Enteral feeding tubes and home enteral nutrition — branching viva

Station opening

Examiner: "When do you choose enteral over parenteral nutrition in a child, and how do you decide between a nasogastric tube and a gastrostomy?" [1]

Strong candidate (must-hit)

• States that enteral nutrition is preferred whenever the gut is functional because it feeds and protects the gut mucosa, avoids the line-infection and liver risks of parenteral nutrition, and is cheaper; chooses the device by the expected duration of feeding, with a nasogastric tube for short-term feeding under four to six weeks and a gastrostomy, as a percutaneous endoscopic gastrostomy or low-profile balloon button, for anything longer, adding a post-pyloric jejunostomy or gastrojejunostomy when reflux, aspiration or gastric intolerance make the stomach unsafe. [1]

Weak candidate

• "A gastrostomy is for any child who cannot feed, and I would put one in straight away." [1]

Branch A — The child with cerebral palsy referred for a gastrostomy

Examiner: "A four-year-old with severe cerebral palsy has faltering growth and an unsafe swallow. What is your assessment before a gastrostomy, and would a nasogastric tube do instead?" [8]

Strong

• Explains that because feeding will last well beyond four to six weeks, a gastrostomy is appropriate and a nasogastric tube is not the long-term choice; the pre-gastrostomy assessment 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, checks coagulation and full blood count, and confirms the indication and consent with the family. [8]

Weak

• "I would just book the gastrostomy and not worry about reflux." [8]

Branch B — The nasogastric tube whose pH will not confirm

Examiner: "A newly passed nasogastric tube gives aspirate with pH 6.5, and the child is not on acid suppression. What do you do, and what would you tell a nurse who wants to use the whoosh test?" [4]

Strong

• Explains that a pH above 5.5 is not acceptable as sole confirmation, so the safe next step is X-ray confirmation reading the tube tip below the diaphragm within the stomach before feeding; tells the nurse the whoosh test is unreliable and must not be used as sole confirmation because it cannot distinguish gastric from oesophageal or airway placement, and that the accepted standard is pH 5.5 or below, escalating to X-ray when equivocal, after first insertion, after dislodgement, and before the first feed in a high-risk child. [4]

Weak

• "The whoosh test is fine; just feed if it sounds right." [4]

Branch C — The non-functioning gastrostomy

Examiner: "A six-year-old with a long-standing percutaneous endoscopic gastrostomy has abdominal pain and feed that will not run despite flushing. What is the diagnosis, and what is the danger of repeatedly flushing?" [1]

Strong

• Recognises buried bumper syndrome, in which the internal bumper of the percutaneous endoscopic gastrostomy migrates into and erodes through the gastric wall so feed cannot pass; explains that repeatedly flushing will not help and delays the definitive management, which is endoscopic confirmation and endoscopic or surgical removal of the buried tube and replacement; names excessive traction on the tube and an over-tight external flange as the preventable drivers. [1] [7]

Weak

• "It must be blocked; I would flush harder and push a guidewire down." [1]

Branch D — The dislodged tube at home

Examiner: "A child's low-profile balloon button has just fallen out at home. What is the time-critical advice, and when should the family come straight to hospital?" [1]

Strong

• Advises replacing the tract promptly with a suitable Foley catheter or spare device to keep it patent, because a mature stoma can close within hours; tells the family to come straight to hospital if the tube cannot be replaced, if the dislodgement happened before the tract matured, or if the child develops peritonism, because intraperitoneal leak of feed is a surgical emergency needing nil by mouth, intravenous fluids and antibiotics, urgent imaging and surgical review. [1]

Weak

• "Come to clinic next week and we will replace it then." [1]

Close

Examiner: "Summarise your approach to paediatric enteral feeding tubes and home enteral nutrition in one sentence." [1]

Strong

• "Enteral feeding is the route whenever the gut works: I choose a nasogastric tube for short-term feeding under four to six weeks and a gastrostomy for longer, adding a post-pyloric tube for reflux or aspiration; I verify every nasogastric tube by pH 5.5 or below before feeding, never the whoosh test; I advance feeding cautiously with refeeding awareness; and I run a home programme of trained carers, supplies, monitoring and a clear emergency plan, while watching for granulation and stoma infection as the common complications and buried bumper and peritonism as the serious ones." [1] [4]