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Kaskie S, Horsley M, Marcuccio E. Experiences in Tube Weaning Children with Congenital Heart Disease and Oral Feeding Aversion. Pediatr Cardiol 2024:10.1007/s00246-024-03515-8. [PMID: 38744695 DOI: 10.1007/s00246-024-03515-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 04/29/2024] [Indexed: 05/16/2024]
Abstract
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.
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Affiliation(s)
- Sarah Kaskie
- Division of Speech-Language Pathology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
| | - Megan Horsley
- Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Elisa Marcuccio
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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2
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Yamamichi T, Imanishi Y, Sakai T, Yoshida M, Takayama K, Uga N, Umeda S, Usui N. Risk factors for and developmental relation of delayed oral nutrition in infants with congenital diaphragmatic hernia. Pediatr Surg Int 2023; 40:2. [PMID: 37991549 DOI: 10.1007/s00383-023-05595-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE To identify risk factors for delayed oral nutrition in infants with a congenital diaphragmatic hernia (CDH) and its impact on developmental delay at 18 months of age. METHODS This retrospective single-center cohort study compared the clinical parameters in patients with isolated CDH born and treated at our hospital between 2006 and 2020. We evaluated clinical features significantly related to delayed oral nutrition (defined as taking ≥ 30 days from weaning from mechanical ventilation to weaning from tube feeding). RESULTS Twenty-six of the 80 cases had delayed oral nutrition. Univariate analyses showed significant differences. Multivariate analyses were performed on the three items of preterm delivery, defect size (over 50% to nearly entire defect), and ventilation for ≥ 9 days. We identified the latter two items as independent risk factors. The adjusted odds ratios were 4.65 (95% confidence interval, 1.27-7.03) and 6.02 (1.65-21.90), respectively. Delayed oral nutrition was related to a significantly higher probability of developmental delay at 18 months (crude odds ratio 4.16, 1.19-14.5). CONCLUSION In patients with CDH, a large defect and ventilatory management over 9 days are independent risk factors for delayed oral nutrition, which is a potent predictor of developmental delay that requires active developmental care.
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Affiliation(s)
- Taku Yamamichi
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan.
| | - Yousuke Imanishi
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Takaaki Sakai
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
| | - Mina Yoshida
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
| | - Keita Takayama
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
| | - Naoko Uga
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
| | - Satoshi Umeda
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
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Wilken M, Mink CM, Böhme J. [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]. Prax Kinderpsychol Kinderpsychiatr 2023; 72:529-551. [PMID: 37830885 DOI: 10.13109/prkk.2023.72.6.529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
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.
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Affiliation(s)
- Markus Wilken
- Institut für Sondendependenz Alfredstr. 167 45131 Essen Deutschland
| | - Carla Marie Mink
- Institut für Sondendependenz Alfredstr. 167 45131 Essen Deutschland
| | - Johanna Böhme
- Institut für Sondendependenz Alfredstr. 167 45131 Essen Deutschland
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Pahsini K, Marinschek S, Reininghaus EZ, Dalkner N, Bengesser SA, Mörkl S, Russell M, Russell AN, Scheer PJ, Dunitz-Scheer M. The Association of Tube Weaning and Oral Skill Development in Infants With Tube Dependency: A Prospective Study. J Pediatr Gastroenterol Nutr 2023; 77:e54-e60. [PMID: 37307357 DOI: 10.1097/mpg.0000000000003856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- Karoline Pahsini
- From the Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Graz, Austria
| | - Sabine Marinschek
- From the Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Graz, Austria
| | - Eva Z Reininghaus
- From the Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Graz, Austria
| | - Nina Dalkner
- From the Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Graz, Austria
| | - Susanne A Bengesser
- From the Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Graz, Austria
| | - Sabrina Mörkl
- From the Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Graz, Austria
| | - Marion Russell
- the Department of Occupational Therapy, Creighton University, Omaha, NE
| | | | - Peter J Scheer
- the Department of Pediatric and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Graz, Austria
| | - Marguerite Dunitz-Scheer
- the Department of Pediatric and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Graz, Austria
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5
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Grunewald W, Smith AR, Brown TA. Treatment of avoidant-restrictive food intake disorder in an older adult: A proof-of-concept case study. Int J Eat Disord 2023; 56:1795-1800. [PMID: 37097823 DOI: 10.1002/eat.23973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/13/2023] [Accepted: 04/13/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVE Cognitive behavioral therapy for Avoidant Restrictive Food Intake Disorder (ARFID; CBT-AR) is an emerging treatment for ARFID. However, this treatment modality has yet to be examined among older adults (e.g., older than 50 years) or with adults presenting with feeding tubes. To inform future versions of CBT-AR, we present the results of a singular case study (G) of an older male with the sensory sensitivity phenotype of ARFID who presented for treatment with a gastrostomy tube. METHODS G was a 71-year-old male who completed eight sessions of CBT-AR in a doctoral training clinic. ARFID symptom severity and comorbid eating pathology changes were examined pre- and post-treatment. RESULTS Posttreatment, G reported significant decreases in ARFID symptom severity and no longer met diagnostic criteria for ARFID. Furthermore, throughout treatment, G reported significant increases in his oral food consumption (vs. calories being pushed through the feeding tube), solid food consumption, and the feeding tube was ultimately removed. DISCUSSION This study provides proof of concept that CBT-AR is potentially effective for older adults and/or those presenting for treatment with feeding tubes. Validation of patient efforts and severity of ARFID symptoms emerged as core to treatment success and should be emphasized when training clinicians in CBT-AR. PUBLIC SIGNIFICANCE Cognitive behavior therapy for ARFID (CBT-AR) is the leading treatment for this disorder; however, it has yet to be tested among older adults or those with feeding tubes. This single-patient case study demonstrates that CBT-AR may be efficacious in reducing ARFID symptom severity among older adults with a feeding tube.
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Affiliation(s)
- William Grunewald
- Department of Psychological Sciences, Auburn University, Auburn, Alabama, USA
| | - April R Smith
- Department of Psychological Sciences, Auburn University, Auburn, Alabama, USA
| | - Tiffany A Brown
- Department of Psychological Sciences, Auburn University, Auburn, Alabama, USA
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6
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Weaning children from prolonged enteral nutrition: A position paper. Eur J Clin Nutr 2022; 76:505-515. [PMID: 34462558 DOI: 10.1038/s41430-021-00992-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 07/17/2021] [Accepted: 07/29/2021] [Indexed: 02/07/2023]
Abstract
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.
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Goldstein SA, Watkins KJ, Lowery RE, Yu S, Knight RM, Drayton AK, Sayers L, Gaies M. Oral Aversion in Infants With Congenital Heart Disease: A Single-Center Retrospective Cohort Study. Pediatr Crit Care Med 2022; 23:e171-e179. [PMID: 34991136 DOI: 10.1097/pcc.0000000000002879] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Neonates undergoing cardiac surgery are at risk for oral aversion (OA). OA is not well described outside of the index hospitalization and impacts patients and families. We evaluated the prevalence of OA at 1 year old after neonatal cardiopulmonary bypass (CPB) surgery. DESIGN Retrospective cohort study. SETTING Single quaternary care hospital. SUBJECTS Our cohort included 157 neonates who underwent CPB surgery from 2014 to 2017 and had follow-up data available at 1 year old. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Three feeding experts reviewed the medical record to define children with OA; 30% of charts were evaluated in triplicate for validation. Neonates with and without OA were compared in univariate analysis, and risk factors for OA were explored in a limited multivariable analysis. OA was present at 1 year in 37 patients (23.6%) and other feeding difficulties were present in an additional 29 patients (18.5%). Thirty-eight patients (24.2%) had a feeding tube, including 12 (7.6%) with a gastrostomy tube. Factors associated with OA at 1 year included total ICU days, duration of mechanical ventilation, total number of nil per os days, and number of postoperative days (PODs) until oral feeding initiation (all p < 0.0001). Number of POD until oral feeding initiation remained independently associated with OA at 1 year in multivariable analysis (adjusted odds ratio, 1.08; 95% CI, 1.04-1.12; p < 0.0001). Infants with any oral intake at discharge had lower odds of OA at 1 year (0.21; 95% CI, 0.08-0.5; p = 0.0003). At hospital discharge, 132 patients (84.1%) were taking some oral feeds, and 128 patients (81.5%) received tube feeding. CONCLUSIONS OA and other feeding difficulties are common at 1 year old in neonates undergoing CPB surgery. Delayed exposure to oral intake may be a modifiable risk factor for OA and efforts to improve early oral feeding could lead to better functional outcomes.
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Affiliation(s)
- Stephanie A Goldstein
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Kimberly J Watkins
- The Children's Heart Clinic, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN
| | - Ray E Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Rachel M Knight
- Department of Pediatric Feeding Disorders, University of Nebraska Medical Center, Munroe-Meyer Institute, Omaha, NE
| | - Amy K Drayton
- Department of Pediatric Feeding Disorders, University of Nebraska Medical Center, Munroe-Meyer Institute, Omaha, NE
| | | | - Michael Gaies
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI
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8
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Huynh G, Vishram A, Graham-Parker C, Blatz D, Carroll M, Turner J. Mealtime Support: A Pilot Case Series study of an Effective, Cost-saving Outpatient Hunger-Based Feeding Program for Tube Dependency. JPGN REPORTS 2022; 3:e154. [PMID: 37168756 PMCID: PMC10158302 DOI: 10.1097/pg9.0000000000000154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 07/14/2021] [Indexed: 05/13/2023]
Abstract
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.
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Affiliation(s)
- Geraldine Huynh
- From the Department of Pediatrics, University of Alberta, Edmonton, AB
| | - Alysha Vishram
- From the Department of Pediatrics, University of Alberta, Edmonton, AB
| | | | - Debbie Blatz
- From the Department of Pediatrics, University of Alberta, Edmonton, AB
| | - Matthew Carroll
- From the Department of Pediatrics, University of Alberta, Edmonton, AB
| | - Justine Turner
- From the Department of Pediatrics, University of Alberta, Edmonton, AB
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9
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Long-term efficacy of clinical hunger provocation to wean feeding tube dependent children. Clin Nutr 2020; 39:2863-2871. [DOI: 10.1016/j.clnu.2019.12.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 11/19/2019] [Accepted: 12/16/2019] [Indexed: 12/12/2022]
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10
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Jones E, Southwood H, Cook C, Nicholson T. Insights into paediatric tube feeding dependence: A Speech-language pathology perspective. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2020; 22:327-337. [PMID: 32366127 DOI: 10.1080/17549507.2020.1754910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Purpose: To explore possible factors contributing to paediatric tube feeding dependency from the speech-language pathology perspective. Tube feeding dependency can have serious repercussions for children and their families with failed or slow weaning/transitioning from tube to oral feeding, more likely after the age of five.Method: A mixed methods approach was conducted. During the first quantitative phase, an online national survey of speech-language pathologists (SLPs) from the health and non-health sectors was carried out followed by interviews with a subset of the respondents. Forty-three SLPs completed the survey. In the second qualitative phase, 10 participants from the survey were interviewed in depth as to their opinions about why tube dependency occurs. Survey data from phase one were analysed using descriptive statistics and chi square comparisons. Interview data were categorised using thematic analysis. Findings from both methodologies were combined to report the results.Result: Two interlinking meta-themes were identified from the combined data sets. These were: (1) Medicalisation of tube fed children in infancy as a root cause of tube feeding dependency and (2) Fragmentation of the tube fed child's continuity of care. The specific results indicated several possible reasons for tube feeding dependency including medical emphasis on weight gain, prolonged nasogastric tube feeding and waiting too long for transition from tube to oral feeding. A lack of integrated care and clinician confidence in non-health settings also appeared to be a factor contributing to tube feeding dependency.Conclusion: Early and ongoing biomedical focus on weight gain affected long-term goals for transitioning leading, subsequently, to tube feeding becoming normalised by school age.
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Affiliation(s)
- Emily Jones
- Institute of Education, College of Humanities and Social Sciences, Massey University, Auckland, New Zealand
| | - Helen Southwood
- Institute of Education, College of Humanities and Social Sciences, Massey University, Auckland, New Zealand
| | - Catherine Cook
- School of Nursing, College of Health, Massey University, Auckland, New Zealand
| | - Tom Nicholson
- Institute of Education, College of Humanities and Social Sciences, Massey University, Auckland, New Zealand
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Lively EJ, McAllister S, Doeltgen SH. Characterizing International Approaches to Weaning Children From Tube Feeding: A Scoping Review. JPEN J Parenter Enteral Nutr 2020; 45:239-250. [PMID: 32374934 DOI: 10.1002/jpen.1842] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 03/26/2020] [Accepted: 03/30/2020] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Emily J Lively
- Speech Pathology, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia.,Swallowing Neurorehabilitation Research Laboratory, Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Sue McAllister
- Sydney School of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
| | - Sebastian H Doeltgen
- Speech Pathology, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia.,Swallowing Neurorehabilitation Research Laboratory, Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
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12
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Marinschek S, Pahsini K, Aguiriano-Moser V, Russell M, Plecko B, Reininghaus EZ, Till H, Dunitz-Scheer M. Efficacy of a standardized tube weaning program in pediatric patients with feeding difficulties after successful repair of their esophageal atresia/tracheoesophageal fistula. Eur J Pediatr 2020; 179:1729-1737. [PMID: 32415337 PMCID: PMC7547996 DOI: 10.1007/s00431-020-03673-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/22/2020] [Accepted: 04/29/2020] [Indexed: 01/17/2023]
Abstract
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.
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Affiliation(s)
- Sabine Marinschek
- Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Auenbruggerplatz 31, 8010, Graz, Austria.
| | - Karoline Pahsini
- Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Auenbruggerplatz 31, 8010 Graz, Austria
| | - Victor Aguiriano-Moser
- Department of Paediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Auenbruggerplatz 34/2, 8010 Graz, Austria
| | - Marion Russell
- School of Pharmacy and Health Professions, Creighton University, 2412 Cuming sT #201, Omaha, NE 68131 USA
| | - Barbara Plecko
- Department of Paediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Auenbruggerplatz 34/2, 8010 Graz, Austria
| | - Eva Z. Reininghaus
- Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Auenbruggerplatz 31, 8010 Graz, Austria
| | - Holger Till
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8010 Graz, Austria
| | - Marguerite Dunitz-Scheer
- Department of Paediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Auenbruggerplatz 34/2, 8010 Graz, Austria
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13
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Johnson TW, RN SS, Epp L, Mundi MS. Addressing Frequent Issues of Home Enteral Nutrition Patients. Nutr Clin Pract 2019; 34:186-195. [DOI: 10.1002/ncp.10257] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Teresa W. Johnson
- Department of Kinesiology & Health Promotion; Troy University; Troy AL USA
| | | | - Lisa Epp
- Mayo Clinic; Rochester Minnesota USA
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Krom H, van Zundert SM, Otten MAG, van der Sluijs Veer L, Benninga MA, Kindermann A. Prevalence and side effects of pediatric home tube feeding. Clin Nutr 2019; 38:234-239. [DOI: 10.1016/j.clnu.2018.01.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 11/27/2022]
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Chiatto F, Coletta R, Aversano A, Warburton T, Forsythe L, Morabito A. Messy Play Therapy in the Treatment of Food Aversion in a Patient With Intestinal Failure: Our Experience. JPEN J Parenter Enteral Nutr 2018; 43:412-418. [DOI: 10.1002/jpen.1433] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/11/2018] [Indexed: 01/27/2023]
Affiliation(s)
- Fabrizia Chiatto
- Department of Translational Medical Sciences; Section of Paediatrics; University Federico II; Naples Italy
| | - Riccardo Coletta
- Department of Paediatric Surgery; Royal Manchester Children's Hospital; Manchester United Kingdom
- Paediatric Autologous Bowel Reconstruction and Rehabilitation Unit; Royal Manchester Children's Hospital; Manchester United Kingdom
| | | | - Tracy Warburton
- Department of Therapeutic and Specialised Play; Royal Manchester Children's Hospital; Manchester United Kingdom
| | - Lynette Forsythe
- Department of Dietetics and Nutrition; Royal Manchester Children's Hospital; Manchester United Kingdom
| | - Antonino Morabito
- Department of Pediatric Surgery; Meyer Children's Hospital; University of Florence; Florence Italy
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Gardiner AY, Vuillermin PJ, Fuller DG. A descriptive comparison of approaches to paediatric tube weaning across five countries. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2017; 19:121-127. [PMID: 27333201 DOI: 10.1080/17549507.2016.1193898] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 04/23/2016] [Indexed: 06/06/2023]
Abstract
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.
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Affiliation(s)
- Alison Y Gardiner
- a Occupational Therapy Department , Barwon Health , Geelong , Australia
| | - Peter J Vuillermin
- b Children Services, Barwon Health , Geelong , Australia
- c School of Medicine Deakin University , Geelong , Australia
- d Child Health Research Unit , Barwon Health , Geelong , Australia , and
- e Murdoch Children's Research Institute , Melbourne , Australia
| | - David G Fuller
- b Children Services, Barwon Health , Geelong , Australia
- c School of Medicine Deakin University , Geelong , Australia
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Krom H, de Winter JP, Kindermann A. Development, prevention, and treatment of feeding tube dependency. Eur J Pediatr 2017; 176:683-688. [PMID: 28409284 PMCID: PMC5432583 DOI: 10.1007/s00431-017-2908-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 04/04/2017] [Indexed: 11/29/2022]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Hilde Krom
- Emma Children's Hospital, Box 22666, 1100 DD, Amsterdam, The Netherlands.
| | - J. Peter de Winter
- 0000 0004 0568 6419grid.416219.9Spaarne Hospital, Box 770, 2130 AT Hoofddorp, The Netherlands
| | - Angelika Kindermann
- 0000 0004 0529 2508grid.414503.7Emma Children’s Hospital, Box 22666, 1100 DD Amsterdam, The Netherlands
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Abstract
OBJECTIVES The present study highlights the occurrence of unintended adverse effects of enteral nutrition in infancy and childhood, as viewed and reported from a parental perspective. METHODS Quantitative analysis of a standardized questionnaire, filled out online by parents of enterally fed children. The questions focused on the nutritive and nonnutritive adverse effects, and other medical and biometric data. Data were collected from January 1, 2009 to December 31, 2013. RESULTS The study cohort consisted of 425 infants and children with different underlying medical conditions and an average age of 2.17 (median = 1.63) years. Nasogastric tubes were used in 44.2% of all the patients, and 55.8% of the children were fed by percutaneous endoscopic gastrostomy tube. Nearly all of the children have been tube-fed since birth. A total of 56.0% of all tube-fed children showed regular gagging and retching episodes, 50.0% vomited frequently, 14.8% experienced nausea, 7.5% experienced extreme nervous perspiration during the feeding, 45.2% showed loss of appetite, 5.2% experienced local granulation tissue, and 1.9% had other skin irritations. No significant correlations could be found between age, sex, medical diagnoses, type of feeding tube, feeding schedules (bolus or continuous), and parental and child's behavior regarding the feeding situation and duration of tube feeding. CONCLUSIONS Enteral nutrition affects the child and the whole family system on more than just nutritional level. It is suggested that children and their families should be followed-up by health professionals periodically for nutritional optimization, growth documentation, and other aspects of tube management.
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Nutritional/Growth Status in a Large Cohort of Medically Fragile Children Receiving Long-Term Enteral Nutrition Support. J Pediatr Gastroenterol Nutr 2016; 62:157-60. [PMID: 26237372 DOI: 10.1097/mpg.0000000000000931] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of the present study was to assess the nutritional status and growth of medically fragile children receiving long-term enteral nutritional support (ENS). METHODS A retrospective cross-sectional survey was conducted at a tertiary-level pediatric hospital. Growth features and nutritional intake of children (n = 287) receiving ENS were evaluated. During a period of 5 years (2009-2013), study patients in the age group of 1 to 36 months had been referred for the explicit reason of tube weaning. Data were documented with the help of ARCHIMED (version 46.2) and analyzed using SPSS for Windows version 21. Nutritional/growth status was determined by using World Health Organization growth standard tables. RESULTS Anthropometric parameters of children were compared with World Health Organization standards, and the prevalence of underweight, wasting, and stunting was very high despite being exclusively or predominantly on ENS. Results revealed that the age of a child, inadequate amount of caloric supply/day, the diagnosis of small-for-gestational age, and the type of tube (nasogastric tube) were significantly associated with growth/nutritional status (P < 0.05). Duration of ENS in the percentage of the cohort's lifetime and the main diagnosis were not associated with nutritional/growth outcomes. CONCLUSIONS In medically fragile children, ENS does not ensure adequate growth per se. ENS requires highly specialized and individually tailored management and in many cases regular adjustments. Long-term tube feeding plans often seem unable to ensure the required amount of nutritional support, which surely compromise the individual efficacy of ENS.
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21
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Abstract
BACKGROUND Children with congenital malformations, mental retardation, and complex early medical history frequently have feeding problems. Although tube feeding is effective in providing the necessary energy and nutrients, it decreases the child's motivation to eat and may lead to oral aversion. In this study, we sought to confirm our previous results, showing that a multidisciplinary clinical hunger provocation program may lead to quick resumption of oral feeding. METHODS In a crossover study, 22 children of 9 to 24 months of age who were fully dependent on tube feeding were randomly assigned to one of two groups: group A, intervention group (2-week multidisciplinary clinical hunger provocation program); and group B, control group (4-week outpatient treatment by the same multidisciplinary team). Patients failing one treatment were reassigned to the other treatment group. Primary outcome measures were at least 75% orally fed at the conclusion of the intervention and fully orally fed and gaining weight 6 months after the intervention. RESULTS In group A, 9/11 patients were successfully weaned from tube feeding (2 failures: 1 developed ulcerative colitis, 1 drop-out). In group B, only 1 patient was weaned successfully; 10/11 were reassigned to the clinical hunger provocation program, all being weaned successfully. Six months after the intervention, 1 patient had to resume tube feeding. In total, in the control group, 1/11 (9%) was weaned successfully as compared with 18/21 (86%) in the hunger provocation group (P < 0.001). CONCLUSIONS Multidisciplinary clinical hunger provocation is an effective short-term intervention for weaning young children from tube feeding.
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Marinschek S, Dunitz-Scheer M, Pahsini K, Geher B, Scheer P. Weaning children off enteral nutrition by netcoaching versus onsite treatment: a comparative study. J Paediatr Child Health 2014; 50:902-7. [PMID: 24946136 DOI: 10.1111/jpc.12662] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2014] [Indexed: 12/14/2022]
Abstract
AIM The Graz model of tube weaning has been internationally recognised as a successful and rapid tube weaning program. Beside the onsite treatment option, a telemedical counselling was specifically developed in 2009. This study aims to show outcomes of this newly invented treatment in a large sample of patients. METHODS Our retrospective open-label study compared success of onsite versus telemedical Graz-based weaning methods for patients with diverse clinical diagnoses with either nasogastric, gastric or jejunal tubes. Outcome variables were successful transition to oral feeds, partial transition to night tube feeds, and failure or interruption of intervention. Patients and physicians chose the intervention method. RESULTS Complete weaning was achieved in 153 of 169 (90.5%) children in the netcoaching group versus 170 of 209 (81.3%) of those opting for onsite treatment (no significant differences, P > 0.05). Higher partial weaning rates were observed in the onsite group (15.3% vs. 4.7%, P < 0.01, degrees of freedom = 3, χ(2) = 22.76). There were no significant differences regarding the outcomes 'weaning trial without success' (netcoaching: 0% vs. onsite: 2.9%, P > 0.05) and 'interruption of programme' (netcoaching: 4.7% vs. onsite: 0.5%, P > 0.05) between the two groups. CONCLUSION Despite limitations of study design, we have demonstrated similar efficacy of Graz-based less expensive netcoaching versus more expensive onsite intervention in a large referral population with chronic tube dependency with the majority transitioning to complete oral feeds.
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Affiliation(s)
- Sabine Marinschek
- Department for General Paediatrics and Psychosomatic, Medical University of Graz, Graz, Styria, Austria
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Abstract
This article describes the Two Week Intensive Feeding Program for Tube Fed Children at Seattle Children’s Hospital. The program uses a hunger-based model of treatment to wean children from tube dependence to oral feeding. It occurs as an outpatient, day treatment program over a 2-week period. The first phase is a multidisciplinary preprogram evaluation to determine the child’s suitability for enrollment in the program. Once the child is accepted into the program, significant calorie reduction occurs over the 4 days prior to beginning the on-site program. During the 2-week intensive phase, further caloric reductions may occur and both child and family are supported to learn new patterns of eating and mealtime structure. After completing the program, the follow-up phase includes appointments at 2, 5, and 9 weeks postcompletion. Several of the issues typically encountered will be highlighted through a detailed case study report of a child with developmental disabilities. Interventions contributing to the success of the 2 Week Intensive Feeding Program will be emphasized.
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