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

Abstract

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.

A clinical consensus paper on jejunal tube feeding in children

“…37 Children who require frequent GJT replacement for dislodgement or equipment issues or who have challenging GJT placement may benefit from consideration of a SJ. 26 There are several limitations related to this consensus paper, including inconsistency with definitions and classifications of JTs in the literature, heterogeneity, and low number of high-quality studies identified on this topic (many retrospective, with small sample sizes and lacking a comparator group). Although a systematic search strategy of multiple databases was undertaken, this study was not a systematic review and studies were included based on relevance and quality.…”

“…DJTs are inserted using either percutaneous placement of a tube from the abdominal wall directly into the proximal jejunum or by bringing a Roux-en-Y loop up from below the duodenojejunal flexure to the skin to form a stoma for catheterization with a feeding tube or button device. [27][28][29] Various insertion methods for jejunal feeding tube placement are described using endoscopic, radiological, and surgical techniques, as well as bedside approaches (for NJT), 26 and combined approaches may be used. nasointestinal tubes should be confirmed by x-ray prior to use for feeding, especially for blind insertion methods.…”

“…nasointestinal tubes should be confirmed by x-ray prior to use for feeding, especially for blind insertion methods. 26 Singh retrospectively reviewed 48 patients with JT feeding using different tube types and insertion methods, concluding a role for both SJ and GJT depending on individual patient circumstances and consideration of local expertise and resources. 32 In infants, a onestep method for GJT insertion via a de novo gastrostomy has been described in three patients using a neonatal endoscope and guidewire; however, most studies describe NJT use in this age group.…”

“…In some institutions, nasal tube retaining systems are used as a retention device for NJT to avoid accidental dislodgement and further radiation exposure with tube reinsertions; however, care should be taken with nasal tube retaining systems to avoid excessive pressure or trauma to the nasal passage. 26 Michaud retrospectively reviewed 29 children requiring conversion from GT feeding to JT feeding between 2001 and 2008 and identified 31 tube dislodgements, 16 blocked tubes, and seven patients with stomal leakage. 35 Blocked tubes and faulty or broken equipment frequently require troubleshooting by clinicians or trained carers experienced in feeding tube management, and tube replacement may be required.…”

“…26 Bedside techniques for NJT insertion with or without assistive devices may use strategies such as patient positioning (right lateral decubitus for gravity assistance), gastric insufflation, pH guidance, prokinetics, or electromagnetic devices 11,31. A recent systematic review on bedside postpyloric feeding tube insertion in hospitalized children found no conclusive best method but identified safety and efficacy of gastric air insufflation, however, minimal evidence to support efficacy of erythromycin use.…”