Assessment of Effectiveness in

Gastrostomy Placement in Patients

with Cystic Fibrosis
By: Kate Leventry Morton, RD
Objectives
1) Provide education on the importance of nutrition in relation to Cystic Fibrosis
(CF)

2) To understand malnutrition

3) To evaluate the use of gastrostomy tubes in patients with Cystic Fibrosis

4) To evaluate the increased hospitalizations in malnourished patients

Cystic Fibrosis (CF)
Progressive genetic disease that causes complications throughout the body

30,000 people in the United States are living with CF, and more than half of
these patients are children.
CF and Nutrition Complications

CF requires an increased caloric intake due to increased work of breathing

and fat malabsorption.

When high calorie demands are not met patients with CF can fall off their
established growth curve
Pediatric Malnutrition Definition
Factors Identified Mild Malnutrition Moderate Malnutrition Severe Malnutrition

Weight for height z score -1.0 to -1.9 z score -2.0 to -2.9 z score -3.0 or greater z score

BMI for age z score -1.0 to -1.9 z score -2.0 to -2.9 z score -3.0 or greater z score

Length for age z score No data No data -3.0 z score

Mid - upper arm -1.0 to -1.9 z score -2.0 to -2.9 z score -3.0 z score
circumference z score

Consensus Statement of AND/ A.S.P.E.N.

Implications of malnutrition

1) Decreased lung function

2) Increased infection

3) Increased hospitalizations

4) Stunted growth

5) Muscle wasting

6) Decreased overall health

14 year old female with CF

 43.6%
Of patients 2-19 years at Childrens of Alabama CF center have a BMI percentile
less than the 50th
2015 Patient Registry - Center Specific Report pg 39
Guidelines from the CF Foundation

enteral tube feeding can be used as a means to improve age-dependent

anthropometrics in individuals with CF that are unable to consume adequate
calories and protein to meet growth/weight maintenance goals
Guidelines from the CF Foundation

A multidisciplinary team should evaluate the patient before placement

Guidelines from the CF Foundation

The CF Foundation does not recommend for or against enteral tube feeding to
improve or stabilize pulmonary function in individuals with CF
Guidelines from the CF Foundation

The CF Foundation recommends that patient and family education about

nutritional care, including the role of enteral tube feeding, be done throughout the
lifetime of the individual with CF.
Guidelines from the CF Foundation

The CF Foundation recommends against using FEV1 as an absolute

contraindication to percutaneous or surgical enteral tube placement in individuals
with CF.
Guidelines from the CF Foundation

The CF Foundation recommends continuous nocturnal infusion for individuals

with CF who are receiving supplemental enteral tube feeding.
Guidelines from the CF Foundation

The CF Foundation recommends a comprehensive planning approach with a

multidisciplinary CF care team including the managing gastroenterologist, case
manager and home care agency prior to discharge.
When is a Gastrostomy Tube (GT) considered?
BMI at or below the 25th%ile for age

BMI z scores at or below -2.0

Falling 2 standard deviations (SDs) below established growth curve

Factors Success
Sustaining Daily Care

Family Support

Provide support from all CF team members

Review of the Literature on GT & CF
Cystic Fibrosis Foundation recommends that children between the ages of 2-20 years should have a
Body Mass Index (BMI) greater than or equal to the 50th percentile, in order to promote adequate growth and
development.1

According to Truby et al. pediatric patients with CF often fail to thrive due to anorexia, inadequate dietary intake,
maldigestion, malabsorption, and increased energy needs related to chronic respiratory infection. 20

The current research available demonstrates the following trend: a subtle decrease from baseline in both BMI%iles and
FEV1s 1 year post GT placement, but a steady rise in BMI percentiles and FEV1s 2 years after post GT placement. 11

Grime et al. found that of the 77 gastrostomies they have performed over the past 20 years (1990-2010) weight and BMI
significantly increased in 12 months following the placement: weight z score + 0.6 (p>0.001) and BMI z score + 0.74 (
p<0.01), but this study did not find a significant change in FEV1s.16
Review of the Literature on Malnutrition and
Hospitalizations
It is estimated by Lim, et al. that patients of any disease state that are malnourished had 29% longer hospital stays and
were more likely to be readmitted 15 days after discharge.12

Gastalver-Martn and colleagues found in a study of recently hospitalized patients that a malnourished patients hospital
stay costed 45-102% more than a patient of optimal nutrition status. 15

The results of this study showed that patients who presented with either stunting, wasting or both at the time of
admission had a significantly higher bed cost, enteral formula, nursing care, and medical apparatus. 13

Wasting patients also had longer hospital stays and spent more days in the hospital, which was correlated with the total
increased hospital cost (r=0.84 p= 0.01).13
Methods
Sample

Children and adolescents with CF that received a gastrostomy at Childrens of

Alabama tube between the years 2007 2015, with a minimum of 1 year

follow up
 Group 1 Information

Average age 5.7 years

Experimental Group Gender Female = 30%

Male = 70%
( group 1)
CFRD 25%
Sample Size: 19 CF patients with G tubes
Short Bowel 5%
Syndrome

Liver Disease/ 10%

Complications
Control Group (group 2)
19 CF patients

The data collected was compared to a matched control group based on age,
gender, and genotype
Data Collection
Data collection was completed by a retrospective electronic chart review of
the Childrens of Alabama EMR system and Port CF between the years 2007-
2015
SPSS was used to analyze the data
The used alpha level was .05 with 95% confidence interval, and a paired t -
test was used to analyze the data
Results
Group 1 Results

Baseline (GT placement) 1 year post 2 years post

BMI%ile : 28.3%* BMI%ile: 42.9* BMI%ile: 43.3

BMI z score: -0.736* BMI z score: -0.278* BMI z score: - 0.286

Group 2 Results

Baseline 1 year post 2 years post

BMI%ile : 52.85 BMI%ile: 55.35 BMI%ile: 62.05

BMI z score: 0.149 BMI z score: 0.222 BMI z score: 0.443

Surprise Findings

Average Days Hospitalized Over 2 Years

Group 1 46.4 days *

Group 2 13.5 days *

Discussion
Group 1 spend an average of 32.9 more days in the hospital than group 2

Cost of 1 day of inpatient care at a non profit hospital in Alabama

$1,657

$1,657 x 46.5 days = $75,559.2

Rappleye, E. (n.d.).
Discussion
51.59% increase in BMI%ile from baseline to year 1 in group 1

< 1% increase in BMI%ile from year 1 to year 2

The average BMI%ile did not reach the 50th%ile

43rd%ile was the highest average at the end of year 2

Discussion cont.
Group 2 had a BMI%ile 86.75% higher than group 1 at baseline

Group 2 maintained a significantly higher BMI%ile throughout the 2 years

BMI%iles Baseline Year 1 Year 2

Group 1 28.3 42.9 43.3

Percentage increase 51.9% <1%

Group 2 52.85 55.35 62.05

Percentage increase 4.75% 12.65%

Future Research
A research study addressing food insecurity, social environment, health literacy
and behavioral factors in this population could greatly increase health care
professionals understanding of malnutrition.
 Conclusion
G Tubes did improve the patient's BMI%ile
an average of 51.9% in the first year

This improvement was maintained into the

second year

Group 1 did not reach the 50th%ile for BMI

Group 2 maintained a BMI%ile above the

50th throughout the 2 year period

Group 1 spend 32.9 more days in the

hospital than group 2

The success of a G tube is more

complicated than simply performing the
procedure
Questions?
References
1. Cystic Fibrosis Foundation. (n.d.). Retrieved November 29, 2016,from https://www.cff.org/What-is-CF/About-Cystic-Fibrosis/
2. Bradley, G. M., Carson, K. A., Leonard, A. R., Mogayzel, P. J., & Oliva-Hemker, M. (2012). Nutritional outcomes following
gastrostomy in children with cystic fibrosis. Pediatric Pulmonology, 47(8), 743-748. doi:10.1002/ppul.22507
3. Childrens of Alabama Cystic Fibrosis data registry
4. White, H., Morton, A., Conway, S., & Peckham, D. (2013). Enteral tube feeding in adults with cystic fibrosis; patient choice and
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References cont.
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