The instructions for caring for a feeding tube site or stoma are so varied and contradictory that it can sometimes be impossible to know what to do, especially when you are new to feeding tubes. While there is no one-size-fits-all approach, the following are tried and true tips from parents who have fought the battle and won.
A fancy tattoo around a MicKey GJ site
The New Stoma
Most parents are very surprised when they first take a look at the stoma or tube site. In many cases, the site is downright gross. Rest assured, it won't stay that way! Any time you cut a hole in the body, whether for an ear piercing or for a feeding tube, the body will launch a response to try to heal itself. What we may perceive as "gross" is simply the body's attempt at healing.
Initially, the surgeon or doctor may request that the site stay covered with a dressing and tape. While this may necessary at first, it is likely to make the site look even worse, with irritation and residue from tape, and a moist, weepy site. The best strategy is to remove any full dressings as soon as the doctor allows, and then try to keep the site as dry as possible.
New sites tend to weep or drain quite a bit. As long as the drainage is clear or tan, moderate in amount, and not particularly smelly, it is probably normal. Don't be surprised if you find crusted drainage around the site or on your child's clothes. The drainage may contain a small amount of blood. Any drainage that smells putrid or unusual, or is oddly colored, copious, or extremely bloody should be evaluated by your doctor.
As the new site heals, it forms a stable tract or tunnel between the skin and the stomach or intestine where the tube is placed. A stable tract is important, as it decreases pain, promotes healing, and prevents leakage and granulation tissue to some degree. The best way to create this stable tract is to keep the new feeding tube secure, which will be discussed in one of the following sections.
It is also very common for new sites to develop granulation tissue, a topic that will be explored in more detail below.
Cleaning the Site
Most parents prefer the "less is more" approach to cleaning the tube site. In most cases, all that is needed is to wash the site once or twice a day with soapy water, or even water alone for children sensitive to soap. Washing the site in the bath is perfectly fine.
Many families simply wipe the site with a washcloth. Cotton swabs can be used to get off stubborn crusties and access the areas underneath a button or bolster. Sometimes it can help to place a warm, wet washcloth on the site to help loosen up crusties.
In some cases, your doctor may recommend using something other than soap and water to clean the site. Some doctors prefer a hydrogen peroxide solution for new sites. Children with a history of infections or whose sites are colonized by certain bacteria may use a different solution for cleaning, such as chlorhexidine or a mild bleach/water solution. For a slightly uncomfortable site, using a hemorrhoid cleansing wipe works well.
After washing the site, it should be dried thoroughly with a clean towel. If possible, leave it open to the air for a time so it can dry completely.
Securing the Tube or Button
One of the keys to a stable, healthy tract free of trauma or irritation is securing the tube. New tubes in particular need to be stabilized and secured. Once the tube site has healed completely, it is not necessary to stabilize the tube unless your child is particularly active or has ongoing issues with granulation tissue.
There are many methods for securing the tube. Here are just a few:
A large commercial securement device, such as a Hollister Vertical Drain Securement device. These adhere to the skin and hold the tube at a 90 degree angle to the skin.
A small securement device, such as the Bone (now discontinued), StatLock, or Griplok.
Taping the button, tube, or extension set, using hypoallergenic medical tape. Many families put a gentle tape such as Tegaderm or Replicare on the skin weekly, and re-tape the tube to it as needed.
A tape tab (piece of tape wrapped around the tube forming a tab) that is then pinned with a diaper pin to clothing or a diaper.
A Velcro strap, such as the Dale Foley Holder, that fits around the leg and allows the tube to be secured to the leg.
Drying Out the Site
Pretty much everyone agrees that a site must be dry for it to be healthy and free of granulation tissue. The best way to keep a site dry is to leave it uncovered and open to the air. At first, you may see some leakage and crusties. Be persistent, and have your child wear old t-shirts or onesies if some leakage is occurring. After about a month, most sites dry out and are healthy.
If your child has an enormous amount of leakage, skin breakdown, or irritation from the tube rubbing against the skin, it may be necessary to use gauze or a pad under the button, a topic that will be discussed in the next section. Make sure to choose a method that keeps the site as dry as possible and wicks away moisture.
If your child is having significant leakage or leakage of formula from the site, it is appropriate to return to the surgeon or see an ostomy nurse. The tube size may not be correct, the balloon may not be filled adequately, or the site may need special treatment.
Many families place a barrier cream such as Desitin, Aquaphor, or Balmex around the site. Another option is Stomahesive powder or paste. These will prevent moisture from irritating the skin.
Dressings, Split Gauze, Pads, and Sponges
While many families find the site looks best when it is left open to the air, some children need to use a dressing or pad for comfort or due to significant leakage. A very common approach is to take a piece of IV split gauze (with an opening for a tube or line) and place it under the tube or button, taping the two sides together to keep it in place. While this is inexpensive and widely used, it is not recommended by most families. The gauze simply soaks up the moisture but stays wet. The site stays moist and provides the perfect environment for granulation tissue growth.
If you choose to use a dressing, pick one that wicks moisture away from the site. It should never cover the button or tube, but simply slip under so air can still flow around the tube.
Many families have found that reusable homemade pads, typically made of two or three layers for absorption, are an inexpensive and practical choice. See this list from Feeding Tube Awareness for available vendors.
Other recommended dressings include Polymem, Mepilex, and the Stomahesive barrier.
Your child's body will attempt to "heal" the hole that has been created for the feeding tube, and during this healing process, it may produce granulation tissue. The purpose of granulation tissue is to fill a gaping wound or hole until it can heal completely. In many cases, especially new tube sites, the body works really hard to "fill" the stoma by producing granulation tissue.
Granulation tissue is pink or red and tends to be soft, fleshy and blobby. Since it is filled with new capillaries, it tends to bleed easily. It can be painful for some children.
The best treatment for granulation tissue is prevention. Keeping the site dry, leak-free, and preventing trauma to the site usually keeps granulation tissue away. It is especially important to keep the tube site secure, since friction at the site is a major trigger for more granulation tissue growth. In addition, make sure the tube or button fits appropriately and is neither too tight or too long. In some cases, a different style of tube or button may also help prevent tissue growth. Some children struggle with tubes that have large exterior bolsters, while other children may have difficulty with a large button that pulls on the site.
New sites commonly have granulation tissue, and there are a variety of treatments for it. Here are just a few, starting with treatments for mild tissue, and progressing to treatments for more severe growth:
For mild granulation tissue, try dabbing aloe vera juice on the site or rubbing a piece from an aloe vera plant around the site.
Miracle Mist Plus spray or gel also helps treat mild granulation tissue.
Triple paste, made by mixing an over-the-counter antibiotic cream, an over-the-counter hydrocortisone cream, and an over-the-counter antifungal, works well as a preventative.
Calmoseptine lotion may help mild cases.
Cholestyramine ointment is highly effective, and is available by prescription through compounding pharmacies.
Triamcinolone steroid cream is available by prescription and treats mild to severe granulation tissue. Note that it is available in several strengths, and if a low strength is not working, it may be prudent to try a higher strength. Treatment also may take some time, as long as a month or two in some cases.
Silver nitrate sticks literally "burn" the granulation tissue off. These are only available by prescription and lately have become somewhat difficult to obtain. Make sure to cover the healthy skin around the site with barrier cream or Vaseline to prevent it from being "burned." Note that silver nitrate will get rid of granulation tissue but will not prevent it from coming back.
In rare cases, surgical removal of the tissue is required. Contact an ostomy nurse or surgical nurse for more information.
Yeast infections are common around tube sites in children, and are characterized by red, scaly or bumpy patches around the site. In most cases, the infection is mild and needs little more than time to heal. Mild cases may be treated with a vinegar/water solution or tea tree oil, while moderate cases can be treated by over-the-counter medications such as clotrimazole anti-fungal cream. More severe cases may require Nystatin or a similar anti-fungal, which is available by prescription. Many children who develop yeast infections may benefit from prebiotics and probiotics taken orally or by tube to restore the balance of bacteria and yeast in the gut.
Bacterial infections are relatively uncommon, but tend to plague certain children. They tend to be characterized by a red "angry" site that may leak smelly or colored discharge. The red area tends to spread outward from the site. It is prudent to use a marker to draw a line around the area of redness to see if it is spreading in order to distinguish an infection from an area of irritation. Sometimes children will also develop small abscesses, or pus-filled pockets or bumps, next to the site. A physician should always evaluate any suspected infection.
In most cases, a prescription oral antibiotic is required, though Bactroban or other prescription antibiotic ointments may also be prescribed. The site should be cultured to determine the bacterium causing the infection so an appropriate antibiotic can be chosen.
Children with repeated infections may benefit from using an over-the-counter antibiotic ointment to prevent future growth or treat mild infections. Certain children, especially those prone to MRSA, may also want to clean the site with chlorhexidine daily, or use a mild bleach/water solution.
Keeping the tube secured, the site dry, and granulation tissue away may help to prevent bacterial infections in children with tubes.
A healthy, happy G-tube site
The "Do Nothing" Approach
families have found the best approach to taking care of a tube site is
to do nothing. Leaving the site alone, open to the air, and just
cleaning it during normal bath times is perfectly adequate and
appropriate for many children. The body will often do an excellent job
of healing itself when left to its own devices.
Special thanks to the ladies from Parent-2-Parent.com who provided many of the tips and pictures in this article.
Copyright 2010 Complex Child E-Magazine. All Rights Reserved.
The information on these pages is not a substitute for appropriate medical care. Please contact your child's physicians before making any changes in your child's care. Complex Child is for research purposes only and does not constitute medical advice.