Is a surgical gastrostomy (gastrostomy) tube better tolerated than a nasogastric (NG) tube in pediatric patients for long-term enteral nutrition?

Gastrostomy Tube vs Nasogastric Tube in Pediatric Patients

For pediatric patients requiring long-term enteral nutrition (>2-3 weeks), gastrostomy tubes are significantly better tolerated than nasogastric tubes, with superior outcomes in comfort, complications, nutritional efficacy, and quality of life. 1

Duration-Based Decision Algorithm

The choice between NG and gastrostomy tubes should be guided by anticipated feeding duration:

Short-Term Feeding (<4-6 weeks)

• Nasogastric tubes are appropriate for short-term nutritional support in pediatric patients 1
• Fine-bore NG tubes (5-8 French gauge) minimize nasal and esophageal irritation 1
• Can be extended beyond 6 weeks when gastrostomy placement is not suitable or feasible 1

Long-Term Feeding (>2-3 weeks to 6 weeks)

• Percutaneous endoscopic gastrostomy (PEG) should be preferred when enteral nutrition is expected to exceed 2-3 weeks 1
• The 2022 ESPEN guidelines recommend PEG placement for feeding needs >6 weeks (Grade B recommendation, 93% consensus) 1, 2
• Earlier consideration at 2-3 weeks is supported by the 2005 ESPEN guidelines specifically addressing pediatric populations 1

Evidence for Superior Tolerance of Gastrostomy Tubes

Complication Profile

Nasogastric tubes have significantly higher rates of:

• Discomfort and local irritation 1
• Nasal and esophageal ulceration and bleeding 1
• Tube dislodgement (tubes "fall out" easily) 1, 2
• Tube clogging 1

Gastrostomy tubes demonstrate:

• Lower intervention failure rates (including feeding interruption, tube blocking, tube leakage, poor adherence) 2
• Significantly lower risk of tube dislodgement 1, 2
• Reduced rates of esophageal reflux 1
• Reduced rates of aspiration pneumonia 1

Quality of Life and Social Acceptance

• Gastrostomy tubes provide higher subjective and social acceptance in pediatric patients 1
• Less stigmatizing appearance compared to visible nasal tubes 1
• Better quality of life outcomes including reduced inconvenience, discomfort, and improved social activities 1, 2
• Patients receive more of their prescribed feed with gastrostomy tubes 1

Nutritional Efficacy

• Gastrostomy feeding is superior in nutritional efficacy compared to NG tubes 1
• Better improvement in nutritional status including weight gain, mid-arm circumference, and serum albumin levels 2
• Body weight maintained more effectively 1

Safety Outcomes

Mortality and Aspiration

• No significant difference in overall mortality rates between PEG and NG tubes across pediatric populations 1, 2
• No significant difference in aspiration pneumonia rates in systematic reviews 1, 2
• High mortality after PEG placement is typically due to underlying disease severity, not the procedure itself 1

Important Caveats for Pediatric Populations

When to Consider Delaying Gastrostomy

Adolescents (≥12 years) and traumatic brain injury patients warrant special consideration:

• 15% of pediatric inpatient gastrostomy tubes are used for <6 months 3
• Short-term use is more common in adolescents (22.7% vs 4.0% in younger children) and TBI patients (18.2% vs 4.2%) 3
• Consider trial of NG feeding in these populations before proceeding to surgical gastrostomy 3
• One-third of patients with short-term gastrostomy use required gastrocutaneous fistula closure (median charges $29,989 per patient) 3

Potential Advantages of NG Tubes in Specific Contexts

• Less dysphagia in some patient populations 1, 2
• Earlier weaning after completion of radiotherapy in head and neck cancer patients 1, 2

Decision-Making Support for Families

• Decision-making in pediatric gastrostomy placement is difficult and emotionally laden for parents 1
• Families require extensive information and individualized support 1
• Current practice shows significant variability in timing and criteria for transitioning from NG to gastrostomy 4
• The most common factors prompting transition are exceeding temporary feeding duration or need for extended feeding 4

Gastrostomy Placement Technique Considerations

PEG vs Surgical Gastrostomy

• PEG should be preferred over open surgical gastrostomy (Witzel, Stamm, Janeway techniques) 1, 2
• PEG has lower complication rates, reduced costs, and shorter procedure time 1, 5
• Surgical or laparoscopic approaches reserved for anatomic difficulties or when concurrent intra-abdominal procedures are needed 5

Post-Procedure Care

• Proper exit site care during the first 5-7 days is essential to prevent infections 2
• Button systems can be considered after 4 weeks once stoma matures, primarily for cosmetic reasons in socially integrated younger patients 1

Special Situations Requiring Jejunal Access

Consider percutaneous endoscopic jejunostomy (PEJ) or PEG with jejunal extension when:

• Gastroduodenal motility disorders are present 2, 6
• Gastric outlet stenosis exists 2, 6
• High aspiration risk with gastric feeding 2, 6
• Delayed gastric emptying 1

Common Pitfalls to Avoid

• Do not delay gastrostomy placement unnecessarily when long-term feeding (>2-3 weeks) is clearly anticipated 1
• Do not use large-bore PVC NG tubes as they increase gastric reflux and aspiration risk; use fine-bore tubes instead 1
• Ensure proper patient selection by confirming adequate gastrointestinal function and realistic prognosis 1
• Address physician barriers including reluctance for referral from primary care providers 4
• For home NG tube use, ensure families are taught pH paper verification of tube placement and provided with pH paper 4