Comparison of Tolerance and Complication Rates Between Early and Delayed Feeding After Percutaneous Endoscopic Gastrostomy Placement in Children.

BACKGROUND: Enteral nutrition is commonly initiated 24 hours after percutaneous endoscopic gastrostomy (PEG) in children. Adult studies report safe refeeding within 1 to 6 hours of PEG, and these findings have been cautiously applied to children. Comparative studies assessing early versus next-day refeeding in children are currently lacking. This study evaluates feeding tolerance and complications following early versus next-day refeeding in children. METHODS: This is a single-center, pre-post study. In June 2015 our clinical practice changed to begin refeeding within 6 hours of PEG. Children receiving early refeeding from December 2015 to August 2017 were included. A retrospective cohort from February 2013 to April 2015 was used for comparison. RESULTS: Forty-six children received early refeeding after PEG and 37 received next-day refeeding. Gender distribution was similar in the 2 groups. Early refeeding patients were slightly older (3.5 vs 2.2 years) and heavier (15.5 vs 11.5 kg) at PEG placement compared to next-day refeeding patients. Early refeeding patients experienced greater postprocedural nausea and/or vomiting (19% vs 8%, P < 0.001) and leakage, irritation, and infection around the stoma (19% vs 0.0%, P < 0.001). Compared to early refeeders, next-day refeeding patients experienced higher occurrence of fever (35% vs 13%, P = 0.021), longer nutritional disruption (24.6 vs 3.7 hours, P < 0.001), and longer length of stay (51 vs 27 hours; P < 0.001). One next-day refeeding patient experienced peritonitis. One early refeeding patient experienced cellulitis requiring hospitalization and a second experienced gastrostomy tube migration into the peritoneal cavity requiring removal. CONCLUSION: Early refeeders experienced higher rates of postprocedural nausea or vomiting and irritation, leakage, or infection around the stoma; but experienced lower rates of postoperative fever. Early refeeding resulted in reduced nutritional interruption and hospital length of stay.

Quality Improvement Initiative: The Administration of Early Nutrition Following Percutaneous Endoscopic Gastrostomy Tube Placement in Children.

It is common practice for providers to wait up to 24 hours to begin enteral feedings using a newly placed gastrostomy tube in children. As a quality improvement initiative, guidelines were developed to begin early enteral nutrition 4 hours following gastrostomy tube placement. These patient care guidelines standardized electronic ordering, dosing, and feeding administration instructions. Healthcare professionals from the departments of gastroenterology, case management, and nutrition were asked to evaluate the new process by completing a questionnaire. Changes were made to the quality improvement initiative on the basis of the feedback received from the questionnaires. The early feeding initiative aimed to improve patient outcomes and enhance the quality of care received following the child's gastrostomy procedure. These guidelines will then be used in a prospective clinical trial to evaluate the validity of the quality improvement initiative.

Endoscopic closure of persistent gastrocutaneous fistula in children.

PURPOSE: The incidence of persistent gastrocutaneous fistula (GCF) after removal of gastrostomy tubes in pediatric patients is estimated to be up to 44 %. Our aim was to review the outcomes of GCF closure by an endoscopic technique that utilizes cautery and endoclips. METHODS: A retrospective analysis of patients who underwent endoscopic treatment for persistent GCF from January 2010 to September 2013 was performed. This technique utilized esophagogastroduodenoscopy with cauterization of the fistula track and endoclipping of the gastric mucosa. RESULTS: Sixteen patients underwent endoscopic treatment for persistent GCF. Mean age at time of endoscopy was 7.5 ± 5.5 (1.1-17) years. Gastrostomy tubes were in place for mean of 5.4 ± 5.2 (0.5-14.2) years prior to removal. The average time from gastrostomy tube removal to first endoscopic clipping was 6.7 ± 9 (0.1-28.9) months. Seven patients (44 %) had successful closure after one endoclipping procedure. Six patients underwent a second endoclipping procedure, with three successful closures. Four patients (25 %) required surgical closure for persistent fistulas and 2 (13 %) have continued drainage. CONCLUSIONS: While endoscopy with cautery and endoclipping proves to be safe, many patients require multiple procedures and may require surgical closure. Patient selection and refinement of this technique may improve outcomes.

Isoniazid-induced severe hepatotoxicity: an infrequent but preventable cause of liver failure in children treated for latent tuberculosis infection.

Isoniazid (INH) monotherapy has gained widespread acceptance as an efficacious therapy for latent tuberculosis infection (LTBI) especially in low-prevalence settings. Although INH related hepatotoxicity is well recognized, progression to severe liver dysfunction requiring care at a transplant center remains unpredictable. We report the management of a five year-old girl who developed progressive liver failure due to INH prophylaxis. This highlights the potential severity of INH related hepatic injury and underscores the significance of vigilant clinical monitoring throughout the duration of the therapy in children.