https://allyoucaneat.co.nz/blog/2019/11/11/progressing-from-tube-feeding-to-eating-tube-weaning-evidence-for-current-treatments  

Intensive tube weaning: Learn about empirically-supported treatments for tube weaning and paediatric feeding disorders/ARFID by Dr. Sarah Taylor (Leadley) 

WHAT IS TUBE FEEDING OR TUBE DEPENDENCY?

WHAT CAN HELP A CHILD PROGRESS FROM TUBE FEEDING?

This is a summary of a review article we published in Speech, Language, and Hearing. Our review focused on looking at the evidence across different treatment options for transitioning children from tube feeding to eating (commonly known as tube weaning). The article can be accessed here.

You can also see information about the Ready to Eat intervention here (or Research tab above).

WHAT WE DID

• We searched the literature to find studies that focused on using treatment for children dependent on feeding tubes (NG or G tubes)

• Studies could be from any country, and could have taken place in a hospital type setting, outpatient clinics, or homes.

• We sorted studies by type of treatment, and recorded information about the children involved, the specific methods used, and outcomes of treatment (like if tube feeding reduced, if behaviours during the meal improved)

Generally, treatment options were one of three types: Behavioural, Hunger Provocation, or a combination of the two.

Behavioural Treatment

Behavioural approaches consider that eating (or, not eating) is a learned behaviour (or, skill) and that certain events in the mealtime situation can have an impact. Therefore, behavioural treatments involve highly structured meatime sessions, usually run by a team of trained therapists. The child’s behaviour is directly observed and measured (e.g., how many bites eaten) to inform the ongoing treatment process. Tube feeding is generally reduced after the child increases their intake during meals.

Behavioural treatments may involve reinforcement (rewards) provided after eating, such as praise or access to preferred toys. Changes may be made to foods, utensils or feeding methods to reduce the effort of eating. In many cases, extinction is also used (keeping food present until it is accepted).

Hunger Provocation

The underlying assumption of hunger provocation is that hunger provides the primary motivation for eating, and continued tube feeding prevents the child from increasing oral intake. Therefore, hunger provocation programmes try to quickly reduce tube feeds, often over a few days. Mealtimes may take place as a part of a ‘play picnic’ which is child-led, or be more adult-led, where the parent feeds the child and models eating.

Combination Treatments

Some studies combine the above approaches. This means that tube feeds are still reduced quickly, while meals involve behavioural procedures.

SUMMARY OF EVIDENCE

• All treatment approaches reported positive changes for at least one kind of treatment outcome.

• Studies using hunger provocation reported large numbers of children weaned from tube feeding, but did not provide information about oral consumption (e.g., calories consumed) or variety. Weight loss was also reported with this approach.

• Behavioural treatments reported significant gains in oral consumption and improvement in mealtime behaviours but there were less reports of children being tube weaned. Behavioural studies often involved children with very complex and severe feeding difficulties, and many had developmental disabilities.

• Studies using a combination of hunger provocation and behavioural methods showed a number of children weaned from tube feeding, with oral consumption improving. However there was variation in how tube feeds were reduced, and the exact behavioural procedures used.

• Detailed information about the children accessing certain treatments was often not detailed. Therefore it is difficult to determine what treatment may be best for an individual child. There also needs to be more consistent reporting of the changes that occur after treatment, including looking at the longer-term (e.g., if the child remains off the tube, with growth improving).

GENERAL RECOMMENDATIONS FOR TREATMENT

Besides differences in the approach that can be used, these key areas were important:

• A multidisciplinary team is vital in treatment. Generally, the team should include a paediatrician, dietitian, psychologist (Board Certified Behavior Analyst), and speech language therapist.

• A high level of treatment intensity is needed, at least over a few weeks. This involves multiple meals per day, over consecutive days. If this is not possible initially, a less-intensive approach can be attempted (e.g., weekly clinics), but intensive options should be considered if there is no progress within 3 to 6 months.

• Parents or caregivers need to be highly involved in treatment, and receive effective training to continue running meals for their child.

FOR PARENTS OR CAREGIVERS

You can evaluate the options available by: looking for research, looking for unbiased information, and asking questions of your potential treatment provider. There are some excellent questions here, including:

“What is the theory behind this treatment?” “Have studies been done?”

“How will we know if this is working?” “How will that be measured?”

“How long might it take?” “What is the time investment?”

“Do you have any anonymous data from other children to show the effects of this?”

“What are the possible side effects?”

“How will treatment be matched to my individual child/family?”

Click here for link to this research article