Transgastric jejunal tubes – in children

• Unlike gastrostomy tubes, transgastric jejunal tubes must not be rotated. This is because the rotation of the tube would cause a twist (kink) to occur in the jejunal tube.
• Instead of undertaking a tube rotation your child’s care team advise that you perform a 'push in and pull back' procedure twice a week. The purpose of this procedure is to try and prevent the internal bumper becoming buried in the stomach mucosa (a complication called ‘buried bumper’). To perform this procedure, undo the triangle fixation plate, gently push the tube into the gastrostomy tract for 2 to 4cm, then pull it gently back into position and re-secure the fixation plate. This will be discussed by your nurse specialist with you and your community nurses will support you to undertake this until you feel confident yourself.

• To prevent blocking, both the jejunal and gastric ports need to be flushed regularly.
• The tubes should be flushed with cooled, boiled water.
• Flushes should take place before a continuous feed is started and when it is stopped. In addition, a flush should be given before and after a medicine is put down the tube. If more than one medicine is being given, a flush should also be given between each medicine (see section on administration of medicines).
• Your dietitian will specify the amount of water to be used to flush the tube.
• If the gastric access ports are not being routinely used, flush every 24 hours with 10ml of water.
• If the jejunal access port is not being routinely used, flush every six to 12 hours with 5 to 10ml of sterile (cooled boiled) water.

• It is important to always wash your hands carefully before and after using the tube.
• Your child’s dietitian will recommend a feeding plan suitable for your child’s needs.
• Because your child will need to have their feed delivered slowly over the course of many hours, it will be given via a feeding pump (machine).
  Your children’s community nurse or nutrition nurse specialist will arrange teaching on how to use this pump. The pump will be fully portable for ease of use at home. Information leaflets about the actual pump itself will be provided for you.
• It is not necessary to check the position of the tube before starting the feed unless you are concerned that the tube does not have its normal appearance. If you are unsure, take an aspirate (pH should be six to eight).
• Prior to commencing the feed, check that the connectors are tight.
• Before the feed is started and when it finishes, water needs to be given to prevent the tube from blocking. This is normally at least 20ml but your dietitian will advise you on the exact amount for your child. If the water is being given from a syringe, it must be pushed in very slowly (2 to 3ml per minute). The water used should have been boiled and then allowed to cool.

Procedure:

1. Wash hands.
2. Set up the pump as taught.
3. Unscrew the cap from the relevant (gastric/ jejunal) port.
4. Flush the tube with . . . . . . . ml of cooled boiled water (remember to unclamp the tube).
5. Connect the feed as shown by the children’s nutrition nurse specialist.
6. Once the feed has been completed, wash your hands and flush the tube with . . . . . . . ml of water.
7. Reapply the clamp and screw the cap back on.

Replacing feeding sets:

• Feeding sets need to be changed every 24 hours.

• It is important to always wash your hands carefully before and after using the tube.
• Ideally, your child’s medication should be given into the stomach through the gastrostomy port. Where this is not possible, the jejunal port may be used but this must be in discussion with your specialist care team and children’s pharmacist. Reasons for this include the fact that some medicines need to mix with the acid in the stomach (that is not present in the jejunum) to work.
• Administering medication correctly will ensure that the medicine is absorbed properly. While you are in hospital, a member of your specialist care team and a children’s pharmacist will review your child’s medicines so you know which port to use for each medicine.
• Where medicines are being given through the jejunal port, the speed of administration should not exceed 2 to 3ml per minute (there is no limit regarding speed of administration through the gastric port). This is to increase the chances of the medicine being absorbed.
• Administering medication correctly will avoid the tube becoming blocked.
• Request that your child’s medication is provided in a liquid form.
• Some liquid medications are known to be associated with tube blockages and so need to be further diluted with water (same volume of water as medicine) before being given. Ask a member of your specialist care team if unsure.
• If medication is only available in tablet form, seek advice from your GP, pharmacist or nurse specialist. Some tablets can be crushed or mixed with water but others cannot as their particles can lead to tube blockages.
• The tube must be flushed before and after each medicine. If more than one medicine is being given, flush in between as well. The water used should have been boiled and then allowed to cool. For your child, flush with . . . . . . . ml before the medicine, . . . . . . . ml between each medicine and . . . . . . . ml after all medicines have been given.
• Please note, clarithromycin will block your child’s tube and so should never be given through the tube. This is an antibiotic commonly used for chest infections. Other antibiotics which sound similar (for example erythromycin) do not block tubes.

Procedure:

1. Wash hands.
2. Unscrew the cap from the relevant (gastric/ jejunal) port.
3. Connect syringe with flush in.
4. Release clamp.
5. Administer flush.
6. Apply clamp.
7. Disconnect flush syringe and connect syringe containing medication.
8. Release clamp.
9. Administer medication.
10. Apply clamp.
11. Disconnect medication and connect syringe containing the flush.
12. Release clamp.
13. Administer flush.
14. Repeat steps 6 to 13 for each medication.
15. Reapply the clamp and screw the cap back on.

What is decompression?

Some (but not all) children suffer from symptoms of trapped wind (also known as ‘gas bloat’) such as abdominal pain and/or abdominal distension. The trapped wind can be released by ‘gastric decompression.’ This is when the air is released through a syringe which is attached to the end of the gastric port of the PEG J tube. Gastric decompression may be required only occasionally or many times per day depending on the severity of the symptoms.

It is preferred that gastric decompression usually takes place via gravity (see procedure below). However, where this fails to resolve the symptoms, gastric decompression may be performed via aspiration (see note eight below) or via a continuous gastric decompression system (known as a ‘Farrell valve’).

Procedure:

1. Wash hands.
2. Remove the plunger from inside the 60 ml syringe (the plunger is not required for gastric decompression).
3. Connect the empty barrel of the syringe to the gastric port on the PEG J tube.
4. Hold the syringe approximately 10cm above the height of your child’s stomach.
5. Release the clamp.
6. Hold the syringe still for two minutes. You may be able to see bubbles of air coming up into the syringe. If there is a lot of air in the stomach you may also see some stomach secretions (and occasionally small amounts of milk feed) coming up into the syringe. These secretions will travel back down the tube and back into the stomach when all the air has been cleared.
7. Once all the air has been cleared, apply the clamp and disconnect the syringe.
8. If you do not feel that all of the air is being cleared, try holding the syringe at a lower level. If this fails to help, the air can be aspirated out under gentle pressure. To do this, connect a syringe that has the plunger inside and gently pull the plunger out until resistance is felt. If you feel that gastric decompression can only be achieved in your child when it is performed by the aspiration method you should inform your community nurse or nurse specialist as continuous gastric decompression may be required.

How long will the PEG J tube last?

A PEG J tube will last for approximately two to three years after which it will require changing.

How is the tube changed?

Your child will need to have a short general anaesthetic. Whilst asleep under the anaesthetic a special camera (called a ‘gastroscope’) is passed through your child’s mouth, down their oesophagus (food pipe) and into the stomach. A special instrument is passed down the gastroscope which grabs hold of the old tube so that it can be pulled up and out through the child’s mouth.

A new replacement gastric tube can then be threaded through in the same way. Once the gastric tube is in place within the stomach, the jejunal tube can be threaded down inside it. To ensure that the jejunal part is passing through into the correct place, x-rays are taken at the same time.

Once the child has woken and fully recovered from the anaesthetic they can return to their normal feeding regimen.

Cleaning and general skin care:

• The area where the tube goes through the skin is called the stoma site. You may experience a discharge at the stoma site for the first few days (7-10 days) until the stoma heals.
• Daily care of the stoma site will reduce the possibility of soreness or infections.
• Always ensure that you wash your hands before and after caring for your child’s tube.
• The stoma site should be cleaned daily with warm soapy water.
• Always avoid using creams/ powders on the skin around the tube (unless otherwise advised by your care team) as they can damage the tube material and may lead to skin irritation.
• If you notice that the skin is becoming sore or there is oozing from the stoma site you should contact a member of your care team.
• Dressings around the stoma site are usually not required.
• Redness or soreness around the stoma may be the result of gastric leakage so it may be necessary to clean the site more than once per day. Your community nurse will be able to advise you.

Complications regarding PEG J tubes include:

1. displacement of the jejunal part
2. mechanical failure
3. overgranulation
4. tube blockage
5. discharge from the stoma site
6. feed leakage from the stoma site
7. infection

These complications can be managed as detailed below in the section titled ‘problem solving’.

Serious complications related to PEG J tubes are very rare and symptoms are seen usually within a maximum of 72 hours after insertion or change. If your child develops any of the ‘red flag’ symptoms within 72 hours of PEG J tube insertion or change you should contact the paediatric surgery nurse specialist team. The nurse specialist team is available Monday to Friday 08:00 (8am) to 18:00 (6pm) on 01223 586973 excluding bank holidays. Outside of these hours you should speak to your GP or local hospital who will contact the paediatric surgery specialist registrar at Addenbrooke’s.

The ‘red flag symptoms’ are:

• Pain on feeding OR
• Signs of distress on feeding OR
• Prolonged or severe pain post procedure OR
• Fresh bleeding OR
• External leakage of feed around the tubing

Problem solving

Jejunal tube displacement:

Although it is highly unlikely for the gastric part of the PEG J tube to come out, it is possible for the jejunal part to dislodge. This most commonly occurs when the child is being lifted or when the tubing gets caught on the wheel of a buggy/ wheelchair. Ensure care is taken to prevent accidental pulling that can lead to dislodgement.

It is possible to identify the position of the tip of the jejunal tube by aspirating a small amount of fluid and testing its level of acidity (called ‘pH’) on special paper. If the tip is in the correct position, the pH should be six to eight. If the tip has moved into the stomach the ph will be one to five. You may also be able to aspirate feed from the stomach where previously you had been unable to do so.

If you do not have any pH paper, it is possible to gain information about the position of the jejunal tube by performing a 'blackcurrant test'. Administer approximately 10ml of undiluted blackcurrant cordial via the jejunal port. After five minutes, aspirate via the gastric port. If blackcurrant is aspirated this is a strong indicator that the jejunal tube has migrated (moved) into the stomach.

If the jejunal tube has displaced or you suspect that it may have done so, apply the clamp, tape the tubing to your child’s skin to prevent any further dislodgement and call your nurse specialist/ community nurse. Your child will, in most cases, need to come to Addenbrooke’s Hospital where an x-ray may be taken to confirm the tube’s position and further intervention to resolve the problem may be required under general anaesthetic.

Mechanical failure of the PEG J tube:

Unfortunately, with repeated use, parts of the PEG J tube can fail. If the connectors fail (e.g. start to leak) or break, these can be replaced by the nurse specialist team in clinic or on the ward.

In some children, disconnection of the jejunal tubing from the connector has been observed. In these circumstances, if the jejunal tube can still be seen within the outer gastric tubing, the nurse specialist team may be able to repair the PEG J tube. In cases where the jejunal tubing has passed into the stomach, tube replacement will be required. If you suspect a disconnection has occurred, apply the clamp and do not use the tube at all; seek urgent medical attention.

Overgranulation and its management:

Granulation tissue is the result of the body trying to repair itself. You may recognise overgranulation as a clear brownish discharge and occasional bleeding or as pinkish raised tissue. If bleeding occurs or a large amount of tissue builds up, contact a member of your care team for advice as treatment may be required in the form of a dressing or ointment.

Tube blockage and its management:

To prevent tube blockage the tube should be flushed regularly and medications administered in a way that limits the chances of tube blockage occurring (see sections on ‘flushing’ and ‘administering medications’).

If the tube does block you may try the following. If unsuccessful in the first step, move onto the next:

1. Ensure the clamps are released.
2. Ensure the tube does not have any twists/ kinks.
3. Massage the tube around the area of blockage if it is obviously visible.
4. Try to flush with warm water using a ‘pumping action’ with the plunger on the syringe.
5. Connect a 60 ml syringe to the end of the tube and try to draw back (’aspirate’).
6. Mix half a teaspoon of sodium bicarbonate (baking soda) with 30ml of boiling water. Leave this to cool to a warm temperature then use a syringe to flush this solution down the tube. Leave the solution in the tube for two hours and then try to flush it through with warm water.
7. Contact a member of your care team for advice.

Do not:

• Try to administer fruit juices/ fizzy drinks down the tube in an attempt to unblock it.
• Attempt to unblock the tube by inserting objects down it.
• Use excessive force.

If the tube is irreparably blocked it will require changing in theatre under a general anaesthetic.

Discharge from the stoma site and its management:

It is usual to experience a discharge from the stoma site until the stoma heals (usually 7 to 10 days after placement). It is important to clean the area carefully during this time.

If the discharge is spoiling clothing, a small medicated dressing (eg honey based dressing or anti-microbial dressing) can be applied but this should be changed regularly/ removed when no longer needed.

If discharge continues to be seen contact your community or specialist nurse as this may indicate gas bloat, pooling of gastric secretions or a poorly fitting fixation plate.

Feed leakage from the stoma site and related management:

If feed is observed coming from the stoma site you should contact your community nurse or nurse specialist as this may indicate that the jejunal tube is no longer in the correct position.

Managing the child with vomiting/diarrhoea:

• Always check expiry dates of the feed.
• Ensure the feed is brought up to room temperature before administering it. Feed straight from the fridge may be too cold.
• The rate (speed) of the feed may need to be reduced, contact your nurse specialist/ community nurse or dietitian.
• The speed at which medications are given may need to be reduced, contact your nurse specialist or community nurse.

• Mic J tubes must not be rotated. This is because the rotation of the tube would cause a twist (kink) to occur in the jejunal tube.

• To prevent blocking, both the jejunal and gastric ports needs to be flushed regularly.
• The tubes should be flushed with cooled, boiled water.
• Flushes should take place before a continuous feed is started and when it is stopped. In addition, a flush should be given before and after a medicine is put down the tube. If more than one medicine is being given, a flush should also be given between each medicine (see section on administration of medicines).
• Your dietitian will specify the amount of water to be used to flush the tube.
• If the gastric access port is not being routinely used, flush every 24 hours with 10ml of water.
• If the jejunal access port is not being routinely used, flush every 6-12 hours with 5-10 ml of sterile water.

Using an extension set:

• It is not appropriate to insert a syringe directly into the device (as it can break the inner valve). Therefore, every time that the MIC J tube is accessed, whether this is to give medicines, feed, flushes or for decompression, an extension set must be used.
• A different extension set should be used to access the gastric port and the jejunal port.
• The extension sets should be changed once per week.
• To prevent complications with the feed valve it is important that the same brand of extension set is used as Mic J tube itself.
• Between each use the extension set should be cleaned with hot soapy water and then left laying to dry on a clean, flat surface (if the child is under one year or is immune compromised the extension set should be sterilised).

How to connect the extension set to the access port:

1. Wash hands.
2. Place a finger and thumb on either side of the bolster and open the feeding port cover (see diagram above).
3. Line up the black mark on the extension set with the black mark on the access port.
4. Push the extension set downwards into the access port.
5. Rotate the extension set in the direction marked with the arrow (i.e. clockwise) until you feel resistance (this will be felt after a three quarter turn). This locks the extension set in place.

How to remove the extension set from the access port:

1. Wash hands.
2. Place a finger and thumb on either side of the bolster.
3. Rotate the extension set in the direction opposite to that marked by the arrow (i.e. counter/anti clockwise) until the black mark on the extension set is in line with the black mark on the access port.
4. Gently pull the extension set upwards and out of the access port.
5. Cover the access port with the feeding port cover.

Administering fluid/ feed via a MIC J tube:

• It is important to always wash your hands carefully before and after using the tube.
• Your child’s dietitian will recommend a feeding plan suitable for your child’s needs.
• Because your child will need to have their feed delivered slowly over the course of many hours, it will be given via a feeding pump (machine). Your children’s nutrition nurse specialist will arrange teaching on how to use this pump. The pump will be fully portable for ease of use at home. Information leaflets about the actual pump itself will be provided for you.
• It is not necessary to check the position of the tube before starting the feed unless you are concerned that the tube does not have its normal appearance, for example looks like it may be falling out.
• Before the feed is started and when it finishes, water needs to be given to prevent the tube from blocking. This is normally at least 20 ml but your dietitian will advise you on the exact amount for your child. If the water is being given from a syringe, it must be pushed in very slowly (2 to 3 ml per minute). The water used should have been boiled and then allowed to cool.

Procedure:

1. Wash hands.
2. Set up the pump as shown by the children’s nutrition nurse specialist.
3. Apply the clamp and then connect the extension set as described in section ‘How to connect the extension set’ above.
4. Flush the tube with cooled boiled water with. . . . . . . ml of water (remember to unclamp the extension set).
5. Connect the feed as shown by the children’s nutrition nurse specialist.
6. Once the feed has been completed, wash your hands and flush the tube with . . . . . . . ml of water.
7. Apply the clamp and then disconnect the extension set as described in the section ‘How to remove the extension set.’

Replacing feeding sets:

• Feeding sets need to be changed every 24 hours.

Administration of medications through the gastric/ jejunal access port on a low profile balloon retained transgastric-jejunal feeding tube (MIC J)

• It is important to always wash your hands carefully before and after using the tube.
• Ideally your child’s medication should be given into the stomach through the gastrostomy port. Where this is not possible the jejunal port may be used but this must be in discussion with your specialist care team and children’s pharmacist. Reasons for this include the fact that some medicines need to mix with the acid in the stomach (that is not present in the jejunum) to work.
• Administering medication correctly will ensure that the medicine is absorbed properly. While you are in hospital, a member of your specialist care team and a children’s pharmacist will review your child’s medicines so you know which port to use for each medicine.
• Where medicines are being given through the jejunal port, the speed of administration should not exceed 2-3ml per minute. (There is no limit regarding speed of administration through the gastric port). This is to increase the chances of the medicine being absorbed.
• Administering medication correctly will avoid the tube becoming blocked.
• Request that your child’s medication is provided in a liquid form.
• Some liquid medications are known to be associated with tube blockages and so need to be further diluted with water (same volume of water as medicine) before being given. Ask a member of your specialist care team if you are unsure.
• If medication is only available in tablet form, seek advice from your GP, pharmacist or nurse specialist. Some tablets can be crushed or mixed with water but others cannot as their particles can lead to tube blockages.
• The tube must be flushed before and after each medicine. If more than one medicine is being given, flush in between as well. The water used should have been boiled and then allowed to cool. For your child, flush with . . . . . . . ml before the medicine, . . . . . . . ml between each medicine and . . . . . . . ml after all medicines have been given.
• Please note, clarithromycin will block your child’s tube and so should never be given through the tube. This is an antibiotic commonly used for chest infections. Other antibiotics which sound similar (for example, erythromycin) do not block tubes.

Procedure:

1. Wash hands.
2. Apply the clamp on the extension set.
3. Connect the extension set (see section above).
4. Connect syringe with flush in.
5. Release clamp.
6. Administer flush.
7. Apply clamp.
8. Disconnect flush syringe and connect syringe containing medication.
9. Release clamp.
10. Administer medication.
11. Apply clamp.
12. Disconnect medication and connect syringe containing the flush.
13. Release clamp.
14. Administer flush.
15. Repeat steps 6 to 13 for each medication.
16. Reapply the clamp and remove the extension set (see section above).

What is decompression?

Some (but not all) children suffer from symptoms of trapped wind (also known as ‘gas bloat’) such as abdominal pain and/or abdominal distension. The trapped wind can be released by ‘gastric decompression.’ This is when the air is released through a syringe which is attached to the end of the gastric port of the MIC J tube. Gastric decompression may be required only occasionally or many times per day depending on the severity of the symptoms.

It is preferred that gastric decompression usually takes place via gravity (see procedure below). However, where this fails to resolve the symptoms, gastric decompression may be performed via aspiration (see note nine below) or via continuous gastric decompression (known as a ‘Farrell valve’.)

Procedure:

1. Wash hands.
2. Remove the plunger from inside the 60 ml syringe (the plunger is not required for gastric decompression).
3. Apply the clamp to the extension set and then connect the extension set onto the gastric port of the MIC J tube.
4. Connect the empty barrel of the syringe to the extension set.
5. Hold the syringe approximately 10cm above the height of your child’s stomach
6. Release the clamp on the extension set.
7. Hold the syringe still for two minutes. You may be able to see bubbles of air coming up into the syringe. If there is a lot of air in the stomach you may also see some stomach secretions (and occasionally small amounts of milk feed) coming up into the syringe. These secretions will travel back down the tube and back into the stomach when all the air has been cleared.
8. Once all the air has been cleared, apply the clamp and disconnect the extension set.
9. If you do not feel that all of the air is being cleared, try holding the syringe at a lower level. If this fails to help, the air can be aspirated out under gentle pressure. To do this, connect a syringe that has the plunger inside and gently pull the plunger out until resistance is felt. If you feel that gastric decompression can only be achieved in your child when it is performed by the aspiration method you should inform your community nurse or nurse specialist as continuous gastric decompression may be required.

How long will the MIC J tube last?

The MIC J tube usually lasts for approximately six months, after which it requires changing. The MIC J tube should be changed earlier if signs of balloon perforation occur (see section: ‘changing water in the internal balloon’.)

The tube may require changing as your child grows. You will know that a change of size is required as the tube will appear too tight or too loose. If you are concerned that the current tube that your child has is not of an appropriate size, inform your nurse specialist.

How is the tube changed?

The MIC J tube is changed as an outpatient in the specialist x-ray department called ‘interventional radiology’. Unless your child is being admitted for sedation prior to the change of device, you will need to bring your child’s new tube with you (supplied via your community nurse/ home delivery service). Most children can have their MIC J tubes changed whilst fully awake but a few will need sedation; your nurse specialist will discuss this with you.

A guide wire is inserted through your child’s existing MIC J tube and, whilst the guide wire remains in place, the balloon is deflated and the old tube is removed. The new tube is then threaded over the guide wire into its correct position. The balloon is inflated and the guide wire is then removed. This whole procedure is watched on a screen (monitor).

This process is not painful but your child will need to lay still. You can be with your child unless you are, or suspect you are, pregnant.

Once the new tube is in place your child can go home and can recommence feeds straight away if no sedation was given or, as soon as fully recovered from any sedation.

Cleaning and general skin care:

• The area where the tube goes through the skin is called the stoma site. You may experience a discharge at the stoma site for the first few days (7-10 days) until the stoma heals.
• Daily care of the stoma site will reduce the possibility of soreness or infections.
• Always ensure that you wash your hands before and after caring for your child’s tube.
• The stoma site should be cleaned daily with warm soapy water.
• Always avoid using creams/ powders on the skin around the tube (unless otherwise advised by your care team) as they can damage the tube material and may lead to skin irritation.
• If you notice that the skin is becoming sore or there is oozing from the stoma site you should contact a member of your care team.
• Dressings around the stoma site are usually not required.
• Redness or soreness around the stoma may be the result of gastric leakage so it may be necessary to clean the site more than once per day. Your community nurse will be able to advise you.

The water in the retaining balloon needs to be changed once per week.

The purpose of changing the water is to ascertain the condition of the balloon. If the balloon is beginning to perish, this will be indicated by either aspirating less water than expected (up to 1ml loss per week is acceptable in a Mic J tube) and/or the water which is aspirated being discoloured. If either of these signs are observed you should contact your community nurse or nurse specialist within 24 hours. If these signs are ignored the balloon is at risk of rupturing and the tube may then fall out.

Procedure for changing the water in the balloon:

1. Collect together the equipment required:
   Two ‘luer slip’ (clear) syringes (5ml)
   Sterile (cooled boiled) water
2. Wash hands.
3. Draw up 5 ml of the water into one of the syringes.
4. Hold the external bolster by placing a finger and thumb on either side.
5. Insert the empty syringe into the balloon valve (labelled ‘BAL’).
6. Allow the water to be expelled into the syringe.
7. Check the aspirated water in the syringe for volume and colour.
8. Discard this old water.
9. Pick up the syringe containing the new water; push the syringe into the balloon valve and let go of the syringe. If the syringe has been inserted correctly it will stay connected to the tube on release. Inject the water.
10. Once all the water has been injected, remove the syringe using a slight twisting motion. It is important to keep your thumb on the end of the syringe whilst removing it to prevent water being expelled back into the syringe spontaneously.

Emergency action to take if the tube falls out:

It is possible for a MIC J tube to be pulled out if sufficient force is exerted on the tubing. It is therefore important to ensure that the tubing is not allowed to get caught, for example whilst lifting your child or while pushing your child in their buggy/ wheelchair.

A Mic J tube can also fall out if the internal balloon perishes (see section on ‘procedure for changing the water in the balloon’). If the tube does get pulled/ falls out, the gastrostomy stoma can close within one to two hours and therefore it is essential that immediate action is taken.

Your care team will organise for you to have a low profile balloon retained (‘gastrostomy button’) which you can insert in an emergency situation to prevent the tract from closing (you will be taught how to do this by your community nurses and/or nurse specialists). You should then contact your nurse specialist who will arrange for your child to have a new tube inserted.

What is an emergency kit box?

You will be supplied, by your nurse specialist, with an ‘emergency kit box’ to keep your child’s emergency equipment (spare button device, extension set and syringes) in. It is essential that your child’s emergency kit box is carried with your child at all times including to school, hospital visits, trips out or on holidays.

Concern that the jejunal tubing has migrated back into the stomach

It is possible, with repeated retching or, due underlying dysmotility, for the jejunal part of the Mic J tube to migrate back up into the stomach from the jejunum. Symptoms of a migrated jejunal tube include:

• vomiting of feed
• aspiration of feed from the gastric port despite it being delivered via the jejunal port
• pain or discomfort on feeding
• being able to physically see the tip of the jejunal tube during a child’s vomit (see section below ‘tip of jejunal tube has been vomited up into the child’s mouth’)

It is possible to identify the position of the tip of the jejunal tube by aspirating a small amount of fluid and testing its level of acidity (called ‘pH’) on special paper. If the tip is in the correct position, the pH should be six to eight. If the tip has moved into the stomach the pH will be one to five. Some medications alter the pH so it is advised to take an aspirate from the child’s gastric port and one from their jejunal port simultaneously and compare the two results. If the pH is the same from both samples then the jejunal tubing has probably migrated back into the stomach.

If you do not have any pH paper, it is possible to gain information about the position of the jejunal tube by performing a 'blackcurrant test'. Administer approximately 10ml of undiluted blackcurrant cordial via the jejunal port. After five minutes, aspirate via the gastric port. If blackcurrant is aspirated this is a strong indicator that the jejunal tube has migrated (moved) into the stomach.

In any instance when you are concerned that your child’s jejunal tube may have migrated back into the stomach it is important to call your nurse specialist without delay so that urgent review can be arranged to (1) remove the MIC J tube to prevent complications such as coiling/ knotting in the stomach or vomiting of the jejunal tube up into the child’s mouth and (2) to replace the tube.

Tip of jejunal tube has been vomited up into the child’s mouth

If the jejunal tube on a MIC J tube has migrated back up into the stomach and this has not been recognised or, no action taken, it is possible (although extremely rare), for the child to then vomit up the tip of the jejunal tube so it is seen in the child’s mouth. Whilst it will be extremely distressing to observe such a situation, it is essential that you remain calm and take immediate action as the tubing will cause a choking response.

Action to take:

1. Keep calm.
2. Insert a luer slip (clear) syringe into the balloon valve on the MIC J device (marked ‘BAL’).
3. Aspirate the syringe to remove all of the water from the retaining balloon.
4. With a gentle but continuous action pull on the MIC J tube bolster (the part with the gastric and jejunal ports) until the entire length of tubing has been removed.
5. To prevent the gastric stoma (hole) from closing now that there is no tubing in place, you will need to follow the directions for insertion of a gastrostomy button device (see section ‘Emergency action to take if the tube falls out’).
6. Contact your nurse specialist/ community nurse to arrange insertion of a new tube.

Balloon will not deflate:

If you cannot extract water from the balloon with the syringe:

1. Ensure the syringe has been inserted correctly. If the syringe has been pushed in too far or not far enough, water will not be expelled from the balloon.
2. Ensure the recess in the balloon valve is clean. Occasionally this recess can trap spills of feed or other material. Clean inside the recess with warm water (cotton buds are useful for this) then try to insert the syringe again by pushing it firmly into the valve with a push and twist motion.
3. If the balloon will still not deflate you should contact your community nurse or nurse specialist.

Mechanical failure of the device

Unfortunately, with repeated use, parts of the Mic J tube can fail. If the connectors fail (eg start to leak) or break, these can often be temporarily taped in place until tube replacement can be arranged.

Tube blockage and its management:

To prevent tube blockage the tube should be flushed regularly and medications administered in a way that limits the chances of tube blockage occurring (see sections on ‘flushing’ and ‘administering medications’.

If the tube does block you may try the following. If unsuccessful in the first step, move onto the next:

1. Ensure the clamps are released.
2. Ensure the tube does not have any twists/ kinks.
3. Try to flush with warm water using a ‘pumping action’ with the plunger on the syringe.
4. Connect a 60ml syringe to the end of the tube and try to draw back (’aspirate’).
5. Mix half a teaspoon of sodium bicarbonate (baking soda) with 30ml of boiling water. Leave this to cool to a warm temperature then use a syringe to flush this solution down the tube. Leave the solution in the tube for two hours and then try to flush it through with warm water.
6. Contact a member of your care team for advice.

Do not:

• Try to administer fruit juices/ fizzy drinks down the tube in an attempt to unblock it.
• Attempt to unblock the tube by inserting objects down it.
• Use excessive force.

If the MIC J tube is irreparably blocked it will require changing. This may be in the x-ray department or in the operating theatre.

Overgranulation and its management:

Granulation tissue is the result of the body trying to repair itself. You may recognise overgranulation as a clear brownish discharge and occasional bleeding or as pinkish raised tissue. If bleeding occurs or a large amount of tissue builds up contact a member of your care team for advice as treatment may be required.

Discharge from the stoma site and its management:

It is usual to experience a discharge from the stoma site until the stoma heals (usually 7 to 10 days after placement). It is important to clean the area carefully during this time.

If the discharge is spoiling clothing, a small dressing can be applied but this should be changed regularly/ removed when no longer needed.

If discharge continues to be seen contact your community or specialist nurse as this may indicate gas bloat, pooling of gastric secretions or a poorly fitting fixation plate.

Feed leakage from the stoma site and related management:

If feed is observed coming from the stoma site you should contact your community nurse or nurse specialist as this may indicate that the jejunal tube is no longer in the correct position.

Leakage from the feed valve:

The feed valve is designed as a valve which closes each time the extension set is disconnected. This prevents stomach/ jejunal contents from coming out when the extension set is disconnected.

Using a syringe directly into the feed valve or a non-approved extension set (that is, one which is of a different brand to the Mic J tube itself) can break this valve. Ask your community nurse or nurse specialist if you have concerns relating to the feed valve.

Managing the child with a vomiting/ diarrhoea illness:

• Always check expiry dates of the feed.
• Ensure the feed is brought up to room temperature before administering it. Feed straight from the fridge may be too cold.
• The rate (speed) of the feed may need to be reduced, contact your nurse specialist/ community nurse or dietitian.
• The speed at which medications are given may need to be reduced, contact your nurse specialist or community nurse.