Enteral feeding tubes and home enteral nutrition — structured clinical encounter

Station brief (candidate)

You are the paediatric registrar in a general paediatric clinic. A four-year-old with severe cerebral palsy is referred because of an unsafe swallow on a videofluoroscopic study and faltering growth despite maximised oral feeding and fortification. Her weight has fallen from the twenty-fifth to below the third centile. The multidisciplinary team agrees that long-term enteral feeding is needed. The team asks you to choose the device and justify it, to outline the pre-gastrostomy assessment, to explain the device options and the likely conversion, to build the home enteral nutrition programme, and to describe how you would recognise the common and serious complications. You have twelve minutes with the team and five minutes for examiner discussion. [8]

Information available on request

• Four years old, severe cerebral palsy, non-ambulant; unsafe swallow on videofluoroscopic study with aspiration of thin liquids. [8]
• Mealtimes over an hour, ending in a wet cough; oral intake maximised and fortified for three months without improvement. [8]
• Weight fallen from the twenty-fifth to below the third centile over nine months; height centile also falling. [12]
• Reflux reported by parents as occasional regurgitation; no formal pH or impedance study yet performed. [8]
• Coagulation and full blood count normal; no previous abdominal surgery. [1]

Tasks

1. Choose the enteral access device and justify why a nasogastric tube is not the long-term choice. [1]
2. Outline the pre-gastrostomy assessment, including the reflux and nutritional evaluation. [8]
3. Explain the device options (percutaneous endoscopic gastrostomy versus low-profile balloon button) and the likely conversion between them. [1] [10]
4. Build the home enteral nutrition programme for this family. [8]
5. Describe how you would recognise the common and serious complications, including buried bumper syndrome and a dislodged gastrostomy. [7]

Marking anchors

Must-hit

• Chooses a gastrostomy because feeding will last well beyond four to six weeks, and explains that a nasogastric tube is the short-term choice for feeding under four to six weeks and is not the long-term answer because it dislodges, irritates the nose and requires repeated verification. [1]
• Outlines a pre-gastrostomy assessment that quantifies the nutritional deficit by plotting growth, assesses reflux and aspiration (because uncontrolled reflux may change the choice to a post-pyloric device or prompt an anti-reflux procedure), and checks coagulation and full blood count. [8]
• Describes the device options, naming a percutaneous endoscopic gastrostomy with an internal bumper and external flange and a low-profile balloon gastrostomy button retained by a water-filled balloon, and explains that a PEG is commonly converted to a button once the tract has matured, around six to twelve weeks. [1] [10]

Merit

• Builds a home programme of trained carers able to run the feed and look after the stoma, reliable supplies of formula and consumables with a spare device, regular growth and micronutrient monitoring, and a clear written emergency plan for the blocked, dislodged or infected tube; and recognises stoma infection and granulation tissue as the common complications and buried bumper syndrome (feed that will not run with abdominal pain) and intraperitoneal leak with peritonism as the serious ones, replacing a dislodged gastrostomy promptly because the stoma closes within hours. [8] [7]

Fail

• Recommends a long-term nasogastric tube for years of feeding, or proceeds to a gastrostomy without assessing reflux or nutrition. [1]
• Cannot describe how to recognise buried bumper syndrome or what to do for a dislodged gastrostomy, or plans to delay replacement of a fallen tube. [7]