Skin Care for Feeding Tube Sites

What is Skin Care for Feeding Tube Sites?

A child may need enteral nutrition (tube feeding) as part of supportive care during cancer. Feeding tubes may be placed through the nose (NG tube, NJ tube) or through the abdominal wall (G tube, GJ tube, J tube). Proper care of the tube and skin will reduce discomfort and lower the risk of infection and other problems.

General Care for Feeding Tube Sites

• Keep the skin around the tube clean and dry.
• Always wash hands with soap and water before checking the tube or giving nutrition or medicines.
• At least once a day, look for changes in the appearance of the tube or nearby skin. Check for redness, irritation, pain, bleeding, or drainage.
• Limit pressure and movement of the tube against the skin.

Caring for NG and NJ Tube Sites

Tubes placed through the nose can irritate the inside of the nose and the skin where the tube is taped. Proper care can help prevent discomfort and skin problems.

• Keep the tube secured to limit extra movement of the tube.
• Only use tape and dressings that have been approved by the care team.
• Use a skin protectant as recommended by the care team.
• Remove the tape and dressings carefully to avoid harming the skin. Use an adhesive remover if needed.
• Gently clean the skin around the tube with warm water and a wash cloth. Use a mild soap if needed.
• Nasal tubes can cause pressure injuries. Watch for redness or irritation where the tube presses or rubs against the skin.
• Over time, the placement of the tube will alternate nostrils to prevent breakdown of skin.
• If skin is irritated by the adhesive, change the position of the tape to give skin a chance to heal.
• Secure the loose end of the tube with tape when it is not in use. The important thing is to keep the tube out of the way and prevent it from being pulled out.

Caring for G Tubes, GJ Tubes, and J tube Sites

Gastrostomy (G) tubes, gastro-jejunostomy (GJ) tubes, and jejunostomy (J) tubes are feeding tubes placed through a small opening (stoma) made in the wall of the abdomen. They may be long tubes or low-profile tubes. A long tube may be replaced with a low-profile or button tube after the passage has healed, usually about 6 weeks.

Once healed, the skin around the tube should be painless. The size and shape of the opening should just fit the size of the feeding tube.

Caring for the G Tube Stoma Site

Healthy G tube sites don’t need a lot of extra care. Daily baths with soap and water are usually all that is needed to keep the area clean. General care tips for feeding tube sites include:

• Keep the tube site clean. Skin around the site should be cleaned at least once a day and whenever there is drainage. Clean the area using soap and water. Use a cotton swab to clean around the tube.
• Keep the skin around the site dry. Do not use lotions, creams, or ointments unless instructed.
• Turn tubes as recommended. G tubes and button tubes should be turned one-quarter turn each day. However, GJ tubes should never be turned as this can move the tube out of place and prevent it from working correctly. Ask if and how the tube should be turned.
• New Stomas: A gauze dressing may cover the site for the first few days after the tube is placed. Keep the area clean and dry. Change the dressing if it gets wet or dirty. A small amount of fluid may leak from the site. The fluid often forms a crust as it dries. Clean gently to remove the crust. No dressing is usually needed after 2-3 days.

Addressing Skin Problems

It is important to know what problems can occur, why they happen, and how to address them if they arise.

Leaking Around the Tube

Leaking can occur around the tube. If leaks occur from the tube, it can be due to a problem with the balloon fill. Leaks can also be related to neutropenia.

Moisture and acidic stomach fluids can cause the skin to be red and irritated. If this occurs, clean the skin with water several times each day. The area will have to be cleaned more often if drainage increases. Gently dry the skin after cleaning. A barrier powder or ointment may be needed. If the skin does not improve or leaking continues or occurs in large amounts, talk to your care team.

Possible reasons for leaking include:

• Feeding too much or too fast. The tube can sometimes leak during bolus feedings. Slowing down the rate of feeding or using a different feeding schedule may help. Be sure to talk to a dietitian or other care team member before making changes to nutrition.
• Problems with the internal balloon. Check the amount of water in the balloon. If it has less water than it should, refill with the correct amount. Check the balloon the next day. If the balloon continues to deflate, it may have a leak. Contact the care team for instructions on replacing the tube.
• Incorrect fit of the tube. This can sometimes happen if a child gains or loses weight. A weight gain can cause the tube to be buried in the skin fold around the stomach when sitting up. If the stem of the tube can be seen under the button, the tube may be too long. If the tube is no longer the right size, it may need to be replaced.
• Pressure on stomach or tube. Sleeping on the belly can cause pressure on the tube and trauma to the stomach. Sleeping on the side or back may reduce pressure.
• Gas and constipation. Gas and constipation can also cause fullness and pressure within the digestive tract. Being physically active and getting enough fluids can help. The care team may also recommend medicines or nutrition adjustments to manage constipation.

Medicines that control stomach acid or increase stomach emptying may help reduce damage caused by leaks. Discuss these options with the child’s care team.

Granulation Tissue

Granulation tissue is extra skin tissue that can grow at the site of the stoma. Granulation tissue is common. It usually appears red and moist, similar to the skin inside the mouth. This tissue is delicate, and there may be some bleeding or discharge. Granulation tissue may be caused by friction or chafing as the tube rubs against the skin. Ways to help prevent granulation tissue include keeping the site dry, limiting movement of the tube, and making sure the tube fits properly. Granulation tissue may be treated by applying foam dressings or silver nitrate. In some cases, it may be removed with surgery.

Infection

Infection is rare at the stoma or the skin around it in a healthy child. However, children with weak immune systems are at higher risk for infection of the tube site. Signs of a potential infection include:

• Skin redness around the stoma that increases without signs of leaking
• Fever
• Pain, soreness, or swelling
• Pus or a bad smell

Although redness and discharge can be signs of infection, they can have other causes as well. Sometimes stomach contents will mix with bacteria on the skin and cause a bad smelling discharge. Redness caused by leaks can usually be treated by cleaning the skin more often. Contact the care team if symptoms do not improve or there are signs of infection.

Bleeding

Bleeding around the stoma can have several causes. The site may bleed after a tube change. Bleeding may also occur due to granulation tissue where the skin is more fragile. A small amount of bleeding is not serious. If bleeding does not stop after a few minutes or gets worse, apply pressure to the area, and call the care team immediately.

Skin Changes at the Tube Site due to Neutropenia

Neutropenia occurs when the absolute neutrophil count (ANC) is less than 500. Neutropenia often causes the stoma to become enlarged. Because the immune system is weak, the body stops trying to close the hole and fight off infection. This can cause the site to stay wet, leak, and be painful. Bacteria can form, and an infection can develop. The site will not improve until white cell counts rise again. Sometimes the site will look worse before it begins to look better. The tube site should be treated as recommended by the care team.

Skin Care and Feeding Tubes: Tips and Troubleshooting

• Keep the tube site clean and dry.
• Clean the skin any time there is leaking, even if it needs to be done multiple times a day.
• A G tube button should be turned one-quarter turn each day.
• GJ tubes and GJ buttons should never be turned. Turning or twisting GJ tubes or buttons can move the tube out of place and prevent it from working correctly.
• Remove button adapters when not in use. When not feeding or giving medicine, remove the connection adapter to prevent pulling on or dislodging the button.
• Secure button adapters when in use. While feeding, tape the extension tubing to the stomach to reduce risk of pulling the tube.
• Report any changes to the tube, stoma, or skin around the site to the care team.