

getting into the stomach.b. Pinch the tube off while adding formula

13. DO NOT LEAVE THE BABY UNATTENDED (ALONE) DURING A FEEDING

14. Take care to make sure neither the feeding tube nor the syringe comes loose during the feeding as formula will spill all over the baby. a. If this happens, re-attach the tube or syringe and re-feed the amount of

formula you think was lost.b. If you have questions or concerns about re-feeding your baby, call your

baby’s doctor before doing this. 15. When the feeding is completed, flush the tube with 3-5 cc’s of tap water to

clear the tubing.16. If your baby has a G-Tube:

a. Clamp the tube using a syringe cap in the tubing or double the tube back on itself and wrap a rubber band around it.

17. If your baby has a button: remove the feeding tube and close the flap.a. Feeding should not come back up the button because it has a one-way

valve.b. If you notice feeding coming back up in the button, call your baby’s doctor.(see picture on the next page)

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18. Try to burp your baby. The baby may not burp if he’s had a Nissen Fundoplication.a. If the baby has burped and still seems to have stomach discomfort or

enlargement, attach the syringe barrel and hang the unclamped tube above your baby for 20 minutes to 1 hour may help. This lets your baby “burp.”

19. After feeding, place the baby on his right side or on his stomach with his body elevated (propped up) at a 300 angle.

20. Clean the equipment by washing the syringe in hot soapy water. a. Let it air dry. b. Store in clean towel.

INCREASING FEEDINGS1. DO NOT increase your baby’s feedings unless the baby’s doctor tells you to.2. Feedings are usually increased based on the baby’s weight gain and the

calories he needs for growth.3. Your baby should be weighted once a week either at the baby’s doctor’s office

or at the Public Health Department.4. This will help the doctor make changes in the baby’s feedings

NIPPLE FEEDINGS1. The baby’s doctor will talk with you about when to start nipple feedings. Do

not try nipple feeding your baby without talking with the doctor.2. If your baby is allowed to nipple part of his feeding, the nipple feeding should

be tried before the gastrostomy feeding.3. If your baby does not nipple feed all of his daily feedings, give the 1 or 2 night

feedings by G-Tube.a. This should be done if your baby is asleep or sleepy at that time.b. This may let you get some extra rest.

4. As the baby’s nipple feedings increase, the night feedings can be changed to nipple feedings.

OTHER FEEDING INFORMATION1. If your baby cries or strains to have a bowel movement, formula may back up

into the syringe.2. Briefly pinch the tube closed.3. Help to calm your baby.4. Restart the feeding when he is calm and quiet.5. You may hold your baby during the feeding when you are more comfortable

with feeding your baby by the G-Tube/Button.

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SUPPLIES & EQUIPMENT

SUPPLIES1. The hospital makes arrangements with a supply company near where you live

to get the supplies you will need. The supply company will contact you at home.

2. Do not use your home supplies while your baby is in the hospital.3. Call the supply company if your equipment breaks or to reorder supplies.4. Families with insurance should call the company or caseworker before

reordering supplies. a. The insurance company may not pay for them otherwise. b. The insurance company will tell you how they want this done. They work

with the supply company to make sure you have what your baby needs.5. You will need to order new feeding tubes about every 6 months or if the

adapter that goes into the button does not fit well.

CLEANING & STORING TUBES1. Wash the feeding tube in hot soapy water, rinse well and air dry after each

feeding.2. Wash the feeding tubes once a week with a vinegar (acetic acid) and water

mixture. a. Mix 16 ounces of tap water and 16 ounces of white distilled vinegar.b. Make a new vinegar and water mixture each time.

3. To use the vinegar mixture:a. Wash the tube with mild liquid detergent and tap water. Bottled water

may be used. b. Soak feeding tubes in vinegar mixture for 3 hours or overnight.c. Remove from vinegar mixture. d. Rinse well with tap water and air dry.e. Throw away used vinegar and water mixture.

4. Store feeding tube in a clean towel or baggie.

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HELPFUL HINTS

MEDICINES1. Thick medicines can clog the Button or G-Tube. They need to be diluted with

water or formula before placing them in the syringe.2. Let your pharmacist know that your baby has a feeding tube.3. Medicine in tablet form must be crushed and mixed with water or formula

before being placed in the syringe.4. Give medicines at the beginning of the feeding. The remainder of the feeding

can wash all the medicine down the tube.

MOUTH CARE1. Clean your baby’s mouth and nose at least once a day to keep his mouth &

nose clean.2. Clean your baby’s mouth and nose with cotton swabs and warm water

BABY CARE1. Babies with G-Tubes may have a visiting nurse or Public Health Department

referral to help with questions or concerns once you are at home.2. It is a lot of work taking care of a baby with special problems.3. We suggest that several family members learn the baby’s care so everyone

can get some rest or go out.

PLAY1. You do not need to limit your baby’s play, but do keep an eye on the G-Tube.2. Do not play with the baby for approximately 30 minutes after a feeding.

DOCTOR VISITS1. You will be given appointments times for your 1st visit with each doctor

(specialist and pediatrician) before going home.2. Be sure to take your baby to the pediatrician for routine baby care and shots. 3. As your baby’s health gets better, the visits to the specialist become less often

but it is still important to keep your scheduled appointments.

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CALL THE DOCTOR IF….1. Bloody residuals (formula left in baby’s stomach between feedings) are noted

at the beginning of a feeding.a. The residual may appear bright red or look like coffee grounds.

2. Residuals are greater than 15-29 cc’s or as instructed by your doctor.3. Stomach enlargement not helped by unclamping and hanging the tube for 1

hour.4. Frequent vomiting.5. Leaking formula around the G-Tube or stoma.6. You are unable to replace the G-Tube that has come out.7. Tissue build-up around the G-Tube.8. Unpleasant smell from the stoma or bleeding from the stoma.9. Button or G-Tube is clogged and formula will not go down the tube.

a. Attempt to flush 5 cc’s of tap water down the tube. b. Use very gentle pressure on the plunger. c. Stop if water does not flow easily.

10. Button comes out. a. Save the Button. b. Stoma will stay open for several hours. c. You can put in a Foley catheter until the Button can be replaced by the

doctor.

Reviewed/Revised:11/96, 1/97, 7/98, 6/01 8/05, 4/07, 5/10

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