Possible cause(s)

The technique was applied during or immediately following a meal

What to do?

• Stop the technique immediately unless your child is really congested with secretions.
• Avoid applying the technique within 2 hours before or after a meal.
• If needed, suction the secretions.

Possible cause(s)

• Sore chest or abdominal muscles
• Too much air in the lungs

What to do?

• It is normal that your child feels a slight pulling of the chest muscles when the therapy is first started. This discomfort will gradually disappear.

If he feels pain:

• Stop the technique immediately.
• Contact the healthcare team as soon as possible.

Possible cause(s)

• Less than 10 minutes between each session
• Session is too long

What to do?

• Let your child rest.
• Wait 10 minutes between each session.

If the dizziness is severe:

• Stop the technique immediately.
• If the symptoms reappear again, contact the healthcare team.

Possible cause(s)

Air is entering the stomach instead of the lungs

What to do?

• Remind your child to relax during the insufflations of air; he must not resist air entry.

If the discomfort persists:

• Stop the technique immediately.
• Quickly contact the healthcare team.

Possible cause(s)

• Poor technique
• Thicker secretions
• More secretions than usual

What to do?

• Review the technique.
• Combine more than one technique at a time (ex, pulmonary hyperinflation with abdominal thrusts) in order to increase the efficacy of secretion clearance.
• Make sure that the humidity level is adequate.
• If the problem persists, contact the healthcare team as soon as possible.

Possible cause(s)

Poor seal around the mouthpiece

What to do?

• Make sure that your child closes his mouth firmly around the mouthpiece.
• Make sure that the mouthpiece is properly inserted in the modified ventilatory bag.
• If needed, use a facial mask.
• If the problem persists, contact the healthcare team.

Possible cause(s)

The air is leaking through the nose rather than going to the lungs

What to do?

• Use a nose clip.
• If the problem persists, use a facial mask.
• If the problem continues to persist, contact the healthcare team.

Possible cause(s)

• Poor technique
• Lack of collaboration by your child

What to do?

• Review the technique.
• Make sure that there is no leak (mouthpiece, facial mask, tubing).
• Make sure that your child is relaxed.
• If the problem persists, contact the healthcare team.

Possible cause(s)

• Respiratory tract infection
• Incorrect placement of the tracheal cannula

What to do?

• Suction the secretions if required.
• Rapidly contact your child’s healthcare team.
• Observe your child attentively in order to detect any sign of respiratory distress (see that specific problem).
• In this case, call 911 immediately.
• If required, begin manual ventilation and CPR as instructed.

If your child has increased secretions without respiratory distress, then:

• Suction the secretions if required.
• Raise the head of the bed at night and during naps.
• Keep your child in a sitting and semi-sitting position if more comfortable this way.
• Take your child’s temperature every 4 hours and give the medication recommended by your child’s healthcare team.
• Increase liquid intake to help liquify the secretions.
• Increase the humidity level.

Possible cause(s)

• Obstruction of the tracheal cannula by a foreign object or by secretions (mucus plug)
• Accumulation of secretions or water in the artificial nose
• Respiratory tract infection (eg, tracheitis, pneumonia)
• Granulation tissue around the tracheal cannula site (thick soft scar tissue that sometimes forms around the tracheostomy)
• Bronchospasm (eg, allergic reaction, exposure to smoke, dust, cold air)

What to do?

• Remain calm and reassure your child.
• Immediately identify the cause of the blockage (eg, secretions, mucus plug).

If the tracheal cannula is obstructed

• by a foreign object: change the cannula.
• by secretions:
  • Try suctioning the secretions and,
  • Instill a few drops of normal saline, if recommended by your healthcare team.
  • Repeat suctioning.

If the obstruction persists:

• Change the cannula.
• If needed, suction secretions.
• If needed, repeat instillation and suction up to 2 more times maximum.

If the problem is resolved:

• Verify your child’s breathing to detect any signs of respiratory distress.
• Inform your child’s healthcare team.

If the symptoms persist:

• Call 911 immediately.
• If required, begin manual ventilation and CPR as instructed.

If there is an accumulation of secretions,
in the tracheostomy:

• Try suctioning the secretions.
• Instill a few drops of normal saline, if recommended by your healthcare team.
• If you are able to suction the secretions: repeat instillation and suction up to 2 more times maximum, if needed.
• If you are unable to suction the secretions (blockage of the tracheal cannula):
  • Change the cannula.
  • Suction tracheal secretions if needed.
• If the problem is resolved:
  • Verify your child’s breathing to detect any signs of respiratory distress.
  • Inform your child’s healthcare team.
• If the symptoms persist:
  • Call 911 immediately.
  • If required, begin manual ventilation and CPR as instructed.

in the artificial nose:

• Remove the artificial nose.
• Suction tracheal secretions.
• Replace the artificial nose.
• If the problem is resolved:
  • Verify your child’s breathing to detect any signs of respiratory distress.
  • Inform your child’s healthcare team.
• If the problem persists: re-evaluate the cause of the obstruction.

If your child has difficulty breathing that is not related to the issues above:

• Contact your child’s healthcare team immediately.
• If your child has medications that have been previously prescribed for these symptoms (eg, Ventolin), administer them as prescribed or according to your child’s healthcare team.

Possible cause(s)

• Spasm, irritation or inflammation of the trachea
• Complete or partial obstruction of the trachea (eg, laryngospasm)
• Incorrect positioning of your child’s head
• Granulation tissue around the tracheal cannula site

What to do?

• Do not force insertion of the cannula into the trachea.
• Remain calm and reassure your child, he may still be able to breathe through his tracheostomy.
• If the new cannula is partially inserted:
  • hold the cannula in place and remove the obturator;
  • allow your child to calm down and breathe through the cannula;
  • reposition your child’s head so that it is slightly tilted backwards by replacing the rolled towel under the shoulders;
  • try again to insert the rest of the cannula without forcing, as your child takes a breath in, while gently pulling on the  neck skin just below the tracheostomy;
  • if you are able to insert the cannula completely, secure it with ties and immediately contact your child’s healthcare team to inform them of the situation.
• If the cannula is impossible to insert:
  • remove the cannula and lubricate it again;
  • try re-inserting the cannula with the obturator in place;
  • if this does not work: try again with a smaller size cannula with the obturator;
  • if this also does not work: try again by replacing the obturator with a suction catheter to serve as an insertion guide;
  • observe your child’s breathing to detect any signs of respiratory distress;
  • if you are able to insert the cannula completely, secure it with ties and immediately contact your child’s healthcare team to inform them of the situation.
• If you are unable to insert the new cannula call 911 immediately.
• While waiting for help, if your child is not breathing on his own, begin manual ventilation and CPR as instructed.
• While waiting for help, if your child is breathing on his own through the tracheostomy and if you have been trained to do so by your child’s healthcare team:
  • insert a suction catheter into the tracheostomy to maintain an open airway;
  • hold on to the catheter so that it does not slide into the trachea;
  • verify if your child is in respiratory distress (see that specific problem);
  • if your child is in respiratory distress, remove the suction catheter and begin manual ventilation and CPR as instructed.

Possible cause(s)

• Accident
• Incorrect manipulation of the cannula
• Tracheostomy ties (ribbons or Velcro® band) are too loose or poorly secured around the neck
• Excessive cough

What to do?

• Remain calm and reassure your child, he may still be able to breathe through his tracheostomy.
• If the cannula has come out partially:
  • gently push it back down even if the conditions are not ideal;
  • immediately contact your child’s healthcare team to inform them of the situation.
• If the cannula has come out completely:
  • undo the tracheostomy ties;
  • insert a new cannula if available or reinsert the old one in the meantime;
  • replace the tracheostomy ties;
  • suction tracheal secretions;
  • once the cannula has been inserted, contact your child’s healthcare team to inform them of the situation.
• If the cannula is impossible to insert:
  • remove the cannula and lubricate it again;
  • try re-inserting the cannula with the obturator in place;
  • if this does not work: try again with a smaller size cannula with the obturator;
  • if this also does not work: try again by replacing the obturator with a suction catheter to serve as an insertion guide;
  • observe your child’s breathing to detect any signs of respiratory distress;
  • if you are able to insert the cannula completely: secure it with ties and immediately contact your child’s healthcare team to inform them of the situation.
• If you are unable to insert the new cannula: call 911 immediately.
• While waiting for help, if your child is not breathing on his own, begin manual ventilation and CPR as instructed.
• While waiting for help, if your child is breathing on his own through the tracheostomy and if you have been trained to do so by your child’s healthcare team:
  • insert a suction catheter into the tracheostomy to maintain an open airway;
  • hold on to the catheter so that it does not slide into the trachea;
  • verify if your child is in respiratory distress (see that specific problem);
  • if your child is in respiratory distress, remove the suction catheter and begin manual ventilation and CPR as instructed.

Possible cause(s)

• Irritation of the trachea by:
  • incorrect suctioning technique (too frequent, too deep or using a suction pressure that is too high)
  • injury due to the rubbing of the tracheal cannula
• Respiratory tract infection
• Granulation tissue around the tracheal cannula site
• Insufficient humidification
• Insufficient hydration

What to do?

If fresh blood in the secretions:

• remain calm and reassure your child;
• if bleeding continues, immediately contact your child’s healthcare team;
• observe your child’s breathing to detect any signs of respiratory distress (see that specific problem);
• if your child is in respiratory distress, remove the suction catheter and begin manual ventilation and CPR as instructed.

If blood streaks or pink secretions:

• observe your child’s breathing to detect any signs of respiratory distress;
• check the pressure of the suction device;
• review suctioning technique; be sure to respect the length and the depth of insertion of the suction catheter that is recommended;
• gently suction tracheal secretions;
• increase the level of humidity;
• contact your child’s healthcare team.

Possible cause(s)

• Irritation of the trachea
• Ulceration of the trachea
• Granulation tissue around the tracheal cannula site
• Infection
• Insufficient humidity
• Cannula replacement

What to do?

• Immediately contact your child’s healthcare team.
• Increase the level of humidity.

Possible cause(s)

• Accident during a bath, while washing hair or splashing
• Accumulation of water in the tubing of a heated humidifier or air compressor humidifier system

What to do?

• Suction tracheal secretions.
• Immediately contact your child’s healthcare team.
• Observe your child’s breathing to detect any signs of respiratory distress.

Possible cause(s)

• Dysphagia (difficulty in swallowing)
• Gastric reflux (stomach contents rise up through esophagus)

What to do?

• Stop feeding your child food and liquids immediately.
• Suction tracheal secretions.
• If solid food or thick liquid bits are present in the secretions:
  • instill a few drops of saline solution according to the recommendations of your child’s healthcare team;
  • try suctioning the tracheal secretions again.
• Rapidly contact your child’s healthcare team.

Possible cause(s)

Various

What to do?

• Turn your child’s head to the side so as to avoid vomit from entering the tracheostomy.
• If you think that vomit has entered the tracheostomy, suction tracheal secretions.
• Clean your child’s mouth.
• Observe your child’s breathing to detect any signs of respiratory distress (see that specific problem).
• Rapidly contact your child’s healthcare team.

Possible cause(s)

• Infection
• Dampness of the skin (from secretions, or a soiled tracheostomy dressing)
• Use of products that irritate the skin

What to do?

• The skin around the tracheostomy site should look the same as the skin on the rest of your child’s neck.
• Review the technique for cleaning of the skin around the tracheostomy.
• Keep the tracheostomy site clean and dry by increasing the frequency of cleaning around the tracheostomy and by changing the tracheostomy dressing.
• There are many types of products that can be used to protect the skin such as foam dressings and liquid skin protectors; speak with your child’s healthcare team.
• Contact your child’s healthcare team for more recommendations if the skin is irritated (eg, application of an antibiotic cream).

Possible cause(s)

Tracheostomy ties are too tight

What to do?

• The space between the skin of your child’s neck and the tracheostomy ties (Velcro® or cotton ribbons) should be the thickness of the tip of a finger. Individuals with large fingers should use their small finger. This space can sometimes be reduced particularly when the child is overweight.
• Verify the space between the neck and the tracheostomy tie and adjust, if needed.
• Contact your child’s healthcare team for more recommendations regarding skin protection under the tracheostomy ties.

Possible cause(s)

• Mucous plug in the tracheal cannula: may be caused by insufficient humidity, excess secretions and/or insufficient frequency of suctioning
• Foreign body in the tracheal cannula
• Incorrect insertion of catheter for aspiration

What to do?

• Never force the insertion of the catheter in the tracheal cannula.
• Gently but rapidly, attempt to suction tracheobronchial secretions.
• Instill saline drops into the tracheal cannula, as you have been taught by your healthcare team.
• If you are unable to suction secretions (the tracheal cannula is obstructed), then:
  • change the cannula;
  • suction tracheal secretions if needed.
• If the problem is resolved:
  • observe your child’s breathing to detect any signs of respiratory distress;
  • inform your healthcare team.
• If you are still unable to suction secretions and your child IS in respiratory distress:
  • call 911 immediately;
  • if required, begin manual ventilation and CPR as instructed.
• If you able still unable to suction secretions and your child IS NOT in respiratory distress, immediately contact your child’s healthcare team.
• If you are able to aspirate secretions, then:
  • repeat the aspiration, using installation of saline drops, up to 2 more times, as needed;
  • review methods to prevent mucous plugs with your healthcare team.

Possible cause(s)

• Mucous plug or foreign body in the nostril
• Inflammation inside the nose, causing blockage of the nostril (eg, due to infection or allergy)
• Septum deviation of the nose
• Incorrect insertion of the catheter into the nose

What to do?

• Clean the nose, using saline drops, as taught to you by the healthcare team.
• Never force the insertion of the catheter into the nose.
• Review the method of nasal aspiration.
• Ensure that you are using the correct equipment and materials for nasopharyngeal suctioning.
• Rapidly contact your child’s healthcare team.

Possible cause(s)

• Equipment malfunction including any of the following:
  • suction device battery charge depleted
  • suction regulator pressure too low
  • suction device broken
  • canister containing secretion overfilled
  • canister cover incorrectly closed
  • suction tubing bent or pinched
  • suction device incorrectly assembled
  • suction catheter blocked
• Excess or very thick secretions are obstructing the airway

What to do?

• Quickly verify that the suction device is plugged into a working electrical outlet or that the battery is correctly charged.
• If no power is available, use the manual mucous trap device, as instructed by your healthcare team.
• If the power supply is adequate, quickly verify that the suction device is in working order:
  • verify that the pressure on the suction; regulator is set to the correct value
  • empty the canister if full;
  • verify that the canister cover is closed correctly;
  • verify that the suction tubing is correctly installed and not blocked, pinched, bent or damaged in any way;
  • verify that that all parts of the suction circuit are correctly installed;
  • verify that the suction valve or port is working correctly;
  • verify that the suction catheter is not blocked.
• After these steps, if you are unable to suction secretions (obstruction of the tracheal cannula):
  • change cannula;
  • suction tracheal secretions if needed.
• If the problem is resolved:
  • observe your child’s breathing to detect any signs of respiratory distress;
  • inform your healthcare team.
• If you are still unable to suction secretions and your child IS in respiratory distress:
  • call 911 immediately;
  • if required, begin manual ventilation and CPR as instructed.
• If you able still unable to suction secretions and your child IS NOT in respiratory distress, immediately contact your child’s healthcare team.
• If you are able to aspirate secretions, then:
  • repeat the aspiration, using installation of saline drops, up to 2 more times, as needed;
  • review methods to prevent mucous plugs with your healthcare team.

Possible cause(s)

• Irritation of the trachea by:
  • incorrect suctioning technique (too frequent, too deep or using a suction pressure that is too high)
  • excessive cough
• Respiratory tract infection
• Insufficient humidification
• Insufficient hydration

What to do?

If fresh blood in the secretions:

• Remain calm and reassure your child;
• If bleeding continues, immediately contact your child’s healthcare team;
• Observe your child’s breathing to detect any signs of respiratory distress (see next problem);
• If your child is in respiratory distress, remove the suction catheter and begin manual ventilation and CPR as instructed.

If blood streaks or pink secretions:

• Observe your child’s breathing to detect any signs of respiratory distress.
• Check the pressure of the suction device.
• Review suctioning technique; verify that you are inserting the catheter to the correct depth.
• Aspirate secretions gently.
• Avoid excessive aspiration which can damage the delicate lining of the airways.
• Increase the level of humidity.
• Contact your child’s healthcare team.

Possible cause(s)

• Mucous plug moved further down the airways towards the lungs
• Bronchospasm: narrowing or constriction of the airways (eg, due to irritation, inflammation and/or secretions in the airways)
• Pneumothorax (a puncture in the lining of the lungs)

What to do?

• Remain calm and reassure your child.
• Stop suctioning.
• Remove the suction catheter.
• Give prescribed medication, such as a bronchodilator (eg, Ventolin®) and/or oxygen if available and recommended by the healthcare team.
• If your child IS NO LONGER in respiratory distress, contact your child’s healthcare team.
• If your child REMAINS in respiratory distress:
  • call 911 immediately;
  • if required, begin manual ventilation and CPR as instructed.

Possible cause(s)

• Aspiration too soon after the last meal
• Incorrect aspiration technique (eg, insertion of the suction device such as Yankauer suction tip too far back in the throat)
• Stimulation of the gag reflex during oral or nasopharyngeal suctioning
• Incorrect insertion of the catheter

What to do?

• Turn your child’s head to the side to avoid choking or passage of vomit into the lungs.
• If the secretions were aspirated during a meal, pause your child’s feeding.
• Clean your child’s mouth.
• Closely observe your child’s breathing to detect any signs of respiratory distress (see previous problem).
• Rapidly contact your child’s healthcare team.

To avoid vomiting:

• Minimize aspiration of secretions immediately after meals.
• Review the correct technique for aspiration of secretions.
• Gently insert the suction catheter to avoid stimulating the gag reflex.

Possible cause(s)

• Agitated child, moving a lot during the aspiration procedure
• Incorrect insertion of the suction catheter
• Irritation of the nostril
• Excessive suctioning of the nose
• Suction pressure too high

What to do?

• Reassure your child.
• Apply direct pressure to the bridge of your child’s nose for a few minutes to stop bleeding; if possible put your child in the upright or sitting position.
• If the bleeding persists, rapidly contact your child’s healthcare team.

To avoid nosebleeds:

• Review the correct technique for nasopharyngeal aspiration of secretions.
• Verify that the suction pressure regulator is correctly set, as recommended by the healthcare team.
• Verify that the catheter is well lubricated prior to insertion.
• Gently insert the catheter into the nose.

Possible cause(s)

• Incorrect insertion of the suction catheter
• Bronchospasm: narrowing or constriction of the airways
• Respiratory tract infection

What to do?

• Stop suctioning.
• Remove the suction catheter.
• Reassure your child.
• Assess your child’s breathing and colour.
• If your child calms and stops coughing, gently re-insert the catheter to aspirate secretions.
• If the cough persists, consider administration of a bronchodilator such as Ventolin® and/or oxygen if available and recommended by the healthcare team.
• If your child shows signs of respiratory distress:
  • call 911 immediately;
  • if required, begin manual ventilation and CPR as instructed.
• If the cough persists, rapidly contact your child’s healthcare team.

To prevent this problem: Review the correct technique for aspiration of secretions.

Possible cause(s)

Low level of oxygen in the blood (desaturation or hypoxia)

What to do?

• Stop aspiration of secretions.
• Remove the suction catheter.
• Administer oxygen, if available.
• Closely observe your child.
• If your child is mechanically ventilated, reconnect your child to the ventilator.
• If your child remains in respiratory distress:
  • call 911 immediately;
  • if required, begin manual ventilation and CPR as instructed.
• If your child improves, immediately contact your child’s healthcare team.

Possible cause(s)

Vagal stimulation

What to do?

• Stop aspiration of secretions.
• Verify the general and respiratory status of your child, following the training provided by your healthcare team.
• If your child is in respiratory distress, call 911 immediately and begin manual ventilation and CPR as instructed.

Possible cause(s)

• Break or leak in the suction device system (eg, cover not secured, catheter or filter incorrectly connected)
• Defective suction device

What to do?

• Verify that the suction device is correctly installed and connections are secured.
• If necessary, use the manual mucous trap device to aspirate secretions from the tracheal cannula
• If the problem persists, rapidly contact your healthcare team.

Possible cause(s)

• Canister is overfilled
• Battery depleted
• Defective suction device

What to do?

• Verify that the suction device is plugged into a working electrical outlet or that the battery is correctly charged.
• Empty the canister if full.
• If the problem persists, rapidly contact your child’s healthcare team.

Possible cause(s)

Various

What to do?

• Look at your child immediately; verify that your child is breathing effectively. If not, rapidly establish breathing using either the manual ventilatory bag or a spare ventilatory assistance device.
• If your child is in respiratory distress,
  • call 911 immediately;
  • if required, begin manual ventilation and CPR as instructed.
• If your child is breathing effectively, read the message on the device screen.
• Press once on the alarm/silence button on the device to silence the alarm.
• Identify the cause of the alarm.
• Take appropriate action to address the issue identified by the alarm.
• If necessary, consult the manual of the device to solve the issue.
• If you are still unable to solve the issue, rapidly contact your child’s healthcare team.

Possible cause(s)

• Device lacks power
• Not correctly plugged into electrical wall outlet
• Internal battery depleted
• Device malfunction
• Device plugged into a wall outlet that is controlled by a switch that is turned off

What to do?

• Verify that the device is securely plugged into an electrical wall outlet or that the internal battery is adequately charged.
• Verify that the electrical wall outlet is not controlled by a switch that is turned off.
• Use an alternative device to support your child’s breathing, if necessary.
• If the problem persists, rapidly contact your child’s healthcare team.

Possible cause(s)

• Accident
• Incorrect handling of the equipment

What to do?

• Make sure that the circuit parts are well connected when installing the ventilatory assistance.
• Check that each part of the circuit is in good condition (no cracks or other signs of wear and tear) during installation and disconnection.
• Ensure that the circuit is adequately positioned so that there is no pulling or tension on the circuit.

Possible cause(s)

• Accident
• Incorrect handling of the equipment
• Wear and tear with repeated use

What to do?

• Never use damaged or defective materials or equipment when providing ventilatory assistance to your child.
• Substitute a replacement piece for the broken one.
• Inform your child’s healthcare team that you used spare equipment and arrange to replace the spare items.
• Always handle equipment gently and according the recommendations of your healthcare team.

Possible cause(s)

• Circuit incorrectly assembled
• Circuit bent, crushed or obstructed
• Accumulation of water in the circuit
• Obstructed exhalation valve openings in the mask
• Dirty air filter
• Blockage of air going into the device
• Leaks at the level of the water chamber or humidifier

What to do?

• Verify that:
  • the circuit is correctly assembled;
  • the exhalation valve openings in the mask are clean and not obstructed;
  • the tubing of the circuit is not bent, crushed or obstructed;
  • there is no accumulation of water in the circuit;
  • the air filter is clean; if not clean it or replace it;
  • there is no obstruction to the air intake of the device (eg, curtain, blanket, fabric, etc.);
  • there is no leak in the water chamber or the humidifier.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Dirty air filter
• Ventilatory assistance device placed too close to a source of heat (eg, radiator)

What to do?

• Verify that the air filter is clean and intact. If not, clean it or replace it. To clean it, follow the recommendations of your healthcare team.
• Position the ventilatory assistance device away from direct sunlight or other sources of heat.
• Verify that the circulation of air around the device is unobstructed; keep curtains, bed covers and stuffed toys away from the device.
• Verify that the humidity level of the humidifier of the ventilatory assistance device is correct; lowering it if necessary.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Incorrect handling of the device
• Accident

What to do?

• Use a back up device, if available.
• Unplug the dropped device from the electrical outlet.
• Pick up the dropped device and put it in correct position on a flat surface, being careful not to let water run into the device.
• Remove the water chamber.
• If there is spilled water visible, dry the area with a clean cloth.
• Reinsert the water chamber into the humidifier.
• Verify that no excess water has spilled into the circuit; if present, empty it.
• Reconnect the device to an electrical wall outlet.
• Install the interface on your child and start up the ventilatory assistance device. If it does not function or does not work as usual, contact your healthcare team.
• Prevent accidents by always placing the device in such a way that no one trips on the electrical cord.
• Make sure that the ventilatory assistance device is placed on a stable, solid surface so that it does not fall easily.
• Make sure that the circuit does not pull or put tension on the device.

Possible cause(s)

• Device too close to sources of electromagnetic waves
• Dropped device
• Incorrect handling of the device

What to do?

• Position the device away from objects that emit electromagnetic waves (eg, cellphones, base of wireless telephone, some alarm clocks, microwave, etc.).
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Water chamber was not sufficiently filled
• Excess air leaks around the mask
• Humidity level of the humidifier set too high
• Room temperature too cold or room air too dry
• Cold air flow directed towards the ventilatory assistance device (eg, air conditioning)
• Leak in the water chamber due to cracks or holes.

What to do?

• Make sure that the water chamber is adequately filled to the maximum fill line.
• Ensure that the mask is well positioned on your child’s face; adjust the mask and straps to eliminate any air leaks.
• Verify that the humidity level on the device is appropriately set.
• If necessary, increase the room temperature or ambient room humidity.
• Make sure that the device is not exposed to cold air drafts.
• Ensure that the water chamber is correctly installed in the device.
• If the water chamber is damaged, replace it and contact your child’s healthcare team.

Possible cause(s)

• Cold air flow directed towards the circuit
• Room temperature too cold
• Humidity level of the humidifier set too high

What to do?

• Ensure that the device and circuit are not exposed to cold air drafts.
• Make sure that the room temperature is not too cold.
• Lower the humidity level of the humidifier.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Water chamber of the device
• Condensation in the circuit and/or the mask
• Cold air flow directed towards the circuit
• Room temperature too cold

What to do?

• Do not overfill the water chamber; never fill beyond the maximal fill level line.
• Lower the humidity level of the humidifier.
• Ensure that the device and circuit are not exposed to cold air drafts.
• Make sure that the room temperature is not too cold.

Possible cause(s)

• Cold air flow directed towards the circuit
• Room temperature too cold
• Humidity level of the humidifier set too high

What to do?

• Ensure that the device and circuit are not exposed to cold air drafts.
• Make sure that the room temperature is not too cold.
• Lower the humidity level of the humidifier.
• Remove excess water from the circuit so that it does not move into the mask or the child’s tracheostomy.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Water chamber cracked or damaged
• Incorrect installation of the water chamber

What to do?

• Verify if the water chamber is damaged or cracked; replace it and contact your child’s healthcare team.
• Correctly install the water chamber (refer to the equipment manual if necessary).

Possible cause(s)

• Incorrect positioning of the mask
• Difficulty in adapting to ventilatory assistance
• Incorrect humidity setting of the device
• Respiratory infection or another health problem

What to do?

• This more commonly occurs when ventilatory assistance is first started in children; that is during the initial period of adaptation.
• Ensure that the mask fits correctly:
  • the straps should be correctly positioned and not too tight;
  • verify that there are no pressure points from the mask on your child’s face;
  • verify that the mask is correctly placed, as recommended by your child’s healthcare team.
• Increase the humidity level gradually as needed in order to avoid condensation in the tubing.
• Ensure that there is a sufficient amount of water in the water chamber (eg, during the night).
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Leakage of air at the level of the mask or tracheal cannula
• Child not optimally positioned to receive ventilatory assistance
• Leaks in the circuit (eg, damaged tubing)
• Variation in air flow due to the child talking, coughing or breathing in an unusual way

What to do?

• Verify that the mask is well placed; straps should not be too tight; follow the recommendations of your healthcare team.
• Ensure that the positioning of your child during ventilatory assistance is not causing leaks (eg, hyperextension of the neck if the child has a tracheostomy, mask placement).
• Make sure that the circuit is correctly and securely connected.
• Ask your child to breathe calmly.
• Encourage your child to stay calm and to relax. Consider using distraction techniques, if needed.
• If your child is coughing, remove the mask and reinstall it once your child has stopped coughing.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Mask incorrectly adjusted; too tight
• Mask not cleaned regularly
• Wrong mask type for the child
• Dry skin
• Incorrect positioning of the child during mask use
• Air leaks around the mask

What to do?

• Verify that the mask is well placed; straps should not be too tight; follow the recommendations of the healthcare team.
• Avoid rubbing or pushing the mask over the face during placement.
• Make sure that the child’s skin is well moisturized.
• Verify that there are no pressure points from the mask on the skin caused by the child’s position during use.
• Use a different type of mask or alternate between different models to vary the pressure points on the face so that the skin has a chance to heal.
• It is normal for the skin to be slightly red at the pressure points of the mask, for up to 3 hours after the mask is removed. If the redness persists after this period, rapidly contact your child’s healthcare team to avoid serious skin breakdown.

Possible cause(s)

• Air leaks around the mask
• High air flow from the ventilatory assistance device
• Humidity level on the device set too low
• Nasal dryness present for other reasons (eg, seasonal variation)

What to do?

• This is commonly seen when ventilatory assistance is first started; the mucosa of the nose takes time to adapt to the air flow from the ventilatory assistance device.
• Verify that the mask is correctly placed and the degree of leaks is acceptable.
• As recommended by your healthcare team, use a water-based lubricant to hydrate the nasal mucosa.
• Increase the humidity level gradually as needed in order to avoid condensation in the tubing.
• Ensure that there is a sufficient amount of water in the water chamber (eg, during the night).
• Increase your child’s hydration during waking hours (eg, drink more water).
• Verify that your child’s nasal hygiene is optimized, follow the recommendations of your healthcare team.
• Increase the level of humidity in the environment.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• High air flow from the ventilatory assistance device
• Air leaks around the mask
• Your child sleeps with an open mouth
• Humidity level on the device set too low
• Respiratory infection
• Seasonal allergies

What to do?

• This is mainly an issue during the initial adaptation period to ventilatory assistance.
• Verify that the mask is correctly placed; straps should not be too tight, as recommended by your child’s healthcare team.
• If your child sleeps with an open mouth, discuss with your healthcare team whether a chin strap should be used with the mask.
• Increase the humidity level gradually as needed in order to avoid condensation in the tubing.
• Ensure that there is a sufficient amount of water in the water chamber (eg, during the night).
• Verify that your child’s nasal hygiene is optimized; follow the recommendations of your healthcare team.
• Increase the level of humidity.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Air leaks around the mask, misdirecting air flow into the eyes
• Mask incorrectly adjusted or positioned
• Incorrect mask (eg, size, model)

What to do?

• Verify that the mask is correctly placed; straps should not be too tight, as recommended by your child’s healthcare team.
• Clean the mask daily, following the recommendations of the healthcare team.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Your child sleeps with an open mouth
• Air leaks around the mask
• Humidity level too low

What to do?

• If your child sleeps with an open mouth, discuss with your healthcare team whether a chin strap should be used with the mask.
• Increase the humidity level gradually as needed in order to avoid condensation in the tubing.
• Ensure that there is a sufficient amount of water in the water chamber (eg, during the night).
• Increase your child’s hydration during waking hours (eg, drink more water).
• Increase the level of humidity.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• High air flow from ventilatory assistance device, air enters the lungs and the stomach
• Difficult coordination between the child’s breathing and the ventilation from the ventilatory assistance device

What to do?

• Occasionally present during the initial adaptation period to ventilatory assistance.
• Encourage your child to coordinate breathing with the ventilatory support from the device as taught by your healthcare team.
• If the problem persists, rapidly contact your child’s healthcare team.
• If your child’s abdomen becomes hard or tender to touch or if your child is agitated, in discomfort, reporting abdominal pain or crying for no obvious reason, then rapidly contact your child’s healthcare team.

Possible cause(s)

Difficulty in coordination between the child’s breathing and the ventilation from the ventilatory assistance device

What to do?

• This is mainly observed during the initial adaptation period to ventilatory assistance.
• In order to speak or swallow, the child must coordinate their breathing efforts with the air flow of the ventilatory assistance device. It is easier for the child to speak and swallow during the expiration phase.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Air leaks around the facial mask
• Air leakage around the tracheal cannula (eg, cuff deflation or incorrect positioning of the child)
• Disconnection between the ventilatory bag and the tracheostomy connector or the mask specific for manual ventilation
• Defective ventilatory bag

What to do?

• Reposition the mask.
• Ensure that the child’s head is correctly positioned.
• Verify that the cuff of the tracheal cannula is correctly inflated, if present.
• Ensure that the ventilatory bag and tubing are securely connected.
• Verify that the ventilatory bag is correctly functioning: compress the bag with one hand and then release it; at the same time check with your other hand if air is coming out of the bag at the air outlet. The bag should reinflate quickly and automatically.

Possible cause(s)

• Obstruction of the child’s airways or the interface
• Defective ventilatory bag

What to do?

• Ensure that the tracheal cannula is not obstructed with secretions; suction the secretions if needed.
• Make sure that there are no blockages in the mask.
• Ensure that there is no obstruction of the mouth or nose (secretions or foreign body); suction the secretions if needed.
• Verify that the ventilatory bag is correctly functioning: compress the bag with one hand and then release it; at the same time check with your other hand if air is coming out of the bag at the air outlet. The bag should reinflate quickly and automatically.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

Air pushed into the stomach rather than into the lungs

What to do?

• Rapidly remove the face mask from your child.
• Suction the secretions.
• Clean your child’s face as needed.
• Monitor your child’s breathing after the vomiting; there is a risk that some of the vomit may have entered the lungs (aspiration). This would cause your child to have more difficulty breathing. Rapidly contact your child’s healthcare team.

Possible cause(s)

• Disconnect between the  ventilatory bag and the tracheostomy connector or the mask specific for manual ventilation
• Defective ventilatory bag

What to do?

• Ensure that the ventilatory bag and tubing are securely connected.
• Verify that the ventilatory bag is correctly functioning: compress the bag with one hand and then release it; at the same time check with your other hand if air is coming out of the bag at the air outlet. The bag should reinflate quickly and automatically.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Bag compressions too forceful
• Bag compressions too rapid
• Model of ventilatory bag inappropriate for the quantity of air required by the child

What to do?

• Review the technique for correct manual ventilation.
• Compress the ventilatory bag with less force.
• Ensure that the correct model of ventilatory bag is used. If needed, verify with your healthcare team.

Possible cause(s)

• The body has difficulty in absorbing water
• Reaction of the body to certain foods or medications
• Infection

What to do?

• The stool of an ileostomy may be liquid or pasty, and that of a colostomy may be semi-formed or formed.
• Talk with the nutritionist about foods that can change the consistency of your child’s stool.
• You can put a few cotton balls or an absorbent tampon into the collection bag to absorb the excess liquid and this will also make emptying easier.
• Powdered fibers (eg, “Metamucil”) can be added to the bag so that the content can become jelly-like.
• It is particularly important if your child has an ileostomy, that you ensure your child drinks more than usual in order to prevent dehydration.
• If liquid stool is not normal for your child, or if  there are more than usual, it is important to consult your healthcare team immediately.

Possible cause(s)

• Certain medications/foods can constipate
• Low fluid intake

What to do?

• Children with colostomies may be constipated, ie, no bowel movement for 2 or more days.
• Ensure that your child drinks enough as recommended by the healthcare team.
• See the nutritionist or a member of the healthcare team if necessary.

Possible cause(s)

• Leakage around the collection device
• Injury caused by an ill-fitting device
• Use of products irritating to the skin
• Watery stool
• Sweating

What to do?

• The skin around the stoma of your child should look the same as the skin over the chest and abdomen.
• It is important that the skin barrier fits closely to the stoma but without touching it.
• Do not use products such as powder, lotion, ointment that may prevent the skin barrier from sticking well.
• It can be challenging to avoid stoma irritation in the young child who is active and growing; speak with your enterostomal therapy nurse or your healthcare team as soon as possible as there are many special products that can be tried to solve your child’s specific problem.

Possible cause(s)

Incorrect installation of the collection device

What to do?

• Odor should not be a problem if the collection bag is closed properly and if the opening is kept clean after the bag has been emptied.
• Certain foods can cause more gas. Speak to the nutritionist about this.
• If the odor is strong, or it persists after emptying the bag, or while changing the collection device you can:
  • use a bag with a filter.
    
  • use an odor eliminator for toilets (put 1 drop in the water before you empty the contents of the bag there).
  • clean the inside and outside of the bag opening with toilet paper or a damp washcloth.
  • for bags that have a clasp, roll the edge of the bag down (creating a rolled edge like a turtleneck) before emptying.
    
  • use an odor eliminator in the bag after emptying it, according to the manufacturer’s instructions.

• Discuss other possible “home remedies” as needed with your enterostomal therapy nurse.

Possible cause(s)

• Too much stool in the collection bag
• Skin around the stoma is oily or wet
• Improper fit of the skin protector for the stoma

What to do?

• Empty the bag when it is 1/3 full or almost 1/3 full if you anticipate going out with your child.
• Consult your enterostomal therapy nurse or your healthcare team if the skin around the stoma is irritated (eg, red, red bumps, small wounds).

• Do not clean the skin around the stoma with products that might be oily or leave a residue (creams, soap). Use only those recommended in the section Everyday tips, Bathing.
• Always dry the skin around the stoma after cleaning.
• Use the appropriate equipment for your child, adjusted to the length of the stoma to ensure that the skin barrier sticks well to the skin.
• Warm the skin barrier well in your hands before applying it.
• Change the collection device.

Possible cause(s)

• Collection bag too full
• Collection bag poorly attached to the collar
• Excessive movement of collection bag

What to do?

• Empty the bag when it is 1/3 full or almost 1/3 full if you anticipate going out with your child.
• If the bag fills with gas quickly, you can use bags with filters that permit the passage of air.

• Check whether the portion of the bag that fits the ring of the collar is secure.
• Secure the bag under snug but not tight clothing, especially if your child is young and active.

Possible cause(s)

• Friction between the stoma and the skin barrier
• Bleeding from the stoma itself or from inside the intestine

What to do?

• The skin on the inside of the stoma is fragile; it is normal that it bleeds very slightly (a few pinpoint drops) when touched.
• If appropriate, review how to cut the opening of the skin barrier, ensuring that the cut opening is smooth.
• If there is significant bleeding, apply firm pressure to the site of the bleeding with a clean cloth or gauze; contact your healthcare team immediately.

Possible cause(s)

Causes vary: may happen with increased activity, coughing, etc.

What to do?

• The intestine can sometimes slide out through the stoma, like a hernia. Usually this does not cause pain.
• Contact your healthcare team immediately.

Possible cause(s)

• Tube blockage (eg, debris from residual formula, reflux of stomach contents, improper preparation of medication)
• Incorrect positioning of the tube (eg, end of the tube pressing against stomach walls)
• Pinched tube
• Damaged tube

What to do?

• Try to find the source of the blockage.
• Check the tube for bends, kinks or jamming.
• If solid particles are visible, gently roll the tube between your fingers to try to loosen them, then gently aspirate with a syringe to try and remove particles
• Change your child’s position.
• Try irrigating the tube again.
• If the problem persists:
  • try to unblock the tube by slowly injecting warm water before trying to irrigate again;
  • repeat several times.
• If the problem still persists and it is a nasogastric tube and you have been taught to replace it.
• In all other situations, rapidly contact your child’s healthcare team.

Possible cause(s)

• Blocking of the tube (eg, debris)
• Incorrect positioning of the tube (eg, end of the tube pressed against the stomach walls or away from the accumulation of gastric fluid)
• Collapse of the tube, causing the walls of the tube to stick together during attempt to aspirate
• Empty stomach

What to do?

• Check the tube location as taught by your healthcare team.
• If the problem persists, inject 2 to 3 ml of air through the tube.
• Try again to aspirate gastric secretions.
• If the problem persists, reposition your child on the left side, wait 10 to 15 minutes and then try again to aspirate gastric secretions.
• If the problem still persists and it is a nasogastric tube you have been taught to replace it.
• In all other situations, rapidly contact your child’s healthcare team.
• Until the problem is resolved, do not use the nasogastric tube.

Possible cause(s)

• Mishandling
• Accident

What to do?

• Stop the feeding session, if in progress.
• If your child has a nasogastric tube and you can no longer see the mark on the tube and you have been taught, gently pull the tube until the mark reaches the edge of the nostril.
• If your child has a nasogastric tube and the mark on the tube has moved away from the edge of the nostril and you have been taught, remove the tube and reinsert it.
• Once the tube is correctly positioned:
  • replace the adhesive bandage to secure the tube; make sure it is close to the nostril;
  • make sure you have checked the location of the tube.
• In all other situations, leave the tube in place and rapidly contact your child’s healthcare team.

Possible cause(s)

• Mishandling
• Accident

What to do?

• If your child has a nasogastric tube and you have been taught:
  • inspect the tube for damage;
  • if the tube is in good condition, clean it, rinse it well and reinstall it.
• In all other situations, rapidly contact your child’s healthcare team.

Possible cause(s)

• Agitated child (upset, crying)
• Poor insertion technique
• Nasal obstruction (eg, polyps in the nose)

What to do?

• Remove the tube completely.
• Make sure your child is properly positioned; have a second person help you if necessary.
• Review the method of care (eg, lubricate the tube well before insertion).
• Use a method to distract your child as needed. Make sure your child is calm before trying to insert the tube again.
• If necessary, soak the tube in a container of ice water or put it in the freezer for a few moments to make it more rigid and facilitate insertion into the nostril.
• Encourage your child to swallow or give your baby a pacifier to suck while you insert the tube.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Skin irritation
• Nasal discharge
• Friction from poorly secured tube
• Pressure sore caused by the tube

What to do?

• Check if the tube is rubbing against the nostril.
• If necessary, reposition the tube, making sure it is securely attached.
• If your child has a nasogastric tube and you have been taught, remove the tube and insert it into the other nostril.
• If the redness persists, contact your child’s healthcare team.
• In all other situations, rapidly contact your child’s healthcare team.

Possible cause(s)

• Incorrect insertion of the tube into the airway (trachea) instead of the esophagus

What to do?

• Remove the tube immediately.
• Let your child rest and recover: he or she should be able to breathe better quickly. If this is not the case, call 911 immediately.
• When your child is calmer, review the method of care.
• Encourage your child to swallow or give your baby a pacifier while you try to insert the tube again.
• If the problem persists, rapidly contact your child’s healthcare team.

Possible cause(s)

• Broken nasal tube
• Broken cap
• Forgot to put the cap on the tube
• Worn out cap – less watertight (closes poorly or no longer closes)

What to do?

• Discontinue feeding or irrigating, if in progress.
• Try to find the cause of the discharge.
• Put the cap on the end of the tube between feeding sessions, if not present.
• Put a piece of tape on the cap to securely close it between feeding sessions, if necessary.
• If the nasogastric tube or its cap is broken and you have been taught, change it.
• In all other situations, leave the tube in place and rapidly contact your child’s healthcare team.

Possible cause(s)

• Injury (eg, traumatic insertion of tube)
• Stomach irritation
• Stomach ulcer
• Infection

What to do?

• Remove the tube.
• Rapidly contact your child’s healthcare team.

Possible cause(s)

• Button or tube breakage
• Breakage or obstruction of the anti-reflux valve of the button
• Improperly installed or leaking tube port covers
• Blocking of the button or tube
• Displacement or malposition of the button or tube
• Balloon breakage or deflation
• Presence of granulation tissue
• Skin infection under the button
• Child’s condition (eg, constipation, vomiting, slow digestion, abdominal gas, bloating, chronic cough)

What to do?

• Discontinue feeding or irrigation, if in progress.
• Try to find the cause of the discharge.
• If your child has had the stoma for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team), has a gastrostomy balloon button or tube and you have been taught, check to see if the balloon of the button or tube is properly inflated.
• Make sure the tube or button extension set is securely attached to your child and that there is no tension on the tubing.
• Check the location of the gastrostomy tube by gently pulling it outward until the internal retention mechanism holding the tube in place is snug against the stomach wall.
• Irrigate the button or the tube with water.
• Place a few clean, dry compresses on the button or at the tube inlet to absorb the flow; change the compresses regularly depending on the amount of flow.
• Keep the skin around the stoma clean and dry as much as possible.
• Protect the healthy skin around the stoma with a barrier cream or petroleum jelly like Vaseline®.
• If the problem persists, and if your child has a stoma for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team), and if it is a gastrostomy balloon button or tube and you have been taught, remove the button or the tube and replace it.
• In all other situations, rapidly contact your child’s healthcare team.

Possible cause(s)

• Mishandling
• Accident
• Pulled out by child
• Too much tension on the tube (eg, incorrect use of dressings around the stoma)
• Insufficient volume of water in the balloon or balloon bursting
• Button or tube breakage

What to do?

• If the stomach is too full, the contents may come out spontaneously from the stoma, as if your child were vomiting.
• Thoroughly clean and dry the skin around the stoma.
• If your child has had the stoma for less than 6 to 8 weeks (or other length of time as recommended by your healthcare team), rapidly contact your child’s healthcare team.
• If your child has had the stoma for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team), has a gastrostomy balloon button or tube and you have been taught:
  • check if the button (including its balloon) is in good condition;
  • if so, clean it, rinse it well and then put it back in place.
• If your child has had the stoma for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team) and he has another type of button or long tube:
  • install a urinary Foley™ catheter and leave it in place until you have a new button or replacement tube;
  • contact your healthcare team.
• If you are unable to insert the urinary catheter, try a smaller size catheter.
• If you are still unable to insert a urinary catheter into the stoma, put a compress over the stoma opening and immediately contact your child’s healthcare team. A tube or button must be reinstalled very quickly to prevent the stoma from closing.

Possible cause(s)

Granulation tissue (or Granuloma or Hypergranulation) which is a reaction of the skin in response to irritation caused by:

• Excessive movement of the button or tube (eg, insufficiently inflated balloon, loose external tube retention disc)
• Incorrect adjustment of the button or tube (eg, button stem too long, tube diameter too small)
• Rubbing of the tube or button inside the stoma

What to do?

• Contact your child’s healthcare team who:
  • will evaluate the most appropriate treatment for your child’s condition (eg, medicated cream, silver nitrate),
  • will treat the infection, if present,
  • will check the appropriateness of changing the button or the tube, if necessary.

While waiting to discuss with your healthcare team:

• If your child has had an the stoma for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team) and you have been taught, check that the balloon of the gastrostomy button or tube is not broken and is properly inflated.
• Make sure the tube or button extension set is securely attached to your child and that there is no tension on the tubing.
• Put a few clean compresses around the button or tube if there is any discharge and change the compresses as soon as they get wet.

Possible cause(s)

• Infection
• Inadequate ostomy care
• Gastric fluid discharge
• Improper fit of the tube or button causing injury to the skin around the stoma
• Incorrect attachment of the tube or extension tube
• Pressure sore

What to do?

• Inspect the button or the tube; check the anti-reflux valve of the button for damage.
• If your child has had the stoma for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team) and you have been taught, check that the balloon of the gastrostomy button or tube is not broken and is properly inflated.
• Make sure the tube or button extension set is securely attached to your child and that there is no tension on the tubing.
• If the problem persists, rapidly contact your healthcare team.

While waiting to discuss with your healthcare team:

• Keep skin clean and dry and leave it exposed to air as much as possible.
• Put a few clean compresses around the button or tube if there is any discharge and change the compresses as soon as they get wet.

Possible cause(s)

• Empty stomach
• Gastrostomy tube displacement

What to do?

• Change your child’s position and try again to aspirate.
• Make sure the extension set is properly connected.
• Irrigate the button or the long tube with a small amount of water, as recommended by your healthcare team, then retry to aspirate stomach contents.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Blockage of the button, extension set or tube (eg, debris, reflux of stomach contents, improper preparation of medication)
• Pinched tube or extension set
• Button, extension set or long tube damaged (eg, wear)
• Gastrostomy tube displacement

What to do?

• Try to find the source of the blockage.
• Check to see if the button extension set or the tube is bent, kinked or jammed.
• Check if all clamps are open.
• Roll the tube between your fingers if solid particles are visible (to try to remove them).
• Try to aspirate with a syringe if particles are present (to try to mobilize them).
• Disconnect the extension set, if in place, and try to irrigate it to check for blockage; change the extension set if necessary.
• Do not use a sharp object to attempt to unblock the tube or button.
• Do not press too hard on the syringe plunger to attempt to irrigate the button, as excessive pressure may damage the extension set.
• If the problem persists, try to unblock by slowly injecting lukewarm water.
• If the problem persists, if your child has had the stoma for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team), has a gastrostomy balloon button or tube and you have been taught, remove the button or the long tube and change it.
• In all other situations, rapidly contact your child’s healthcare team.

Possible cause(s)

• Agitated child
• Poor insertion technique
• Shrinkage of the stoma

What to do?

• Remove the button or the long tube.
• Make sure your child is in the correct position; have a second person help you if necessary.
• Review the method of care.
• Use a method to distract your child if necessary.
• Make sure your child is calm before trying to insert the tube or button again.
• If the problem persists:
  • install a urinary Foley™ catheter,
  • leave it in place until you have a new button or replacement tube.
  • notify your healthcare team.
• If you are unable to insert a temporary urinary catheter into the stoma, put a compress over the opening and contact your healthcare team immediately. A long tube or button must be reinstalled very quickly to prevent the stoma from closing.

Possible cause(s)

• Button or tube damaged (eg, wear)
• Manufacturing defect of the button or long tube
• Mishandling

What to do?

• Discontinue feeding or irrigation, if in progress.
• If your child has had the stoma for less than 6 to 8 weeks (or other length of time as recommended by your healthcare team):
  • do not change the button or tube;
  • contact your healthcare team.
• If your child has had the stoma for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team), has a gastrostomy balloon button or tube and you have been taught:
  • remove the button or the long tube;
  • insert a new button or a replacement tube.
• If your child has had the stoma for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team) and has another type of button or long tube:
  • do not change the button or tube;
  • contact your child’s healthcare team.

Possible cause(s)

• Accidental disconnection
• Wrong connection of the button extension

What to do?

• Stop the feeding session, if in progress.
• Try to estimate the volume of formula lost.
• Thoroughly clean the button feeding port with soapy water and rinse it well.
• Clean the inside of the extension set port.
• Connect the extension set to the button and irrigate it.
• Resume the feeding session and replace the estimated amount of formula lost during disconnection if possible.

Possible cause(s)

• Injury
• Irritation
• Granulation tissue
• Infection

What to do?

If the bleeding is severe:

• Discontinue feeding or irrigating session, if in progress.
• Apply pressure with a compress or clean cloth to the site of bleeding.
• Contact your healthcare team immediately.

If the bleeding is light:

• Thoroughly clean and dry the skin around the stoma.
• Keep the skin clean and dry and leave it exposed to air as much as possible.
• Put a few clean compresses around the button or tube and change the compresses as soon as they get wet.
• Contact your child’s healthcare team.

Possible cause(s)

• Injury
• Stomach irritation
• Stomach ulcer
• Infection

What to do?

• Rapidly contact your child’s healthcare team.

Possible cause(s)

• Insufficient volume of water in the balloon or broken balloon
• Excess tension on the tube (eg, use of dressings around the stoma)
• Incorrect adjustment of the tube or button

What to do?

• Stop the feeding session, if in progress.
• Check the tube for excessive tension and reattach it properly, if necessary.
• If your child has had the stoma for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team), has a gastrostomy balloon button or tube and you have been taught:
  • check the volume of water in the balloon;
  • gently push the button stem or tube inward;
  • add the necessary amount of water missing from the balloon, if necessary.
• In all other situations, rapidly contact your child’s healthcare team.

Possible cause(s)

• External bolster (to stabilize the tube at skin level) displaced or absent
• Incorrectly secured tube
• Button stem too short
• Incorrect adjustment of the tube or button

What to do?

• Stop the feeding session, if in progress.
• If your child has had the stoma for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team), has a gastrostomy balloon button or tube and you have been taught:
  • gently pull the tube outward until the internal bolster is seated against the stomach wall;
  • make sure the tube’s external bolster is attached to the stomach wall, leaving a space about the thickness of a dime;
  • secure the tube to the belly.
• If the problem persists and in all other situations, rapidly contact your child’s healthcare team.

Possible cause(s)

• Debris in the balloon fill valve
• Button or tube breakage

What to do?

• Make sure that the balloon fill valve is clean and not blocked by debris from formula; clean it if necessary.
• Then firmly insert the syringe into the valve by pushing and turning it a quarter turn; try withdrawing the syringe plunger again.
• If the problem persists and in all other situations, contact your child’s healthcare team.

Possible cause(s)

• Incorrect button adjustment
• Inadequate ostomy care

What to do?

• Cleanse the skin around the button.
• Then try turning the button again.
• If you are unable to rotate the device, contact your child’s healthcare team.

Possible cause(s)

• Various

What to do?

• Press the appropriate button to stop the alarm tone.
• Look at the message on the screen.
• Follow the instructions accordingly.
• If a help screen is available for the alarm, follow the instructions provided.
• If necessary, consult the pump instructions that you have been given.
• If you still cannot resolve the problem, contact your healthcare team.

Possible cause(s)

• Blockage of the button, extension set, tube or tubing of the bag (eg, inadequate irrigation of the button or tube before use, accumulation of debris, thick texture of the formula, nature of the medication), poor preparation of the medication, interactions between formula and medication, between medications or with gastric secretions, contaminated formula during preparation or poor maintenance of the equipment, which can change the consistency)
• Tube, extension set or tubing clamped
• Button, extension set or tube damaged (eg, worn out)
• Pump malfunction
• Poor administration technique (eg, bag hung too low)
• Intermittent administration of the formula
• Stomach too full

What to do?

• Try to find the source of the blockage.
• Make sure that all tubes are properly connected.
• Check the button extension set, tube or bag tubing for bends, kinks or pinches.
• Make sure clamps are fully open.
• Reposition your child.
• Roll the tube between your fingers if solid particles are visible.
• Try to irrigate the tube or button. Disconnect the extension and irrigate as needed before reconnecting it again.
• Do not use a sharp object to clean the tube or button.
• If necessary, try to unblock by slowly injecting lukewarm water.
• Revise the technique if necessary.
• Look at the message on the screen and if appropriate, follow the instructions accordingly.
• If necessary, consult the pump instructions.
• Change the pump to a back up pump if available, in case of emergency.
• If your child has had the stoma for more than 6 to 8 weeks (or other length of time as recommended by your healthcare team), has a gastrostomy balloon button or tube and you have been taught, change the tube or button.
• In all other situations, rapidly contact your child’s healthcare team.

Possible cause(s)

• Interval between feeding sessions too short
• Formula administration speed too fast
• Too much formula administered
• Intolerance or allergy to the formula
• Constipation
• Gastric reflux (stomach contents rise up into the esophagus)
• Dumping syndrome (or rapid gastric emptying): the stomach empties too quickly into the intestine

What to do?

• If your child is nauseated, place the child in an upright seated position
• If your child is vomiting, put your child’s head to the side.

In both cases:

• Postpone the next feeding session for 30 to 60 minutes.
• Reduce the amount or rate of formula to be administered, as recommended by your healthcare team.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Formula administration speed too fast
• Excess air in the stomach
• Too much formula administered
• Formula too cold
• Formula too concentrated
• Intolerance or allergy to the formula
• Contamination of the formula (during preparation, poor maintenance of the equipment)
• Gastric reflux (stomach contents rise up into the esophagus)
• Gastric emptying is fast or too slow (the stomach empties too quickly or too slowly into the intestine)
• Change in administration schedule
• Constipation
• Infection

What to do?

If your child has nausea:

• Place the child in an upright seated position, if possible.
• Slow down or stop feeding until your child is comfortable and then resume feeding.
• If the problem persists, contact your child’s healthcare team.

If your child vomits:

• Turn your child’s head to the side.
• Stop feeding for 30 to 60 minutes and then start again more slowly.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Aspiration (accidental entry of formula into the lungs): caused by improper positioning of the child or the nasal tube, vomiting or gastric reflux
• Condition of the child
• Respiratory infection

What to do?

• Stop the feeding session immediately.
• Stay calm and reassure your child.

If your child is in respiratory distress:

• Call immediately 911.
• Begin CPR as taught.

If your child is not in respiratory distress:

• Put your child in a sitting position or turn the child onto the side to make breathing easier.
• If your child has a nasogastric tube, check the tube location. If it is not in the stomach, remove it immediately and reinsert it when your child becomes calm again.
• If your child has a button or another type of tube, rapidly contact your child’s healthcare team.
• If your child has other discomforts in addition to breathing difficulties, rapidly contact your child’s healthcare team.

Possible cause(s)

• Formula administration speed too fast
• Excessive swallowing of air (eg, in children with non-invasive ventilatory support, crying)
• Excess gas produced by digestion or infection
• Too much formula at each feeding session
• Intolerance to the formula
• Poor absorption of the formula
• Gastric emptying too slow (the stomach contents empty too slowly into the intestine)
• Bowel obstruction
• Condition of the child

What to do?

• If your child has severe abdominal pain and/or other discomforts (eg, vomiting), stop the feeding session and immediately contact your child’s healthcare team.
• If this is not the case, reduce the flow rate of the formula, according to your child’s tolerance.
• If the problem persists:
  • stop the feeding session for 30 to 60 minutes;
  • if you have been instructed, decompress (or vent) the button or tube to let air out of the stomach.
• If your child does not have any more discomfort afterwards, resume the feeding session by increasing the speed of flow progressively.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Excessive swallowing of air (eg, in children with non-invasive ventilatory support, crying)
• Excess gas produced by digestion or infection
• Too much formula at each feeding session
• Intolerance to the formula
• Poor absorption of the formula
• Gastric emptying too slow (the stomach contents empty too slowly into the intestine)
• Bowel obstruction
• Condition of the child

What to do?

• If your child has severe abdominal pain and/or other discomforts (eg, vomiting), stop the feeding session and and immediately contact your child’s healthcare team.
• If this is not the case and if you have been instructed, decompress (or vent) the button or tube to let air out of the stomach.
• Be sure to close the tube cap tightly between feeding sessions.
• If your child can also feed by mouth, eliminate liquids and foods that cause gas or intolerance, as recommended by your healthcare team.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Formula administration speed too fast
• Too much formula at each feeding session
• Formula too cold
• Excess air in the stomach
• Gastric emptying too slow (the stomach contents empty too slowly into the intestine)
• Intolerance to the formula
• Constipation
• Gastrointestinal problems (eg, intestinal obstruction)
• Infection

What to do?

• If your child has severe abdominal pain, stop the feeding session and and immediately contact your child’s healthcare team.
• If the pain is fairly mild, reduce the flow rate of the formula, according to your child’s tolerance
• If the problem persists, discontinue administration for 30 to 60 minutes, which may help reduce symptoms and then gradually resume the feeding session.
• If the problem still persists and you have been taught, decompress (or vent) the button or tube to let air out of the stomach and then gradually resume the feeding session.
• If the problem persists, contact your child’s healthcare team.

Possible cause(s)

• Infection
• Formula administration speed too fast
• Use of formulas that have passed the expiry date
• Contamination of the formula (during preparation, poor maintenance of the equipment)
• Side effects of medication (eg, antibiotics)
• Intolerance to the formula
• Movement of the tube or button
• Too much fiber in the diet
• Food allergies or intolerances
• Dumping syndrome (or rapid gastric emptying): the stomach contents empty too quickly into the intestine.
• Condition of the child

What to do?

• Discontinue feeding session if in progress.
• If your child has bloody diarrhea, fever or episodes of diarrhea are frequent, immediately contact your child’s healthcare team.
• If this is not the case, check your child’s hydration level (thirst, dry lips and tongue, darker urine, with a strong odour and in small quantities, weakness, dizziness).
• If your child seems dehydrated or is having many more stools than usual, immediately contact your child’s healthcare team.
• If your child is adequately hydrated, delay feeding for 30 to 60 minutes to relieve symptoms; resume feeding session more slowly over the next few hours.
• Review the cleanliness guidelines for formula preparation and storage recommendations (including in the hanging bag).
• Check the expiry date of the formula: discard products that are past their expiry date or return them to the pharmacy.
• If the problem persists, consult your child’s healthcare team.

Possible cause(s)

• Insufficient hydration
• Inactivity
• Lack of fibre in the diet
• Change of formula
• Side effects of medication
• Intolerance to the formula
• Change of medication
• Condition of the child

What to do?

• Make sure your child gets all the fluid he or she needs.
• Increase the amount of physical activity your child gets, if possible.
• Contact your healthcare team for advice on nutrition (eg, increasing dietary fibre).
• If the problem still persists, contact your child’s healthcare team.

Possible cause(s)

• Insufficient hydration
• Lack of mouth stimulation
• Side effects of medication
• Condition of the child

What to do?

• If your child can take fluids by mouth and has no fluid restriction, give more water by mouth.
• Rinse your child’s mouth often with water.
• Moisten your child’s mouth with foam-tipped oral swabs or a clean damp washcloth.
• Brush or clean your child’s teeth and mouth at least twice a day.
• Apply lip balm as needed.

Possible cause(s)

• Movement of the gastrostomy tube or urinary Foley™ catheter into the intestine
• Bowel obstruction
• Intussusception or intestinal invagination (folding of the intestines on top of each other, like a telescope: most common with nasojejunal or gastrojejunal tubes)

What to do?

• Discontinue feeding session or irrigation, if in progress.
• Check that the gastrostomy tube or urinary Foley™ catheter is in the right place, as taught to you by your healthcare team.
• If not, reinstall the tube or catheter correctly.
• If the tube or catheter is in the right place and the problem persists, immediately contact your child’s healthcare team.

Possible cause(s)

• Hypoglycemia (low blood sugar)
• Infection
• Dumping syndrome (or rapid gastric emptying): the stomach contents empty too quickly into the intestine

What to do?

• If your child is having a convulsion or is not responsive, immediately contact 911.
• If not, check your child’s blood glucose, if already discussed and you have been taught by your healthcare team.
• Rapidly give your child an additional source of sugar as recommended by your healthcare team in this situation.
• Immediately contact your child’s healthcare team.

Possible cause(s)

• Hyperglycemia (high blood sugar)
• Infection
• Dumping syndrome (or rapid gastric emptying): the stomach contents empty too quickly into the intestine

What to do?

• Check your child’s blood glucose, if already discussed and you have been taught by your healthcare team.
• Immediately contact your child’s healthcare team.

Possible cause(s)

• Dehydration because of low water intake or significant fluid loss (eg, through vomiting, diarrhea, excessive sweating, fever, certain medications)

What to do?

• Rapidly contact your child’s healthcare team.
• Give your child rehydration formulas (eg, Pedialyte™, Gastrolyte™), if recommended by your healthcare team.

Possible cause(s)

• Fluid overload in the body
• Low protein levels in your child
• Infection
• Condition of the child

What to do?

• Immediately contact your child’s healthcare team.

Possible cause(s)

• Infection or inflammation at the catheter entry site
• Phlebitis (irritated vein)

What to do?

• If the pump is running:
  • press the “STOP / START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Contact your healthcare team quickly.

Possible cause(s)

• Contact dermatitis (ie, irritation of the dressing on the skin)
• Allergy to the adhesive of the dressing
• Allergy to disinfectant solution
• Reaction of the skin to the disinfection technique

What to do?

• Contact your healthcare team who may suggest:
  • a change in dressing materials,
  • use of a topical corticosteroid,
  • a change in disinfection technique.

Possible cause(s)

Phlebitis (irritated vein)

What to do?

• If the pump is running:
  • press the “STOP/START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and of the tubing of the pump.
• Contact your healthcare team quickly.

Possible cause(s)

• Infiltration (the nutrition solution is leaking out of the vein and into the skin)
• Phlebitis of the vein (irritated vein)

What to do?

• If the pump is running:
  • press the “STOP/START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Immediately contact your healthcare team.
• If your child’s arm with the catheter is swollen, lift it as much as possible.

Possible cause(s)

• Disconnection from the implantable chamber of the catheter
• Displacement of the catheter
• Displacement of the noncoring needle

What to do?

• If the pump is running:
  • press the “STOP/START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and the tubing of the pump.
• If during irrigation:
  • close the clamp of the catheter tubing,
  • stop attempting to flush the line.
• Immediately contact your healthcare team.

Possible cause(s)

• Breakage or disconnection of the catheter or tubing
• Recent catheter insertion
• Child’s underlying health condition

What to do?

• If there is continuous bleeding, put a compress over the dressing and apply firm pressure.
• If the pump is running:
  • press the “STOP/START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Immediately contact your healthcare team.

Possible cause(s)

• Breakage or disconnection of the catheter or tubing
• Blockage of the catheter
• Displacement of the catheter
• Displacement of the needle if the child has an implantable chamber device
• Infection
• Contact dermatitis
• Child’s underlying health condition

What to do?

• If the pump is running:
  • press the “STOP/START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Immediately contact your healthcare team.
• If the dressing is falling off, put another dressing over it while waiting for the advice of your care team.
• If the dressing is partially detached, do not remove it as you might remove the catheter by mistake.

Possible cause(s)

Various causes

What to do?

• If the dressing is falling off, tape the sides down.
• If it is punctured or torn, install another clear adhesive dressing over the old one.
• If the dressing is partially detached, do not remove it as you can remove the catheter by mistake.
• Immediately contact your healthcare team.

Possible cause(s)

Return of blood (reflux)

What to do?

• Irrigate the catheter with the saline solution. Refer to steps 5 and 8 to 12 of the “Catheter irrigation” care method.
• If this happens more than once or twice a week, contact your healthcare team.

Possible cause(s)

Pump malfunction

What to do?

Contact your pharmacy or healthcare team quickly.

Possible cause(s)

• Contamination of the solution
• Problems in preparing the solution
• Heat-exposed bag

What to do?

• Do not administer the medication.
• Contact your pharmacy or healthcare team quickly.

Possible cause(s)

• Contamination of the solution
• Problems in preparing the solution

What to do?

• Do not administer the solution.
• If during the administration: press the “STOP/START” button on the pump and close the catheter tubing clamp and the pump tubing clamp.
• Contact your pharmacy or healthcare team quickly.

Possible cause(s)

Various

What to do?

• Close the clamp of the catheter tubing and the tubing of the pump.
• Press the “SILENCE” button to stop the alarm tone.
• Look at the message on the screen.
• Follow the instructions accordingly.
• If a help screen is available for the alarm, follow the instructions provided.
• If necessary, consult the pump instructions that you have been given.
• If you still can not resolve the problem, contact your healthcare team.

Possible cause(s)

• Blockage or displacement of the catheter
• Blockage of the tubing
• Clamps are closed
• Displacement of the needle in children with an implantable chamber device (PORT)

What to do?

• Do not push the plunger of the syringe with saline solution or locking solution forcefully.
• Make sure tubing clamps are fully open.
• Check that the tubing is not pinched or bent.
• Ask your child to:
  • move the arm on the side of the catheter,
  • turn on each side,
  • cough,
  • turn the head towards the opposite side of the catheter or to bear down (as if they were going to have a bowel movement).
• If your child has an implantable chamber catheter (eg, Port-a-Cath®): check if the needle has moved out of the correct position.
• If the problem persists:
  • close the clamp of the catheter tubing,
  • stop attempting to flush the line,
  • contact your healthcare team immediately.

Possible cause(s)

• Accident
• Mishandling

What to do?

• If the pump is running:
  • press the “STOP/START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Immediately contact your healthcare team.

Possible cause(s)

• Mishandling
• Catheter or other defective equipment
• Blocked catheter

What to do?

• You may notice a flow of blood or fluid at the point where the catheter or other piece of equipment is broken.
• If the pump is running:
  • press the “STOP/START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and the tubing of the pump.
• If you can see where the equipment is broken or where the leakage is coming from:
  • close the clamp between the catheter and the point of leakage.
  • if there is no clamp, use the hemostat clamp, as your healthcare team has taught you, or bend the catheter in half and keep it folded in place with tape.
• If you do not see where the leakage is coming from or where the equipment is broken: put a gauze compress on the dressing to absorb the leakage.
• Immediately contact your care team.

Possible cause(s)

• Accidental displacement of the catheter
• Mishandling of the catheter
• Improperly adjusted dressing
• Child has moved excessively and displaced the catheter

What to do?

• Never push the catheter back into the vein.
• If the pump is running:
  • press the “STOP/START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and the tubing of the pump.
• If the catheter has been completely pulled out, put a clear dressing over the previous entrance site.
• Immediately contact your healthcare team.

Possible cause(s)

Displacement of the internal (inside the body) portion of the catheter

What to do?

• Close the clamp of the catheter tubing.
• Stop attempting to flush the line.
• Immediately contact your healthcare team.

Possible cause(s)

Contact between the saline solution and the plastic of the syringe may activate your child’s sense of taste and smell

What to do?

• This is commonly reported. There is no danger to your child’s health.
• If the taste is very intense, contact your healthcare team.

Possible cause(s)

• Signs of hypoglycemia (low blood sugar)
• Rapid termination of solution administration
• Infection

What to do?

• Take your child’s blood glucose, if possible.
• Quickly give your child extra glucose (ask your child’s healthcare team for specific guidelines).
• Immediately contact your healthcare team.

Most hypoglycemia can be avoided by gradually decreasing the rate of the infusion in the last hour of delivery. Ask your child’s healthcare team for more specific instructions.

Possible cause(s)

• Signs of hyperglycaemia (high blood sugar)
• Infection

What to do?

• Take your child’s blood glucose, if possible.
• Immediately contact your healthcare team.

Possible cause(s)

Dehydration

What to do?

• Contact your healthcare team quickly.
• Give oral rehydration solutions to your child (eg, Pedialyte™, Gastrolyte™), if recommended by your healthcare team.

Possible cause(s)

• Fluid overload in the body
• Lack of protein in the blood
• Infection

What to do?

• Immediately contact your healthcare team.

Possible cause(s)

• Infection at the catheter entry site
• Blood infection
• Other infection

What to do?

• Note the other discomforts of your child (eg, pain, chills, difficulty breathing, blood in the stool, vomiting with blood, drowsiness, etc).
• Contact your healthcare team quickly.

Possible cause(s)

• Phlebitis of the vein (irritated vein)
• Blood clot in the vein with the catheter

What to do?

Immediately contact your healthcare team.

Possible cause(s)

• Infection or inflammation at the catheter entry site
• Phlebitis (irritated vein)

What do to?

• If your child uses an elastomeric infusion pump:
  • stop the infusion by closing the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP/START” button on the pump to stop the infusion or shut the pump off as you have been shown by your healthcare team,
  • close the clamps of the catheter tubing and the tubing of the pump.
• Contact your healthcare team quickly.

Possible cause(s)

• Contact dermatitis (ie, skin irritation due to the dressing)
• Sensitivity to the adhesive of the dressing
• Sensitivity to disinfectant solution
• Reaction of the skin to the disinfection technique

What to do?

• Contact your healthcare team who may suggest:
  • a change in dressing materials,
  • use of a topical corticosteroid,
  • a change in disinfection technique.

Possible cause(s)

Phlebitis (irritated vein)

What to do?

• If your child uses an elastomeric infusion pump:
  • close the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP/START” button on the pump or close the pump as indicated,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Contact your healthcare team quickly.

Possible cause(s)

• Infiltration (medication is leaking out of the vein and into the skin)
• Phlebitis of the vein (irritated vein)

What to do?

• If your child uses an elastomeric infusion pump:
  • close the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP/START” button on the pump or close the pump as indicated,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Immediately contact your care team.
• If your child’s arm with the catheter is swollen, elevate it as much as possible.

Possible cause(s)

• Disconnection from the implantable chamber of the catheter
• Displacement of the catheter
• Displacement of the noncoring needle

What to do?

• If your child uses an elastomeric infusion pump:
  • close the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP/START” button on the pump or close the pump as indicated,
  • close the clamp of the catheter tubing and the tubing of the pump.
• If during irrgation:
  • close the clamp of the catheter tubing,
  • stop attempting to flush the line.
• Immediately contact your care team.

Possible cause(s)

• Breakage or disconnection of the catheter or tubing
• Recent catheter insertion
• Child’s underlying health condition

What to do?

• If there is continuous bleeding, put a compress over the dressing and apply firm pressure.
• If your child uses an elastomeric infusion pump:
  • close the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP/START” button on the pump or close the pump as indicated,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Immediately contact your care team.

Possible cause(s)

• Breakage or disconnection of the catheter or tubing
• Blockage of the catheter
• Displacement of the catheter
• Displacement of the needle if the child has an implantable chamber device
• Infection
• Contact dermatitis
• Child’s underlying health condition

What to do?

• If your child uses an elastomeric infusion pump:
  • close the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP / START” button on the pump or close the pump as indicated,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Immediately contact your care team.
• If the dressing is falling off, put another dressing over it while waiting for the advice of your care team.
• If the dressing is partially detached, do not remove it as you might remove the catheter by mistake.

Possible cause(s)

• Various causes

What to do?

• If the dressing is falling off, tape the sides down.
• If it is punctured or torn, install another clear adhesive dressing over the old one.
• If the dressing is partially detached, do not remove it as you can remove the catheter by mistake.
• Immediately contact your healthcare team.

Possible cause(s)

Return of blood (reflux)

What to do?

• Irrigate the catheter with the saline solution. Refer to steps 5 and 8 to 12 of the “Catheter Irrigation” method of care.
• If this happens more than once or twice a week, contact your healthcare team.

Possible cause(s)

• Medication too cold
• If using an elastomeric infusion pump and it is placed lower than the catheter insertion site
• Malfunction of ambulatory infusion pump
• Displacement of the catheter
• Partial obstruction of the catheter

What to do?

• A cold solution can also cause headaches or chills.
• Irrigate the catheter with the saline solution. Refer to steps 5 and 8 to 12 of the “Catheter irrigation” method of care.
• If your child uses an elastomeric infusion pump:
  • make sure the medication is at room temperature. A solution that is too cold increases the time it takes for the drug to flow.
  • place the elastomeric infusion pump at the same height as the catheter insertion site.
•  If the problem persists, contact your healthcare team promptly.

Possible cause(s)

• Breakage of the portable infusion device
• Technical defect of the device

What to do?

• Close the clamp of the catheter tubing and the tubing of the pump.
• Disconnect the catheter from the infusion pump.
• Irrigate the catheter with the saline solution. Refer to steps 5 and 8 to 12 of the “Catheter irrigation”.
• Contact your healthcare team quickly.

Possible cause(s)

• Contamination of the solution
• Problems in the preparation

What to do?

• Do not administer the medication.
• Contact your pharmacy or healthcare team quickly.

Possible cause(s)

Various

What to do?

• Close the clamp of the catheter tubing and the clamp of the pump tubing.
• Press the “STOP/START” button to stop the alarm or as indicated.
• Look at the message displayed on the screen.
• Follow the instructions accordingly.
• If necessary, consult the pump instructions you have been given.
• If you still can not resolve the problem, contact your healthcare team.

Possible cause(s)

• Blockage or displacement of the catheter
• Blockage of the tubing
• Clamps are closed
• Displacement of the needle in children with an implantable chamber device (PORT)

What to do?

• Do not push the plunger of the syringe with saline solution or locking solution forcefully.
• Make sure tubing clamps are fully open.
• Check that the tubing is not pinched or bent.
• Ask your child to:
  • move the arm on the side of the catheter,
  • turn on each side,
  • cough,
  • turn thir head towards the opposite side of the catheter or to bear down (as if they were going to have a bowel movement).
• If your child has an implantable chamber catheter (eg, Port-a-Cath®): check if the needle has moved out of the correct position.
• If the problem persists:
  • close the clamp of the catheter tubing,
  • stop attempting to flush the line,
  • contact your healthcare team immediately.

Possible cause(s)

• Accident
• Mishandling

What to do?

• If your child uses an elastomeric infusion pump:
  • close the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP/START” button on the pump or close the pump as indicated,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Immediately contact your care team.

Possible cause(s)

• Mishandling
• Catheter or other defective equipment
• Blocked catheter

What to do?

• You may notice leakage of blood or fluid at the point where the catheter or other piece of equipment is broken.
• If your child uses an elastomeric infusion pump:
  • close the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP/START” button on the pump or close the pump as indicated,
  • close the clamp of the catheter tubing and the tubing of the pump.
• If you can see where the equipment is broken or where the leakage is coming from: close the clamp between the catheter and the point of leakage. If there is no clamp, use the hemostat clamp, as your healthcare team has taught you, or bend the catheter in half and keep it folded in place with tape.
• If you do not see where the leakage is coming from or where the equipment is broken: put a gauze compress on the dressing to absorb the leakage.
• Immediately contact your care team.

Possible cause(s)

• Accidental displacement of the catheter
• Mishandling of the catheter
• Improperly adjusted dressing
• Child has moved excessively and displaced the catheter

What to do?

• Never push the catheter back into the vein.
• If your child uses an elastomeric infusion pump:
  • close the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP/START” button on the pump or close the pump as indicated,
  • close the clamp of the catheter tubing and the tubing of the pump.
• If the catheter has been completely pulled out, put a clear dressing over the previous entrance site.
• Immediately contact your healthcare team.

Possible cause(s)

Displacement of the internal (inside the body) portion of the catheter

What to do?

• Close the clamp of the catheter tubing.
• Stop attempting to flush the line.
• Immediately contact your care team.

Possible cause(s)

Contact between the saline solution and the plastic of the syringe may activate your child’s sense of taste and smell

What to do?

• This is commonly reported. There is no danger to your child’s health.
• If the taste is very intense, contact your healthcare team.

Possible cause(s)

• Phlebitis of the vein (irritated vein)
• Blood clot in the vein with the catheter

What to do?

Immediately contact your care team.

Possible cause(s)

• Ongoing infection for which your child is being treated
• Infection of the skin at the catheter entry site
• Blood Infection
• Other infection

What to do?

• Note any other symptoms that your child may have including: pain, irritability, loss of appetite, drowsiness, etc.
• Contact your healthcare team quickly.

Possible cause(s)

• Urinary tract infection
• Catheterization not frequent enough
• Malfunctioning Mitrofanoff valve

What to do?

• Identify the time of the last catheterization.
• Contact your healthcare team quickly.

Possible cause(s)

• Too frequent catheterization: therefore little urine in the bladder
• Insufficient hydration
• Inadequate functioning of kidneys
• Mechanical blockage of the catheter (eg, kinked)
• Catheter too small
• Blockage of the Mitrofanoff stoma (eg, presence of mucus)
• Poor technique

What to do?

• Identify the time of the last catheterization.
• Check how well your child is hydrated:
  • review the amount of liquid drunk by your child in the last 2 days,
  • look for the signs of dehydration: dry mouth and lips, sunken eyes, headache, weakness, dizziness.
• Make sure the catheter is not stuck, bent or kinked.
• Use a larger catheter after discussing it with your healthcare team.
• Review the steps of catheterization and make sure to follow them well.
• Contact your healthcare team quickly if the problem lasts for a longer period than what is agreed with your healthcare team.
• Mitrofanoff: if your child has had surgery to enlarge the bladder, deposits can form and build up thus making the emptying difficult. To avoid this problem, the bladder must be irrigated regularly. Talk to your healthcare team.

Possible cause(s)

• Resistance at the level of the sphincters
• Mechanical blockage of the catheter (eg, kinked)
• Mitrofanoff: injury at the level of the tunnel

What to do?

Natural ways: You may feel a slight resistance at the level of the urethral sphincter when trying to insert the catheter:

• encourage your child to relax and breathe slowly,
• roll the catheter itself with your fingers and push gently, but not forcefully,
• ask your child to change position (eg, roll to the side).

If the resistance persists:

• try a smaller catheter,
• if this is not effective, remove the catheter to avoid hurting your child,
• contact your healthcare team immediately.

Mitrofanoff:

• follow the path of the canal between the stoma and the bladder with the catheter,
• if there is some resistance at the entrance of the bladder proceed gently,
• do not force the catheter in.

If the resistance persists:

• remove the catheter,
• contact your healthcare team immediately.

Possible cause(s)

• Urinary tract infection
• Insufficient hydration
• Bladder not completely emptied

What to do?

• Make sure the bladder completely empties during catheterization.
• If the problem is new, repeat the catheterization.
• Check if your child has other symptoms that may indicate a urinary infection:
  • change in the color of urine
  • need to empty the bladder more often
  • pain in the urethra or abdomen
  • nausea, vomiting
  • fever: rectal  ≥ 38⁰C, oral or armpit ≥  37.5⁰C
  • chills
  • irritability
  • tiredness, lack of energy
• If the problem persists after catheterization or if your child has other symptoms, quickly contact your healthcare team.

Possible cause(s)

• Irritation caused by frequent catheterizations
• Urinary tract infection

What to do?

• 1 or 2 small blood drops may be seen during catheterization: it is not worrying if it happens infrequently. Nevertheless, discuss it with your healthcare team.
• If there is more bleeding or if it is more frequent:
  • check if your child has a fever (rectal ≥ 38⁰C or oral/armpit ≥ 37.5⁰C),
  • contact your healthcare team quickly.

Possible cause(s)

In rare cases, the catheter may have rolled up on itself

What to do?

• Do not forcibly remove the catheter. Leave it in place.
• Contact your healthcare team quickly.

Possible cause(s)

• Skin irritation around the stoma
• Infection of the skin around the stoma

What to do?

• The skin around the stoma your child should have the same appearance as that of the rest of the belly.
• Contact your healthcare team quickly.

Possible cause(s)

Various causes

What to do?

Contact your healthcare team immediately.

Possible cause(s)

• Urinary infection
• Irritation

What to do?

Contact your healthcare team quickly.

Possible cause(s)

• Urinary infection
• Other infection

What to do?

• Record your childs other symptoms: pain, irritability, loss of appetite, fatigue, etc.
• Contact your healthcare team quickly.