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

Home enteral nutrition does not decrease oral feeding in children during the first year of nutritional support

BACKGROUND

Enteral nutrition is necessary when nutritional status is poor and oral intake is insufficient or impossible. Although it has been suspected to reduce spontaneous oral feeding, no study has formally assessed the influence of enteral nutrition on pediatric oral intake. The present study aimed to evaluate variation in oral feeding intake after enteral nutrition initiation, and to identify factors influencing oral feeding.

METHODS

This retrospective cohort study included 149 pediatric patients from two French tertiary care hospitals, who received home enteral nutrition from 2009 to 2022. The patients were aged 2 months to 17 years (median age 3 years, interquartile range 1.3-9.2). Oral and enteral intakes were assessed when enteral nutrition was initiated (M0), and again at M3 (n = 123), M6 (n = 129), and M12 (n = 134) follow-ups, based on dieticians' and home services' reports. Oral feeding and body mass index z score variations during follow-ups were evaluated using a linear mixed regression model, including "time" as a fixed effect and "patient" as a random effect. Factors associated with oral feeding changes were assessed using a model interaction term.

RESULTS

Oral intake did not vary significantly (P = 0.99) over time and accounted for 47.4% ± 27.4%, 46.9% ± 27.4%, 48.4% ± 28.2%, and 46.6% ± 26.9% of the ideal recommended daily allowance (calculated for the ideal weight for height) at M0, M3, M6, and M12, respectively. Delivery method (nasogastric tube versus gastrostomy), prematurity, underlying disease, history of intrauterine growth retardation, and speech therapy intervention did not influence oral intake. Administration (i.e., exclusively continuous nocturnal infusion versus daytime bolus) led to different oral intake development, although oral intake also differed at M0.

CONCLUSIONS

Enteral nutrition, although increasing total energy intake, does not alter oral feeding during the first year of administration. Only the mode of administration might influence oral intake.

The Association of Tube Weaning and Oral Skill Development in Infants With Tube Dependency: A Prospective Study

OBJECTIVE

This study was the first of its kind by assessing oral skills development during and after applying the "Graz Model" of tube weaning.

METHODS

This prospective case series study included data of 67 (35 females, 32 males, treated from March 2018 to April 2019) tube dependent children, who participated in the effective "Graz Model" of tube weaning. Parents filled out the standardized Pediatric Assessment Scale for Severe Feeding Problems (PASSFP) prior to and immediately after completion of the program. Paired sample t tests were conducted to examine pre-to-post changes in the children's oral skills.

RESULTS

The study showed that oral skills increased significantly during tube weaning PASSFP score of 24.76 (standard deviation, SD = 12.38) prior to versus 47.97 (SD = 6.98) after completion of the program. Furthermore, significant changes in their sensory and tactile perception and in their general eating behavior were observed. Children also showed reduced oral aversion symptoms and food pocketing, could enjoy their meals, and increased their food repertoire. Mealtime duration could be decreased, and parents were less anxious about their infants' intake and less frustrated because of their children's eating behavior.

CONCLUSION

The results of this study demonstrated for the first time that tube dependent children can improve their oral skills significantly during and after their participation in the child-led approach of the "Graz model" of tube weaning.

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.

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.