Gastrostomy tubes (G tubes) are feeding devices that provide liquid nutrition, medications, and other fluids directly into the stomach. G tubes are placed through a surgical opening in your child's abdomen (tummy) called a stoma. The tunnel from the outside into the stomach is called the tract.
Balloon G tubes have a balloon on the end that sits inside the stomach to keep the tube in place. These tubes may be non low-profile or low-profile.
This information in this article does not apply to GJ tubes, combination G/GJ tubes or non-balloon G tubes.
| The SickKids G-Tube Feeding Program has developed a one page guide to help you quickly troubleshoot any issues with your child's feeding tube: G-Tube Feeding Program Family One Pager |
Types of balloon G tubes
Non low-profile balloon G tubes
There are several brands of non low-profile balloon tubes, including:
- Avanos Mic-G
- Kangaroo
- Cook Entuit
Low-profile balloon G tubes
A low-profile balloon G tube is a type of feeding tube that sits close to the skin and is easy to conceal. These tubes are sometimes referred to as a “button” because of how they sit on the skin. It is very important to know the specific brand of tube your child has. Low-profile balloon G tubes need a special extension set to connect to the tube to feed your child.
There are several different brands of low-profile G tubes, including:
- Mic-Key
- AMT MiniONE
- Nutriport
Caring for your child’s balloon G tube
Keep the tube and stoma as dry and clean as possible, washing with soap and water daily. Your child’s stoma will not need a dressing.
Flush the tube with at least 5 to 10 mL of water before and after each feed and medication dose, and every four hours during continuous feeds. This helps prevent the tube from becoming blocked.
The balloon
The balloon at the end of your child’s tube is what keeps the tube in place and prevents it from being accidentally pulled out. The balloon is inflated with sterile or distilled water. You may also use tap water that has been boiled and cooled down. The water is inserted through the hard plastic port, which may be marked "BAL". Do not fill the balloon with saline or air. Do not give feeds into the balloon port.
The doctor who inserts the tube may fill the balloon with less than the recommended balloon volume. If this is the case, you will need guidance from your health-care team before you increase the balloon volume.
If you are unsure how much water your child’s balloon tube can safely hold or you are not sure how much water the balloon was originally filled with, ask your G tube specialist (at SickKids this is the G Tube Resource Nurse) or refer to the chart below.
| Non-low profile | Low-profile | |||
|---|---|---|---|---|
| Mic-G | Kangaroo | Mic-Key | AMT miniONE | |
| 12FR | 3 to 5 mL (max 7 mL) | 5 mL | 3 to 5 mL | 2 to 3 mL |
| 14FR | 3 to 5 mL (max 7 mL) | 5 mL | 5 to 10 mL | 3 to 5 mL |
Checking the volume of water in the balloon
It is important to check the amount of water in the balloon at least once a week. This will help you to know if there is a problem with the balloon. Use a slip-tip syringe to check the balloon.
- Insert an empty syringe into the balloon port.
- Remove all the water from the balloon. Throw away the old water. It is normal for the water to become discoloured (brown or yellow).
- Re-inflate the balloon with new sterile or distilled water.
It is normal for less water to be removed from the balloon than you originally put in. This is because some of the water might have evaporated. It is normal for there to be a difference of up to 0.5 mL.
If there is a difference of more than 0.5 mL of water from what you put in and what you remove, the balloon may be damaged, and the tube may need to be replaced. If this happens:
- Re-inflate the balloon with the amount of water you normally put in and check the volume again in three to four hours.
- If you get all the water back, the water may have simply evaporated quicker than usual. Re-inflate the balloon with the amount of water you normally put in and check the balloon volume every three to four days to be sure there are no further problems.
- If you get less water back again after three to four hours, the balloon is likely damaged, and the tube will need to be replaced.
- If you get more fluid than what you originally put in the balloon, and it looks like stomach contents or food, this means the balloon is broken and the tube will need to be replaced.
If the balloon is broken, there is a risk that the tube may be accidentally pulled out. Tape the tube in place to the abdomen until you can change the tube yourself or book an appointment with your G tube specialist to help you change the tube.
Meanwhile, the tube is still in the stomach so you can continue to use the tube for feeding and medications. There is no need to go the emergency department if the balloon is broken.
Fit of balloon tube
For low profile balloon tubes, filling the balloon with more or less water can affect the fit of the tube to the skin. Leaking and stoma issues may occur if the tube does not fit properly. Less water in the balloon makes the tube sit looser and stick out from the skin. More water in the balloon makes the tube sit tighter and closer to the skin.
Adjusting the balloon for a tighter/looser fit
If the tube is so tight you can see an indent in your child’s skin, you can decrease the amount of water in the balloon.
If the tube sticks out too much and is dangling from the stoma or leaking, increase the amount of water in the balloon. If adjusting the balloon volume does not help with the fit of your child’s tube, you may need to have the tract re-measured by your G tube specialist.
For non low-profile balloon tubes, the retention disk may be adjusted to manage the fit of the tube. Ensure the balloon is in a good position against the stomach wall before adjusting the disk. You can achieve this by pulling the tube upward until you feel resistance, which represents the balloon against the stomach wall. You can then slide the retention disk down the tube shaft, flush against the abdominal wall.
Feeding extension set for a low-profile balloon G tube
The feeding port for a low-profile balloon G tube is where your child’s feeds will enter the tube and then go into their stomach. The feeding port has a one-way valve to prevent stomach contents, feeds, water, and medications from flowing back out of the tube. To open this one-way valve, and give feeds and medications, you must use a feeding extension set. Each brand of a low-profile balloon G tube has their own extension set. You will receive one in the box with a newly purchased low-profile balloon G tube. Replacement extension sets are purchased separately when needed.
Connecting the extension set to the tube
- Open the plastic cover on the feeding tube.
- Make sure the clamp on the extension set is closed.
- Match the line on the extension to the line on the tube and push the extension into the valve.
- Holding the button tube in place, turn the extension clockwise until you feel the extension lock into place. There is an arrow on the extension to show you which direction to turn it.
- Attach your feeds, fluids, and medications to the appropriate port at the end and open the clamp.
- When you have finished using the extension, flush it and remove it from the tube.
Removing the extension from the tube
- Clamp the extension.
- Holding the tube in place, turn the extension counter clockwise (opposite to the arrow on the extension).
- Match the line on the extension to the line on the tube and remove the extension.
- Close the plastic cover on the feeding tube.
The extension set should be changed once every month, or if you notice the plastic is becoming stiff or there is formula, food or medications built up inside. It is important to flush the extension set with water between each use and clean it with soap and water once daily. Remove the extension set from the tube when it is not in use to prevent pulling.
How often should you change the balloon G tube?
Most G tube manufacturers do not give a set time for how long you can use the tube. They suggest that it can stay in as long as it is functioning without leaks or defects. However, the tube should be changed at least every six to eight months to prevent leaks in the balloon, which could cause the tube to accidentally fall out.
It may be time to change the tube when:
- The balloon is broken
- The one-way feeding port is broken
- The balloon port is broken
- The tube is blocked
- The tube has been dislodged
When changing the tube, it is important to remember the risks involved.
Infection: When you replace the tube, the stoma and the tract can become irritated and bacteria can be introduced. This increases the risk of infection. Wash the stoma with soap and water before inserting the new tube to reduce the risk of infection. Always wash your hands before handling the tube and continue to clean the site with soap and water daily. Keep the site open to air.
Increased hypergranulation tissue: Removing an old tube and inserting a new one can irritate the skin and cause hypergranulation tissue. This is a common occurrence. Your G tube specialist can help you deal with hypergranulation tissue.
Perforation: There is a possibility that, when inserting a new tube, the tube is not inserted along the existing tract. It could create a new tract and space inside the body. This is extremely rare. If your child has instant intolerance (vomiting) or severe pain after their first feeding with a new tube, stop using the tube and go to the emergency department for assistance. A G tube check may need to be scheduled in the interventional radiology department. Perforation can lead to a condition called peritonitis.
How to change the balloon G tube
Primary balloon G tubes (i.e., surgical tubes) should not be changed in the first 8 weeks from insertion. These instructions do not apply to GJ tubes or combination G/GJ tubes.
Supplies
- New balloon G tube
- Soap
- Warm water
- Washcloth
- Sterile or distilled water
- Five syringes (two 5-mL slip tip syringes and three syringes that fit the feeding extension – either slip tip or ENFit)
- Water-based lubricant or jelly
- Feeding extension set (for low-profile G tubes)
- pH strips and colour reference guide
Procedure
- Wash your hands with soap and water and prepare your equipment and supplies.
- Into one slip tip syringe, draw up the amount of water recommended by your health-care team to fill the balloon of your child’s tube. Draw 5 mL of water into another syringe that fits the feeding extension to flush the tube. Leave the other three syringes empty. You will use these to remove the old water from the balloon and check the pH.
- Prepare your washcloth with soap and water on one half of the cloth and non-soapy water on another part.
- Confirm the placement of the balloon G tube by checking the pH of the gastric contents, as described below. This will give a baseline assessment for gastric aspirate before removing the G tube.
- Remove the sterile or distilled water from the balloon of the old G tube using one of the empty slip tip syringes. Throw the water and syringe away.
- Remove the old G tube. It is normal for the inner part of the tube to be brown or black. This is caused by acidic stomach contents. Throw away the old tube.
- This is a great time to assess the stoma for any changes, such as redness, drainage, rash, or hypergranulation tissue. Wash the stoma with soap and water and rinse it with non-soapy water. Then let it air dry.
- Lubricate the tip of the new balloon G tube and, at a slight angle, insert it into the stoma, following the existing tract. The tube may be slightly resistant, so it is OK to exert light force. Try to time insertion with when your child breaths in, as they are most relaxed at that time.
- Once the tube is in place, check that the tube is in the stomach by checking the pH as described below. The tube is in the stomach if you get a pH of less than 6.0 and/or the appearance of the gastric contents is similar to the gastric contents from pre-procedure.
- Once you know that the tube is in the stomach, inflate the balloon with the amount of sterile or distilled water you usually put in.
- For non low-profile balloon tubes, gently pull the tube until you feel resistance. This indicates that the balloon has reached the inside of the stomach wall. Adjust the outer disk so that it sits snug against the skin.
- Flush the tube with 5 mL of water. If your child has a low-profile tube you can use the feeding extension to do this.
- You may now use the tube for feeding and medications.
Checking that the newly changed balloon tube is in the right spot
Before inflating the balloon, flushing the tube, or using the newly changed tubes for feeds and medications, you will need to check that it is in the stomach by checking the pH of the contents that are pulled from the tube.
How to check the pH
You will need:
- One empty slip tip syringe
- The feeding extension set for a low-profile balloon G tube
- pH strips
- pH colour reference guide
What to do:
- Once you have inserted the new tube, insert the empty syringe into the feeding extension feeding (for a low-profile balloon G tube) or directly into the tube’s feeding port and pull back a small amount of stomach contents. If you cannot get stomach contents, move your child side to side or sit them up while holding the tube in place.
- Empty the stomach contents from the syringe onto the pH strip.
- Compare the colours on the pH strip to the colours on the reference guide.
If the pH is less than 6.0, this means the tube is in the stomach and you can flush the tube and use it for feeding and medications.
If the pH is 6.0 or higherthe tube may not be in the stomach. Medications and recent feedings can affect the pH. If your child recently had medications or feeds and their stomach contents look like the photos in the video, you may continue to use the tube. If you get a high reading and your child has not had recent feeds or medications, do not use the tube and check the pH again one hour later. If the reading is still 6.0 or higher, do not use the tube and contact your G tube specialist during business hours or go to the Emergency Department after hours to have the position checked by fluoroscopy.t. In the meantime, you can tape your child’s tube to their stomach as shown in the photo above.
What to do if your child’s balloon G tube is pulled out or becomes blocked
If the tube is accidentally pulled out
It is possible that the G tube may accidentally fall out or be pulled out. This may happen if the balloon is broken or does not have enough water in it.
To check if the balloon is broken, fill it with 5 mL of water. If you do not see a leak, remove the water from the balloon, wash the G tube with soap and water and reinsert it into the stoma as described above. Fill the balloon with the amount of water you normally use. Check the balloon every two to three days to be sure there are no further problems.
If the balloon is broken, replace it with a new tube as described above.
If you cannot replace the G tube, insert a temporary Foley catheter. To learn how to insert the Foley catheter, please see the article "What to do if your child’s feeding tube is pulled out". You can use the Foley catheter for feeds and medication until a new G tube is inserted if placement is confirmed by checking the pH.
Remember to always carry an emergency kit that includes:
- Back-up balloon G tube or Foley catheter
- Water-based lubricant gel
- Slip tip syringes
- Water
- pH strips and colour reference guide
- Tape in case of unexpected tube changes
- Kangaroo extension
You do not need to go to the emergency department if the tube falls out or becomes blocked and you replace the tube or insert a Foley catheter. You will only need to go the emergency department if you cannot insert a Foley catheter and there is nothing in the tract, or if after inserting a Foley catheter, you cannot verify that it is in the stomach.
If the tube becomes blocked
To learn what to do if your child’s G tube becomes blocked, please see the article "What to do if your child’s feeding tube is blocked".
G tube migration
Balloon G tubes such as Foley catheters are at high risk of migrating from the stomach into the small bowel. The tube must be secured to the abdomen with tape to prevent tube migration.
Signs and symptoms of G tube migration include:
- Increased vomiting
- Gagging and retching
- Abdominal discomfort or pain
- Bloated stomach
- Diarrhea
If you are concerned that your child’s Foley catheter feeding tube has migrated, gently pull back on the tube until you feel the balloon against the stomach wall. Tape the tube in place in this position. If these signs and symptoms continue or you are concerned about your child, stop using the tube and contact your G tube specialist during regular business hours or go to the emergency department.
Resources
For more information about the Mic-Key, visit www.mic-key.com.
For more information about the AMT miniONE, visit www.appliedmedical.net/enteral/minione/balloon/.