Table 3.

Summary of recommendations

Question		Recommendation	Grading of evidence
1. When should enteral tube feeding be commenced?	1.1	We suggest supplemental or exclusive enteral tube feeding should be commenced in children who are unable to meet their nutritional requirements orally, in order to improve their nutritional status.	Grade B, strong recommendation
	1.2	We suggest that there should be prompt intervention once deterioration in weight centile is noted.	Grade B, strong recommendation
2. What are the optimal feeding devices for short-term and long-term enteral feeding?	2.1	An NG tube is the preferred option for short-term enteral feeding, and may be considered a bridging option to a long-term enteral feeding tube.	Ungraded
	2.2	A gastrostomy device is preferable to an NG tube for long-term enteral feeding.	Ungraded
	2.3	The enteral feeding device for long-term management should be determined in partnership between the parents/caregivers and healthcare team.	Ungraded
3. What preparations should be made prior to insertion of a gastrostomy device? What are the techniques used for the insertion of gastrostomy devices?	3.1	Investigations such as an upper gastrointestinal contrast study, esophageal impedance or pH studies prior to gastrostomy device placement may be considered on an individual patient basis	Grade D, weak recommendation
	3.2	Gastrostomy devices can be placed by percutaneous endoscopic gastrostomy (PEG), percutaneous radiologically inserted gastrostomy (RIG), open surgical, or percutaneous laparoscopic-assisted gastrostomy (PLAG).	Ungraded
4 What patient characteristics determine which gastrostomy insertion technique should be used?	4.1	A PLAG or open gastrostomy is the preferred procedure in patients already receiving PD.	Grade C, strong recommendation
	4.2	We suggest that in a child who is likely to need PD, and in whom enteral tube feeding is required, gastrostomy tube insertion by PEG or RIG should, wherever possible, be performed before placement of a PD catheter.	Grade C, strong recommendation
	4.3	A PLAG or open gastrostomy are the preferred procedures for patients who have had previous abdominal surgery, or who have severe kyphoscoliosis, and gastric ulcers or varices.	Grade C, weak recommendation
5. Is a gastrostomy device associated with an increased risk of peritonitis in the long-term?	5.1	We suggest strict attention to care of exit sites of the gastrostomy and PD catheter to help prevent exit site infections and cross infection.	Grade B, moderate recommendation
6. Can a gastrostomy device be inserted at the same time as a PD catheter?	6.1	We suggest that a gastrostomy device can be inserted simultaneously with a PD catheter if the gastrostomy is placed by PLAG or open surgery.	Grade B, strong recommendation
7. What precautions should be taken to prevent peri- and post-operative complications in the child on PD?	7.1	Antibiotic prophylaxis, based on local antibiotic sensitivities, is recommended for all children undergoing gastrostomy placement.	Grade C, strong
	7.2	We recommend that children who are already established on PD or who receive a gastrostomy at the same time as a PD catheter receive broad spectrum antibiotic and antifungal prophylaxis in the peri-operative period of gastrostomy placement.	Grade C, strong
	7.3	We suggest that PD should be withheld for 24 h or longer after gastrostomy placement if it is clinically safe to do so.	Ungraded
8. When and how can enteral tube feeding be started?	8.1	We suggest cautious introduction of a water bolus (after discussion with the insertion operator), followed by gradual introduction of feeds over the next 6 h.	Ungraded
9. How can the feed be delivered using the enteral feeding tube?	9.1	Tube feeding may be exclusive or supplementary to oral feeding. The method of feeding, rate and volume should be discussed with the family.	Ungraded
	9.2	To encourage the continuation of oral intake during the day, all the tube feed, or a proportion of it, may be given overnight.	Grade D, weak recommendation
	9.3	Continuous infusion feeding may be beneficial if vomiting is a problem.	Ungraded
	9.4	NG tubes must only be used with close supervision in the home environment, as there is a significant risk of aspiration, which can be fatal.	Grade X
10. How should vomiting be managed if it is affecting growth despite medical therapy and continuous gastrostomy feeding?	10.1	We suggest evaluation for gastro-esophageal reflux if vomiting continues in association with gastrostomy feeding and affects growth. Upper GI contrast and pH studies are needed to exclude malrotation and to define the severity of gastro-esophageal reflux, respectively. Nissen fundoplication may be needed.	Grade D, weak recommendation
11. When can a child transition from tube to oral feeding?	11.1	If the child develops an interest in taking food by mouth, we suggest decreasing the nutrition provided by tube feeding in proportion to oral intake, provided an adequate rate of growth is maintained. The goal is for the child to feed orally to meet nutritional goals.	Grade D, weak recommendation