Making the GJ Decision: When Gastric Feeds Aren’t Tolerated
There is nothing more difficult than watching your child retch and vomit 20 times a day, clearly in pain and discomfort. Your heart literally aches to see your child in that much agony. Most children with this level of vomiting already have feeding tubes, because their digestive motility problems and other medical conditions demand them. But what do you do when regular gastric feedings are not being tolerated through a G-tube?
Sometimes, the best option is to try a Gastro-Jejunal or GJ-tube instead. This article will help you to determine if a GJ-tube might be a good option for your child.
Benefits of the GJ-Tube
A GJ-Tube is similar to a regular G-tube in that it enters the stomach using the same stoma or site as a G-tube. However, unlike a G-tube that empties right into the stomach, the GJ-tube has a longer tube (15-30cm) on the inside that empties into the small intestine, in the area called the Jejunum. In most cases, there are actually two separate ports, one that empties into the stomach (the G port) and one that empties into the intestine (the J port). Occasionally, children may have a tube that does not have a G port.
The purpose of the GJ-tube is to feed slowly into the intestine. This helps improve feeding tolerance for several reasons. First of all, the stomach is not used at all for feeding. Without any food in the stomach, there is less reflux, vomiting, or visceral pain in the stomach. If gastric secretions or air are still accumulating in the stomach and causing symptoms, the GJ-tube allows venting and draining through the G port.
In addition, the GJ-tube empties directly into the region where nutrients are typically absorbed. This means that you do not need to wait for the stomach to empty into the intestine for feeds to be absorbed. In children with significant delayed gastric emptying, this benefit of the GJ-tube is considerable.
Drawbacks to the GJ-Tube
The GJ-tube is a bit more complicated than having a simple G-tube. First of all, the intestine cannot expand to accommodate food like the stomach can, so feeds must be continuous, typically 18-24 hours per day. Also, since food does not pass through the stomach, children typically require a formula with broken down proteins that are easy to absorb.
The GJ-tube is unable to be replaced at home. If it is pulled out or breaks, you must go to a hospital with a specialized Interventional Radiology team to have it replaced. Many local or community hospitals neither carry the tubes nor have staff available on a daily basis to change out the tube. If the tube falls out at night or on a weekend, often the child must be admitted even if the hospital has the equipment, since changes are only available during business hours. Routine changes must be made every three to six months, which means a lot of extra trips to the hospital.
While changing the GJ-tube isn’t usually painful, it can be uncomfortable. Some children may also have anxiety during the procedure because they will need to lie still on a table for about 15 minutes. In some cases, children may need sedation during the procedure. Some children also have problems with the long tube into the intestine migrating or coiling upward into the stomach. If this happens, the tube must be replaced. Often, using a tube with a longer J-portion, such as 30cm, or choosing a tube designed to prevent migration may help.
Finally, the GJ-tube requires more equipment, since there are two ports, and children often vent and drain the G port. GJ-tubes are also more prone to clogging, due to the smaller diameter of the J portion of the tube, and may tug at the site a bit more due to their increased size.
Before Going to the GJ-Tube
The GJ-tube is a great option for many children, but it is important to try a variety of other changes to improve feeding tolerance before moving to it. Here are some techniques to try before switching:
- Vent the tube before and after feeding, or use a Farrell bag to vent continuously.
- Try slow, continuous feeds. Remember that a GJ-tube requires continuous feeds anyway, so it is worthwhile trying continuous feeds through the stomach before switching to a GJ-tube.
- Try other changes to the feeding schedule, such as longer feeds or feeding at a different time of the day.
- Try a different formula or blenderized diet. Some children have better luck with an easily digestible formula, such as an elemental formula. Others do better with a thicker, whole foods diet, such as a commercial or homemade blenderized diet. Changing the caloric composition of the formula may also help.
- Make sure any medical conditions, such as reflux, allergies, or constipation, are being treated appropriately.
- Consider medications for visceral hyperalgesia, a condition that makes the gut oversensitive, or medications for poor motility.
Trialing a GJ-Tube
One of the best things about a GJ-tube is that it is not a permanent intervention. It can be placed without surgery, and if it does not work, it can be removed easily. Children can return to gastric feeds at any time, with or without the tube in place.
The GJ-tube also gives you options. If your child tolerates feeds most of the time, but has frequent periods of intolerance, you can feed the G port most of the time and only use the J port as needed. If your child improves, all feeds can be transitioned to the G port, and the tube can eventually be changed back to a regular G-tube. Sometimes, just giving the stomach a chance to rest for a little while will really help a child. In addition, oral feeds may be continued with a GJ-tube if they are tolerated. In some cases, children who cannot tolerate oral feeds but want to eat can use a GJ-tube to drain anything consumed orally while being fed formula into the intestine.
Making Your Decision
There are definitely pros and cons to the GJ-tube. But if you have tried everything else possible and feeding intolerance continues to occur, it may be just the thing your child needs. Talk to your doctor about trialing a GJ-tube if your child has ongoing vomiting, retching, or other serious symptoms of feeding intolerance.