Clinical tube weaning supported by hunger provocation in fully-tube-fed children

Structured Tube Weaning Using the Hunger Provocation Method in Infants with Single Ventricle Heart Defects: A Multicenter Study

Despite improvement in hemodynamics, children with single ventricle heart disease remain on feeding tubes long after stage 2 palliation (S2P). Use of a hunger provocation method in a multidisciplinary team setting has been successful at weaning these children from feeding tubes. The objective of this study is to describe patient characteristics and outcomes in the single ventricle population who underwent a formal tube weaning process using a standardized hunger provocation method. Single ventricle patients after S2P from six centers were included. Patient data collected included baseline demographics, swallow evaluation results, and feeding characteristics such as percent oral intake at the start of tube wean. Tube wean data included tube weaning process and duration, interruptions to the tube wean, adverse events, and weights before, during, and after the tube wean. 94% (60 of 64) of patients achieved oral independence. The median time to tube wean was 12.5 days. 62% of patients had transient weight loss during the tube wean. 61% of the cohort was taking less than 10% goal volumes by mouth with 90% of those patients successfully tube weaned. All patients with history of aspiration were successfully tube weaned. 75% of successfully weaned patients were above baseline weight at 1-month post-tube wean. The most common cause of tube wean interruption was contraction of a viral illness. Use of a standardized tube weaning process via hunger provocation method is both feasible and safe in the single ventricle population, resulting in successful feeding tube removal in a timely manner with minimal adverse effects.

Experiences in Tube Weaning Children with Congenital Heart Disease and Oral Feeding Aversion

Infants and children with congenital heart disease (CHD) often require supplemental nutrition via tube feeding before and after surgery. Tube feeding may be required due to poor weight gain, inadequate oral-motor skills, and/or reduced endurance for oral feeding. Our team has described a successful approach to weaning this population (Horsley et al. (2022) Pediatr Cardiol 43:1429-1437). A subgroup of tube-fed patients with CHD who demonstrate oral feeding aversion (OA) presents unique challenges to the tube weaning process. We discuss our team's experience with tube weaning orally averse children with CHD. Of 36 patients enrolled in the Cincinnati Children's Heart Institute Cardiology Feeding Tube Wean Clinic, 11 (31%) were determined to have oral feeding aversion (OA) by a speech-language pathologist (SLP). Descriptive data comparing the OA group to the non-averse group was gathered prior to and during the wean. Both groups had the ability to tube wean successfully, although the OA group had lower median oral intake (9 vs 24%) and higher age at start of the wean (9 vs 4 months). Those with OA also had a longer median duration of wean in days (17 vs 12 days) and higher likelihood of return to tube feeds within six-month post-wean (22 vs 0%). Additionally, the OA group had a higher percentage of genetic syndromes (36 vs 16%), although this was not found to be statistically significant in this study. Children with OA present with unique challenges for tube weaning. The results of this study show that weaning children with CHD and OA is possible with a multidisciplinary team who is knowledgeable about this population.

Pediatric Tube Weaning: A Meta-Analysis of Factors Contributing to Success

Approximately 3-10% of children have severe feeding issues, and some require enteral/tube nutrition to grow and thrive. For many children, tube feeding is temporary, making efficacious interventions for tube weaning essential. We conducted a systematic review and meta-analysis of tube weaning treatments. Outcomes included percentage of participants completely weaned from the tube, and mean percentage of kilocalories consumed orally following treatment. Data were extracted from 42 studies, including cohort studies and single-subject research design studies. We evaluated moderators of treatment success, including treatment setting, use of behavioral approaches, use of hunger provocation, and use of a multidisciplinary approach. Results indicated that, after treatment, children received significantly more calories orally, and 67-69% of children were fully weaned. These analyses suggest that current interventions are generally effective; however, variability within treatments exist. Prospective randomized clinical trials are needed to understand effective components of weaning interventions.

[The Need of Evidence-Based Treatment of Early-Onset Feeding Tube Dependency: A Pico- Framework Based Analytic Review of Clinical Features and Treatment of Feeding Tube Dependency]

Feeding Tube Dependency is a constant increasing perinatal mental health condition, with estimated 350 new cases per year in Germany.The early onset feeding tube dependency is the consequence of a generalized food aversion. To establish an evidence-based nationwide treatment plan, relevant research from the past twenty years were narratively reviewed. Feeding tube dependency is an international increasingmental health condition, with a high symptom persistence and a low spontaneous remission. The generalized food aversion would prevent the transition to oral feeding.The treatment protocols, supported by the German Health System, based on low-frequency individual treatment and intensive inpatient treatments are not supported by the most recent evidence. In treatment outcome research more promising and effective programs can be distinguished from ineffective programs. As a result, treatment which are designed as intensive treatment, home-based or inpatient and are psychodynamicbased are most effective. Day-clinic and behavioral modification programs are not or low in treatment effectiveness.The German Health System approach to assist families with feeding tube dependency is not evidence-based. A new structure of treatment is imperatively required.

Nutritional and feeding challenges in aerodigestive patients

PURPOSE OF REVIEW

Aerodigestive disorders encompass conditions that affect both the airway and gastrointestinal tract. These include conditions such as acquired and congenital defects of the airway and esophagus as well as neuromuscular disorders. Patients often suffer from dysphagia, aspiration, and respiratory disorders. This article will provide a review of current practices in the management of feeding disorders, oropharyngeal dysphagia, and nutritional support in the aerodigestive population.

RECENT FINDINGS

Oral aversion, aspiration, and feeding-tube dependence are all commonly encountered problems in the aerodigestive population. Intensive inpatient and outpatient programs along with use of appetite stimulants and psychotropic medications may help to improve feeding-related disorders. Aspiration affects many patients and requires close monitoring of clinical symptoms along with routine assessment with video fluoroscopy. Developments in blenderized feeds and formula supplementation have also provided new options for patients with feeding intolerance.

SUMMARY

Patients with aerodigestive disorders require complex medical care, and multidisciplinary teams are the most effective in addressing their medical needs. Advances in feeding, occupational, and pharmacologic therapy have allowed healthcare providers to better address the needs of these patients.

Mothers' experiences and perceptions of their child's weaning process from tube feeding within a multidisciplinary Paediatric Feeding Program

OBJECTIVES

Previous studies have described the negative impact that tube feeding of children with complex chronic diseases has on the caregivers' emotions, relationships and daily life. It is unclear whether these negative experiences persist or change during and after the weaning process. We sought to explore mothers' experiences and perceptions of their child being weaned off tube feeding within a Paediatric Feeding Program (PFP).

METHODS

We conducted a qualitative study using semi-structured interviews with mothers whose children <4 years old had experienced feeding tube weaning within an outpatient, family-centred, telemedicine-supported PFP. The transcripts were analyzed using thematic analysis.

RESULTS

We conducted 9 interviews with mothers of children (n = 10) in the PFP at which point data saturation was achieved. Three main themes emerged: a) the initial emotional toll on mothers stemming from fear of perceived adverse consequences of decreasing tube feeds and uncertainty surrounding efficacy of weaning; b) achievement of weaning via a family-centered approach through gaining trust, close contact, and collaboration with the team; and c) attainment of mothers' expectations of family life through transformed relationships and social activities. A positive evolution of emotions was observed, attributable to the support of the PFP.

CONCLUSIONS

These experiences suggest that our outpatient weaning program had a positive impact on the stress, fear, and relational challenges that mothers reported before and during initial tube weaning. These findings highlight potential areas of discussion with families at multiple stages of the child's tube feeding experience, to help normalize emotions for families and support coping strategies.

Evaluation of an Outpatient and Telehealth Initiative to Reduce Tube Dependency in Infants with Complex Congenital Heart Disease

Infants with congenital heart disease (CHD) often require supplemental nutrition via tube feeding, even after corrective surgical repair. The need for tube feeding can persist months after discharge home, and outpatient weaning from the tube can be a slow and difficult process. Lack of consensus exists in the literature as to the best approach to this challenge. We describe a single institution's initiative to decrease tube dependency after discharge through an intensive, telehealth-centric program for children with CHD. Of 16 children aged 1-26 months, 94% were able to be successfully tube weaned at home, with median time to tube-free of 12 days. No significant weight loss was noted during or after the wean process. Longer tube wean time was associated with older age at onset and comorbid genetic syndrome. Our telehealth-based intensive tube weaning program was successful but required a multidisciplinary team, targeted pre-participation patient evaluation, and frequent communication.

Tube Feeding in Neurologically Disabled Children: Hot Topics and New Directions

Tube feeding is a therapeutic intervention that is aimed at providing nutritional support and is important in the nutritional and gastrointestinal management of children with neurological disability (ND) worldwide. Since the publication of the first European Society of Gastroenterology, Hepatology, and Nutrition (ESPGHAN) consensus paper in 2017, some aspects of tube-feeding modalities have attracted the interest of the scientific community more than others, including the type of enteral formulas, enteral access, and the challenging practice of tube weaning. The purpose of this review was to report on the most recent hot topics and new directions in tube-feeding strategies for children with ND.

Weight loss during ambulatory tube weaning: don't put the feeds back up

OBJECTIVE

To describe the prevalence of weight loss during tube weaning and its impact on wean duration and growth.

SETTING

Tertiary feeding clinic, UK.

PATIENTS

All children seen for weaning from long-term enteral feeding between 2008 and 2016.

INTERVENTIONS

Outpatient withdrawal of enteral feeding.

DESIGN

Case series of children being weaned from tube feeding, documenting clinical details, periods of weight loss and timing of feed changes, as well as height and weight at baseline and within 1 year after feed cessation.

MAIN OUTCOME MEASURES

Amount and frequency of weight loss, wean duration, change in body mass index (BMI) and height SD z score.

RESULTS

Weaning was attempted in 58 children, median age 2.7 years, and 90% had stopped feeds after median (range) 5.9 (1-40) months. Weight loss was seen in 51 (88%) children and was more common and severe in children with initially higher BMI. Time to feed cessation reduced by median 4.9 months between 2008-2011 and 2012-2016, while having feeds increased prolonged the wean duration, by median 13 months. After feed cessation, mean (95% CI) BMI had dropped by 0.84 (0.5 to 1.2) z scores, but neither change in BMI, nor the amount and frequency of weight loss, related to growth.

CONCLUSIONS

Short-term weight loss is to be expected during tube weaning and is not associated with compromised growth. It is important to avoid overfeeding enterally fed children and not to increase feeds again in response to weight loss.

Appetite guided approach to pediatric enteral tube weaning in the home setting pilot study

BACKGROUND

Infants and children, who temporarily use feeding tubes to maintain body composition and growth, often have difficulty resuming oral feeds once medically stable. We report survey results from Growing Independent Eaters (GIE), an interdisciplinary approach providing home-based virtual support during a child-led appetite guided enteral wean.

METHOD

Surveys addressing participant wean success, weight, and feeding practices were sent to 76 families who participated in a GIE-led wean; 31 surveys were completed and returned.

RESULTS

All participants who were not eating or drinking orally pre-wean, fully or partially weaned off enteral support. Infants weaned faster (37.7 days) than children (80.1 days). Mean weight loss during the intervention was 6.6% for infants and 5.9% for children. Six-months post-wean 93% of participants surpassed their pre-wean weight.

CONCLUSION

The GIE method was successful for weaning infants and children off enteral support. This article is protected by copyright. All rights reserved.

Weaning children from prolonged enteral nutrition: A position paper

Enteral nutrition (EN) allows adequate nutritional intake in children for whom oral intake is impossible, insufficient or unsafe. With maturation and health improvements, most children ameliorate oral skills and become able to eat orally, therefore weaning from EN becomes a therapeutic goal. No recommendations currently exist on tube weaning, and practices vary widely between centres. With this report, the French Network of Rare Digestive Diseases (FIMATHO) and the French-Speaking Group of Paediatric Hepatology, Gastroenterology and Nutrition (GFHGNP) aim to develop uniform clinical practice recommendations for weaning children from EN. A multidisciplinary working group (WG) encompassing paediatricians, paediatric gastroenterologists, speech-language therapists, psychologists, dietitians and occupational therapists, was formed in June 2018. A systematic literature search was performed on those published from January 1, 1998, to April 30, 2020, using MEDLINE. After several rounds of e-discussions, relevant items for paediatric tube weaning were identified, and recommendations were developed, discussed and finalized. The WG members voted on each recommendation using a nominal voting technique. Expert opinion was applied to support the recommendations where no high-quality studies were available.

Mealtime Support: A Pilot Case Series study of an Effective, Cost-saving Outpatient Hunger-Based Feeding Program for Tube Dependency

Tube feeding is essential for children who cannot meet nutritional requirements orally. Over time, this can lead to tube dependency with negative impacts on the quality of life of children and families.

Objective

We aimed to examine the efficacy of a multidisciplinary child-led, hunger-based approach called "Mealtime Support" at the Stollery Children's Hospital in Edmonton. Nutritional outcomes, parental satisfaction, and cost implications were evaluated over 9 months postprogram completion per child.

Methods

The ambulatory meal program was delivered 2-3 times a day, for 2 weeks, by an occupational therapist and dietitian, under medical supervision. Hunger was promoted by reducing tube fed calories by 80% before commencement. Caregivers completed 12-question subjective surveys pre- and postintervention. Microcosting methods compared costs between the program and ongoing tube feeding.

Results

From 2016 to 2017, 6 children were enrolled and 5 completed the program. At 1-month postintervention, 4/5 of the children were 100% orally fed. Parents reported improvement in mealtime struggles (P = 0.005), reduction in worry about their child's eating (P = 0.005), and improvement in their child's appetite/variety foods eaten (P = 0.004). Over 2 years, the potential cost savings were estimated at $43,471.00. By 6 months, all feeding tubes were removed.

Conclusions

Mealtime support was safe and successful in reducing tube dependency and cost-effective compared to no intervention or hospital based programs, which suggests that there is a need to develop and fund Canadian outpatient feeding programs.

Weaning children from prolonged enteral nutrition: A survey of practice on behalf of the French Society of Paediatric Gastroenterology, Hepatology, and Nutrition

BACKGROUND

No consensus currently exists on tube-weaning practice worldwide. The aim of this study was to describe tube-weaning practice (indications and modalities) of a panel of pediatric gastroenterologists involved in the management of prolonged enteral nutrition (EN).

METHODS

A cross-sectional survey of pediatric gastroenterologists involved in the management of children receiving prolonged (>3 months) EN who were likely to be weaned was conducted. A questionnaire containing 24 questions was disseminated to the French Speaking Group of Paediatric Gastroenterology, Hepatology, and Nutrition members. The association between weaning practice and the experience of respondents was investigated.

RESULTS

In total, 311 professionals were approached, and 64 questionnaires were completed (response rate 21%). Nearly all respondents (n = 61, 95%) reported using individualized weaning programs. Weaning attempts were performed more frequently at home, and follow-up was performed in the outpatient clinic (97%) by progressive EN volume reduction (83%). Inpatient weaning was performed by only 28% of participants. The choice of the setting was predominantly (59%) based on parental request. Management and follow-up involved mainly the referring pediatric gastroenterologist and the dietitian. Fifty-one (80%) of the respondents experienced ≥1 weaning failure.

CONCLUSIONS

This is one of only a few studies examining real-life pediatric tube-weaning practices. Considerable practice variation between centers was observed; some of the common practices included the setting of weaning (outpatient vs inpatient) and the eligibility criteria. Increasing knowledge about weaning modalities is the starting point for the design of consensual standardized programs.

Long-term Outcomes of Children With Pediatric Feeding Disorders Treated in an Inpatient Multidisciplinary Program

ABSTRACT

The purpose of this longitudinal observational study was to evaluate the effectiveness of a multidisciplinary inpatient treatment model for feeding disorders by analyzing long-term nutritional and health outcomes 12 months following discharge. Fifty patients completed the study. Average caloric intake by mouth as a percentage of goal for gastrostomy tube (GT)-dependent patients (n = 31) increased from pre-admit, week 1, and week 2 of the inpatient program (30%, 70%, and 84%, respectively), and was sustained from week 3 to 12-month follow-up (85% and 86%, respectively). Eighty-one percentage were discharged without GT support and 65% remained off GT support at 12 months. Oral supplement dependence for non-GT patients (n = 19) decreased from pre-admit, discharge, and 12-month follow-up (51%, 31%, and 19% of caloric intake, respectively). BMI z-scores improved during and after treatment. The present study demonstrated an effective approach for treatment of pediatric feeding disorders, including decreased reliance on oral supplementation and GT dependence.

Factors Associated With Success and Failure of Weaning Children From Prolonged Enteral Nutrition: A Retrospective Cohort Study

OBJECTIVES

The aims of the present study were to assess the efficacy of a tube weaning program, and to identify factors associated with success and failure.

METHODS

This was a retrospective cohort study including all pediatric patients on enteral nutrition (EN) for ≥6 months for whom at least 1 attempt of weaning was performed in a single tertiary referral center from 2012 to 2017, with a minimum follow-up of 6 months after EN discontinuation. Weaning program was individualized to each child. Weaning success was defined a priori. Factors associated with success were investigated using multivariate analysis.

RESULTS

Ninety-four patients were enrolled, in whom a total of 114 attempts of weaning were performed at a median age of 51 ± 40 months. Success was achieved in 80 attempts (success rate of 70%). One hundred three (92%) weaning attempts were performed at home with a follow-up in the outpatient clinic, mostly (74%) by a progressive (>1 month) reduction of tube feeding. Patients who required psychological support during weaning had more failures than patients who did not (odds ratio = 5.7, 95% confidence interval [1.2-27.0], P = 0.03). The presence of impaired oral feeding skills at the time of EN discontinuation was also predictive of failure (odds ratio = 6.2, 95% confidence interval [0.05-0.5], P = 0.005).

CONCLUSIONS

Our progressive, mostly outpatient-based, patient-tailored program of weaning from EN is effective for tube-dependent children. Children who need psychological support during weaning and those who present impaired oral feeding skills represent a subgroup of at-risk patients for whom alternative weaning strategies may need to be considered.

Occupational Therapy Practice Guidelines for Early Childhood: Birth-5 Years

IMPORTANCE

This Practice Guideline provides stakeholders with a condensed summary of a large number of effectiveness studies. It is a valuable tool for facilitating decision making related to occupational therapy interventions for children ages birth-5 yr.

OBJECTIVE

Early childhood (birth-5 yr) is a critical period in which the foundation of key life occupations is developed (e.g., eating, dressing, play, learning, social participation, rest and sleep, and chores). The development of cognitive, motor, social-emotional, and self-care skills is important to support these occupations. This Practice Guideline synthesizes recent systematic reviews (SRs) on these areas of development to promote decision making for and high-quality interventions with this population.

METHOD

Four SRs related to cognition, mental health, motor function, and ADLs analyzed studies published from 2010 to 2017 retrieved from six electronic databases (MEDLINE, PsycINFO, CINAHL, ERIC, OTseeker, and Cochrane).

RESULTS

A total of 196 articles were included in the SRs, which served as a guide to final clinical recommendations. Case studies describe translation and application to practice.

CONCLUSION

and Recommendations: A variety of interventions within the domain of occupational therapy were found to support the development of cognitive, social-emotional, motor, and self-care skills. Although some of these interventions are typically implemented by occupational therapy practitioners, others can be implemented by parents after training or by teams working in preschool settings. These findings should be used to inform evidence-based practice provided by occupational therapy practitioners working in various early childhood settings.

WHAT THIS ARTICLE ADDS

This Practice Guideline gives occupational therapy practitioners clear information about which interventions will be effective for specific outcomes. Better intervention choices mean better outcomes for young children and their families.

Interventions Within the Scope of Occupational Therapy Practice to Improve Activities of Daily Living, Rest, and Sleep for Children Ages 0-5 Years and Their Families: A Systematic Review

IMPORTANCE

Research studies supporting occupational therapy interventions to address feeding, toileting, and sleep can be applied to practice in early intervention and preschool settings to improve the outcomes of young children and their families.

OBJECTIVE

To examine the effectiveness of interventions within the scope of occupational therapy practice to improve activities of daily living, rest, and sleep for children ages 0-5 yr and their families.

DATA SOURCES

Five databases (MEDLINE, PsycINFO, CINAHL, OTseeker, ERIC) and Evidence-Based Medicine Reviews, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, and Database of Abstracts of Reviews of Effectiveness were searched for studies published between January 2000 and March 2017.

STUDY SELECTION AND DATA COLLECTION

Inclusion criteria were Levels I-III evidence, being within occupational therapy's scope of practice, including participants with a mean age younger than 6 yr, and addressing self-care, activities of daily living, and rest and sleep.

FINDINGS

Forty articles were appraised, and three themes emerged: interventions to address feeding and eating, interventions to address toileting, and interventions to address rest and sleep. Additional subthemes of behavioral approaches, parent and caregiver education, and contextual intervention were revealed.

CONCLUSIONS AND RELEVANCE

Occupational therapy practitioners should consider the use of interventions with moderate or strong evidence as described in this review. Limitations include risk of bias and limited evidence for several interventions.

WHAT THIS ARTICLE ADDS

This article provides a broader perspective on evidence-based practice by examining studies within the scope of occupational therapy practice published outside of current occupational therapy publications. The review includes studies from nutrition, nursing, and psychology, which address interdisciplinary care, family coaching and education, and behavioral approaches within the professional scope of occupational therapy to improve the functional performance, routines, and quality of life for young children and their caregivers.

Characterizing International Approaches to Weaning Children From Tube Feeding: A Scoping Review

Approaches to tube weaning enterally fed children and evaluating outcomes vary widely. This limits the utility of research for identifying both "what works" and successful implementation of research outcomes. We used a qualitative scoping review methodology to examine internationally published research. Our primary aim was to identify the main philosophies underpinning intervention design and the main outcome variables used to demonstrate success of existing programs. This information can be used to inform future research design and clinical practice. Literature up until June 2019 was sourced via Medline, Scopus, Ovid, and CINHAL databases; hand searching; and gray literature using Google Advanced Search. Three predominant approaches to tube-weaning interventions were identified: behavioral, child- and family-centered, and biomedical. A wide range of intervention variables were identified, with the level of parental involvement and the use of hunger provocation varying between approaches. Our Review also confirms that there is no consistency in outcome measures used, limiting comparability between programs. We suggest that the role of parents in the weaning process and its impact on both the child and the parent/carer while transitioning from enteral to oral eating are insufficiently understood. We discuss these findings in the context of a suggested framework for future research.

Long term nutritional and growth outcomes of children completing an intensive multidisciplinary tube-feeding weaning program

BACKGROUND & AIMS

Children on long-term tube-feeding often need special treatment for oral feeding transitioning. Rapid tube-weaning programs usually result in short-term reductions in food intake and weight loss. This study examined the long-term effects of a "Graz-model" based weaning program on nutritional status and growth.

METHODS

Children aged 0.5-13.0 years on long-term enteral nutritional support (ENS) participated in a three-week multidisciplinary weaning treatment. Data were collected at baseline, after completing the program, and at six and 12 months. Height/length, weight and BMI z-scores were determined according to the WHO growth standards. Energy and protein intake were assessed and presented as % of recommended daily allowance (RDA) values.

RESULTS

Study participants (n = 58) were 64% male. Four children did not complete the three-week program due to acute illnesses. Complete weaning (from 100% ENS to 100% oral) was achieved in 22 children and partial weaning (at least 80% reduction of ENS) in 23 children. No demographic or clinical success predictors were identified. Thirty of the 45 weaned children completed the 12-month follow-up. A significant reduction in energy intake was observed at the three-week time-point [mean (SE): 56 (5.8)% versus 80 (4.7)%, p = 0.001]. This was followed by improvements in eating skills leading to energy intake at 12 months which did not significantly differ from baseline (p = 0.392). Mean (SE) baseline protein intake was 187 (13.0) %RDA. No significant difference from baseline were noted at 12 months (p = 0.301). Estimated mean (SD) height-, weight- and BMI z-scores at baseline were -2.11(0.28), -1.48(0.25), -0.13(0.31), respectively. No significant differences in growth data were observed over time.

CONCLUSIONS

Short-term reductions in nutritional intake and body weight observed after an intensive weaning program were reversible, and growth patterns were stable over 12 months. Further follow-up is recommended to ensure continued positive development in these children.

Efficacy of a standardized tube weaning program in pediatric patients with feeding difficulties after successful repair of their esophageal atresia/tracheoesophageal fistula

Children born with esophageal atresia (EA) might suffer from significant oral feeding problems which could evolve into tube dependency. The primary aim of the study was to define the outcome of tube weaning in children after successful EA repair and to compare outcomes in children with short gap/TEF (tracheoesophageal fistula) and long-gap EA. Data of 64 children (28 with short-gap EA/TEF with primary anastomosis and 36 with long-gap EA with delayed surgical repair) who participated in a standardized tube weaning program based on the "Graz model of tube weaning" (in/outpatients in an intensive 3-week program, online coaching (Netcoaching) only, or a combined 2-week intensive onsite followed by online treatment "Eating School") from 2009 to 2019 was evaluated. Sixty-one patients completed the program by transitioning to exclusive oral intake (95.3%). Three children (4.7%) were left partially weaned at the time of discharge. No significant differences could be found between short gap/TEF and long-gap EA group regarding outcomes.Conclusions: The study's findings support the efficacy of tube weaning based on the published "Graz model of tube weaning" for children born with EA/TEF and indicate the necessity of specialized tube weaning programs for these patients. What is Known: • Children with esophageal atresia/tracheoesophageal fistula often suffer from feeding problems and tube dependency. • Different tube weaning programs and outcomes have been published, but not specifically for children with EA. What is New: • Evaluation of a large sample of children referred for tube weaning after EA repair. • Most children with EA can be weaned off their feeding tubes successfully after attending a specialized tube weaning program.

Variables Impacting the Time Taken to Wean Children From Enteral Tube Feeding to Oral Intake

OBJECTIVES

This study investigated biological factors, which may influence the time taken for children to wean from enteral to oral intake.

METHODS

Retrospective case-note audit of 62 tube-fed children (nasogastric or percutaneous endoscopic gastrostomy) aged 6 months to 8 years, participating in an intensive tube weaning program. Program design included family-focused mealtimes, child autonomy, and appetite stimulation. A regression model was developed, which shows the combination of variables with the most predictive power for time taken to wean.

RESULTS

Data from 62 children who were highly dependent (minimum 93% of calories provided enterally) on tube feeding for an extended period of time (mean = 2.1 years) were analysed. Children's mean body mass index z score at time of weaning was -0.47 (standard deviation 1.03) (mean weight = 10.54 kg) and 54 (87%) presented with a range of medical conditions. Forty-four children (71%) remained completely tube free at 3 months postintervention and an additional 5 children (10%) were fully tube weaned within 10 months of program commencement. Type of feeding tube, medical complexity, age, and length of time tube fed all significantly correlated with time taken to wean. Logistic regression modelling indicated that the type of feeding tube in combination with the degree of medical complexity and time tube fed were the strongest predictors of time taken to wean.

CONCLUSIONS

Biological factors usually considered to impact on successful weaning from tube feeding (volume of oral intake, oral skill, or mealtime behaviours) were not relevant; however, the type of feeding tube in combination with the degree of medical complexity and time tube fed were the strongest predictors. The impact of psychosocial factors should be investigated to identify if these mitigated the effects of the biological variables.

Health related quality of life of infants and children with avoidant restrictive food intake disorder

OBJECTIVE

The aim of this study was to compare health related quality of life (HRQOL) in infants and children with avoidant restrictive food intake disorder (ARFID) to healthy and chronically ill controls.

METHOD

A cross-sectional study was conducted in children who meet ARFID criteria at our tertiary care pediatric feeding clinic (September 2014 to July 2016). Before consultation, parents of patients (n = 100) were asked to complete questionnaires to determine HRQOL: the TNO-AZL Preschool Children Quality of Life (0-5 years), and "Pediatric Quality of Life Inventory" (6-7 and 8-10 years). HRQOL of ARFID patients was compared to both healthy (0-5 years n = 241; 6-7 years n = 61; 8-10 years n = 192) and chronically ill (0-5 years n = 79; 6-7 years n = 11; 8-10 years n = 26) controls.

RESULTS

The prevalence of ARFID was 64%. HRQOL of ARFID patients aged 0-5 years (n = 37) was significantly lower on 6/12 scales (appetite, lungs, stomach, motor functioning, positive mood and liveliness) compared to healthy controls (P < .01), and on 4/12 scales (appetite, stomach, motor functioning, and liveliness) compared to chronically ill controls (P < .01). The ARFID patients scored significantly better on the problem behavior scale compared to healthy and chronically ill controls (P < .01). ARFID patients aged 6-7 (n = 9) had significantly lower scores in 3/6 scales (total score, psychosocial health, and school functioning) (P < .01), and aged 8-10 (n = 2) had a significantly lower school functioning scale (P < .01) compared to healthy controls.

CONCLUSION

HRQOL of children with ARFID is decreased on multiple scales. The effect on HRQOL should be incorporated in clinical practice, and clinical studies should add HRQOL as an outcome measure.

Long-term Outcomes of an Interdisciplinary Tube Weaning Program: A Quantitative Study

BACKGROUND AND OBJECTIVES

Children who become tube-dependent need specialized treatment in order to make the transition to oral feeding. Little is known about long-term effects of tube weaning programs. This study analyzes long-term effects (outcome, growth, and nutrition data) in a large sample of formerly tube-dependent children 1 to 6 years after participation in tube weaning programs, based on the "Graz model of tube weaning."

METHODS

Parents of children who completed a tube weaning program between 2009 and 2014 (N = 564) were asked to complete a questionnaire on their child's growth and nutrition. Data was analyzed using SPSS V22.0 for Windows (SPSS, Chicago, IL).

RESULTS

Response rate was 47.16% (N = 266). Seven children had died between completion of the program and the long-term follow-up. Two hundred and thirty-nine children (92.3%) were still exclusively orally fed 1 to 6 years after completion of the weaning program, 17 children (6.6%) were partially tube-fed. Three children were completely tube-fed (1.1%). Growth data showed no significant changes in zBMI (World Health Organization standards z values for body mass index) between completion of weaning and long-term follow-up. Provided data on nutrition of fully orally fed patients showed that most children (N = 162, 68%) were eating an age-appropriate diet, whereas a small percentage (N = 10, 4%) were fed with a high-caloric formula, a selective diet (N = 12, 5%), or a liquid/pureed diet (N = 55, 23%).

CONCLUSIONS

Many children who undergo a tube weaning program based on the "Graz model of tube weaning" are able to stay on full oral feeds in the years after completion of the wean without deterioration of growth.

Nutrition Considerations After NICU Discharge

Preterm infants are at high nutrition risk during neonatal intensive care and well after discharge. Nutrition care should be individualized and provided by a multidisciplinary team including a dietitian. Breast milk, the gold standard for feeding, may not meet the increased needs of preterm infants and may require fortification or supplementation. Decisions regarding formula choice and calorie concentration can also be challenging and require individualization based on growth, intake, and individual need. Developmental milestones should be considered during the initation of complementary food. This article presents new research on allergenic food introduction to guide practitioners during caregiver education. Finally, an evidence-based weaning practice for enteral feeding-dependent patients is provided with suggestions for outpatient applicability. [Pediatr Ann. 2018;47(4):e154-e158.].

A Program for Weaning Children from Enteral Feeding in a General Pediatric Unit: How, for Whom, and with What Results?

OBJECTIVE

To describe a series of children who were hospitalized for a tube-weaning program in the general pediatric ward of a pediatric tertiary university hospital: describe our method, to determine the success rate of our inpatient pediatric tube weaning program, and search for relevant factors linked to its success or failure.

METHOD

We analyzed the medical files of consecutive children who were hospitalized for gastric-tube weaning over an 8-year period. We analyzed outcomes in terms of feeding and growth with at least 2 years of data. Success (weaning within 3 months) and failure were compared by characteristics of children.

RESULTS

We included 37 children (29 females) with mean (SD) age 31.4 (21) months. Most had a severe medical history (30% prematurity; 50% intrauterine growth restriction, 50% neurological and genetic anomalies). The weaning program was successful for half of the children. Factors linked to success of the program were female sex (p = 0.0188), normal neurodevelopment (p = 0.0016), nasogastric tube (p = 0.0098), and with <24 months on EF before the stay (p = 0.0309).

DISCUSSION

Comparing the efficiency of various methods and results among teams was difficult, which indicates the need to establish consensus about the outcome criteria. We confirm the need for these types of stays and programs.

Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment

PURPOSE OF REVIEW

DSM-5 defined avoidant/restrictive food intake disorder (ARFID) as a failure to meet nutritional needs leading to low weight, nutritional deficiency, dependence on supplemental feedings, and/or psychosocial impairment. We summarize what is known about ARFID and introduce a three-dimensional model to inform research.

RECENT FINDINGS

Because ARFID prevalence, risk factors, and maintaining mechanisms are not known, prevailing treatment approaches are based on clinical experience rather than data. Furthermore, most ARFID research has focused on children, rather than adolescents or adults. We hypothesize a three-dimensional model wherein neurobiological abnormalities in sensory perception, homeostatic appetite, and negative valence systems underlie the three primary ARFID presentations of sensory sensitivity, lack of interest in eating, and fear of aversive consequences, respectively. Now that ARFID has been defined, studies investigating risk factors, prevalence, and pathophysiology are needed. Our model suggests testable hypotheses about etiology and highlights cognitive-behavioral therapy as one possible treatment.

Feeding Disorders

Feeding disorders often present in children with complex medical histories as well as those with neurodevelopmental disabilities. If untreated, feeding problems will likely persist and may lead to additional developmental and medical complications. Treatment of pediatric feeding disorders should involve an interdisciplinary team, but the core intervention should include behavioral feeding techniques as they are the only empirically supported therapy for feeding disorders.

A descriptive comparison of approaches to paediatric tube weaning across five countries

PURPOSE

Many children are requiring tube weaning intervention as a result of increased survival rates of high risk infants and the temporary use of feeding tubes. This study aimed to describe service delivery models and treatment approaches in a variety of paediatric feeding/tube weaning programs.

METHOD

A questionnaire on tube weaning was formulated based on a literature review. Purposive maximum variation sampling was used to include feeding/ weaning programs operating in a variety of settings and countries. Eight feeding teams in Australia, Europe and the USA agreed to participate and completed the questionnaire.

RESULT

All teams employed sensori-motor interventions, with the majority also offering psychological interventions. Six of eight teams utilised hunger induction during the initiation of tube weaning, and in many cases this preceded eating skill development or controlled sensory modulation.

CONCLUSION

A multi-model tube weaning approach is commonly adopted by many centres worldwide. In many cases, psychological theory and theoretical orientation is fundamental to tube weaning practice. Further investigation regarding the efficacy and effectiveness of weaning interventions is recommended to ensure clinical practice is based on sound evidence. This may present as a challenge given many interventions occur concomitantly and the psychotherapeutic experience is difficult to evaluate.

A Systematic Review and Meta-Analysis of Intensive Multidisciplinary Intervention for Pediatric Feeding Disorders: How Standard Is the Standard of Care?

OBJECTIVE

To assess models of care and conduct a meta-analysis of program outcomes for children receiving intensive, multidisciplinary intervention for pediatric feeding disorders.

STUDY DESIGN

We searched Medline, PsycINFO, and PubMed databases (2000-2015) in peer-reviewed journals for studies that examined the treatment of children with chronic food refusal receiving intervention at day treatment or inpatient hospital programs. Inclusion criteria required the presentation of quantitative data on food consumption, feeding behavior, and/or growth status before and after intervention. Effect size estimates were calculated based on a meta-analysis of proportions.

RESULTS

The systematic search yielded 11 studies involving 593 patients. Nine articles presented outcomes based on retrospective (nonrandomized) chart reviews; 2 studies involved randomized controlled trials. All samples involved children with complex medical and/or developmental histories who displayed persistent feeding concerns requiring formula supplementation. Behavioral intervention and tube weaning represented the most common treatment approaches. Core disciplines overseeing care included psychology, nutrition, medicine, and speech-language pathology/occupational therapy. The overall effect size for percentage of patients successfully weaned from tube feeding was 71% (95% CI 54%-83%). Treatment gains endured following discharge, with 80% of patients (95% CI 66%-89%) weaned from tube feeding at last follow-up. Treatment also was associated with increased oral intake, improved mealtime behaviors, and reduced parenting stress.

CONCLUSIONS

Results indicate intensive, multidisciplinary treatment holds benefits for children with severe feeding difficulties. Future research must address key methodological limitations to the extant literature, including improved measurement, more comprehensive case definitions, and standardization/examination of treatment approach.

Development, prevention, and treatment of feeding tube dependency

Enteral nutrition is effective in ensuring nutritional requirements and growth. However, when tube feeding lasts for a longer period, it can lead to tube dependency in the absence of medical reasons for continuation of tube feeding. Tube-dependent children are unable or refuse to start oral activities and they lack oral skills. Tube dependency has health-, psychosocial-, and economy-related consequences. Therefore, the transition to oral feeding is of great importance. However, this transition can be very difficult and needs a multidisciplinary approach. Most studies for treatment of tube dependency are based on behavioral interventions, such as family therapy, individual behavior therapy, neuro-linguistic programming, and parental anxiety reduction. Furthermore, oral motor therapy and nutritional adjustments can be helpful in tube weaning. The use of medication has been described in the literature. Although mostly chosen as the last resort, hunger-inducing methods, such as the Graz-model and the Dutch clinical hunger provocation program, are also successful in weaning children off tube feeding.

CONCLUSION

The transition from tube to oral feeding is important in tube-dependent children but can be difficult. We present an overview for the prevention and treatment of tube dependency. What is known: • Longer periods of tube feeding can lead to tube dependency. • Tube weaning can be very difficult. What is new: • Weaning as soon as possible and therefore referral to a multidisciplinary team are recommended. • An overview of treatment options for tube dependency is presented in this article.

Feeding Problems and Their Underlying Mechanisms in the Esophageal Atresia-Tracheoesophageal Fistula Patient

Feeding difficulties such as dysphagia, coughing, choking, or vomiting during meals, slow eating, oral aversion, food refusal, and stressful mealtimes are common in children with repaired esophageal atresia (EA) and the reasons for this are often multifactorial. The aim of this review is to describe the possible underlying mechanisms contributing to feeding difficulties in patients with EA and approaches to management. Underlying mechanisms for these feeding difficulties include esophageal dysphagia, oropharyngeal dysphagia and aspiration, and aversions related to prolonged gastrostomy tube feeding. The initial diagnostic evaluation for feeding difficulties in a patient with EA may involve an esophagram, videofluoroscopic imaging or fiberoptic endoscopic evaluation during swallowing, upper endoscopy with biopsies, pH-impedance testing, and/or esophageal motility studies. The main goal of management is to reduce the factors contributing to feeding difficulties and may include reducing esophageal stasis, maximizing reflux therapies, treating underlying lung disease, dilating strictures, and altering feeding methods, routes, or schedules.

A Randomized Controlled Trial of an Outpatient Protocol for Transitioning Children from Tube to Oral Feeding: No Need for Amitriptyline

OBJECTIVE

To assess the role of amitriptyline in the effectiveness of an outpatient protocol for weaning medically complicated children from tube to oral feeding.

STUDY DESIGN

Twenty-one children seen in multidisciplinary outpatient feeding teams across 4 sites were recruited to a randomized placebo-controlled trial of a 6-month outpatient treatment protocol with behavioral, oral-motor, nutrition, and medication components.

RESULTS

All of the children who completed the 6-month program (73%) were weaned to receive only oral feeding, regardless of group assignment. The transition from tube to oral feeding resulted in decreases in body mass index percentile and pain, some improvements in quality of life, and no statistically significant changes in cost.

CONCLUSIONS

Amitriptyline is not a key component of this otherwise effective outpatient, interdisciplinary protocol for weaning children from tube to oral feeding.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01206478.