What is the best course of action for a 17-month-old female who is Gastrostomy tube (G-tube) dependent and presenting with coughing, dehydration, and vomiting up G-tube contents?

Immediate Management of G-tube Dependent Infant with Vomiting and Dehydration

This 17-month-old requires immediate assessment for dehydration severity, temporary cessation of G-tube feeds, and initiation of intravenous rehydration if moderate-to-severe dehydration is present, followed by systematic evaluation for G-tube complications including tube malposition, infection, or gastric outlet obstruction. 1, 2

Initial Assessment and Stabilization

Evaluate Dehydration Severity

• Assess for clinical signs of ≥5% dehydration: abnormal capillary refill, abnormal skin turgor, and abnormal respiratory pattern are the three most useful predictors 2
• Check vital signs and mental status, as altered consciousness indicates severe dehydration requiring urgent intervention 2
• Consider obtaining serum bicarbonate if available—levels ≤13 mEq/L predict need for prolonged IV therapy and likely hospital admission 3
• Low serum bicarbonate combined with clinical parameters effectively predicts significant dehydration 2

Immediate Interventions

• Stop all G-tube feeds immediately to allow gastric decompression and prevent further vomiting 1
• Initiate rapid IV rehydration with 20-30 mL/kg isotonic crystalloid over 1-2 hours for moderate dehydration 3, 4
• This approach corrects dehydration and resolves vomiting in 72% of children with gastroenteritis-related dehydration 3
• Monitor for improvement in hydration status during and after fluid bolus 3

Evaluate for G-tube Complications

Check Tube Position and Function

• Verify the G-tube has not migrated or become dislodged—accidental removal occurs in 1.6-4.4% of cases 1
• If the tube was recently replaced or manipulated, consider that immature tracts (within first 7-10 days) can separate, causing free perforation 1
• Examine for tube migration into the colon (gastrocolocutaneous fistula), which presents with diarrhea resembling formula during feeding 1
• Assess tube patency—occlusion occurs in 3.5-35% of gastrostomy tubes 1

Inspect the Stoma Site

• Look for peristomal infection: erythema, purulent/malodorous exudate, fever, and pain 1
• Check for excessive granulation tissue, which is vascular, bleeds easily, and may be painful 1, 5
• Assess for peristomal leakage of gastric contents, which indicates tract enlargement or excessive tension between bolsters 1
• Verify proper tension between internal and external bolsters—excessive pressure causes ulceration and tract enlargement 1

Consider Underlying Causes of Vomiting

Gastric Issues

• Gastroparesis and increased gastric acid secretion are common causes of vomiting in G-tube dependent children 1
• Consider starting a proton pump inhibitor to decrease gastric acid secretion and minimize leakage 1
• Evaluate for constipation and increased abdominal pressure, both risk factors for vomiting and tube complications 1

Respiratory Component

• The coughing may indicate aspiration from gastroesophageal reflux exacerbated by large fluid volumes 1
• This is particularly common in tube-fed infants and can lead to recurrent pulmonary infections 1
• Consider chest examination and possible chest radiograph if respiratory symptoms are prominent 1

Resuming Feeds After Stabilization

Gradual Feed Advancement

• Once vomiting resolves and the child tolerates 1-3 ounces of clear oral fluid, begin slow G-tube feeds 3
• Start with small, frequent feedings to avoid overwhelming the stomach 1
• Careful spacing of feeds and fluid reduces gastroesophageal reflux and vomiting 1

Feed Modifications

• Consider continuous overnight gastric feedings rather than bolus feeds if vomiting recurs 1
• Ensure feeds are at room temperature and administered slowly 1
• Monitor blood glucose before feeds if there's concern for metabolic issues 1

When to Admit

Admission Criteria

• Children with serum bicarbonate ≤13 mEq/L typically require prolonged IV therapy and admission 3
• Inability to tolerate oral/G-tube fluids after rapid IV rehydration necessitates admission 3, 4
• Signs of peritonitis, severe infection, or tube-related perforation require immediate surgical consultation 1
• Persistent vomiting despite IV rehydration and feed modifications warrants inpatient management 6

Common Pitfalls to Avoid

• Do not resume G-tube feeds before vomiting has resolved and hydration is corrected—this perpetuates the cycle 1
• Avoid replacing the tube with a larger diameter, as this enlarges the stoma tract and worsens leakage 1
• If the tube was accidentally removed within 7-10 days of initial placement, do not blindly replace it—use endoscopy or image guidance to prevent free perforation 1
• Do not ignore the coughing—it may represent aspiration requiring feed modification or gastrojejunal tube placement 1
• Ensure adequate follow-up within 24-48 hours if discharged from the emergency department 3