Feeding tubes are recommended for a variety of reasons. The most common being for a child who has a history of poor weight gain and growth or has a medical condition making the transition to oral feeding slow or difficult. Parents have many concerns and fears about placing a feeding tube that often include, “Will my child stop eating by mouth?”, “Can my child still eat by mouth?”, or “How long will my child have a feeding tube?”
The fear that a child will stop eating after a tube is placed is valid. In truth, I have seen many children who have stopped eating after receiving a feeding tube but not all do. I believe there are some important contributing factors as to whether a child will continue to eat by mouth after tube placement that should be considered. Of course, each child is unique and a feeding plan should be individualized to the child. This is not a one size fits all.
Oral feeding is too much work. For some children, oral feeding is effortful and may feel stressful or cause pain. Therefore, after a feeding tube is placed, the child may have reduced desire to orally feed. In these cases, some children may do better if they have a period of time where they are not pushed to feed by mouth but are offered food and liquid in a less stressful environment. We would take the approach of knowing that we can meet their nutritional needs via tube and allow them to have positive feeding experiences to build on instead of having to push them to eat. We would use medical, nutritional, and therapeutic strategies to encourage oral feeding.
Over feeding with the tube causing reflux and discomfort. In an effort to improve weight gain and growth, and meet caloric needs, many children are overfed by tube feeding or fed too fast which causes them to have reflux, vomiting, and discomfort. They stop orally feeding because they associate tube feedings with discomfort. In my opinion, this is the main reason children stop eating by mouth. The child’s history of intake should be considered when developing a tube feeding schedule.
Tube Feeding- bolus or continuous or some combo? There is debate as to how best to use a feeding tube to meet a child’s caloric needs. The most important factor is the child’s comfort with the tube feeding schedule. Some clinicians argue that a “bolus feeding schedule” is more normal because it mimics an oral feeding schedule with periods of fullness and emptiness and allows the child to develop hunger cues. This can be a successful strategy if the child tolerates their tube feedings. However, if the child is uncomfortable with tube feedings (coughing, vomiting, retching, gagging, bloating, irritability, etc), then this will not help a child transition to oral feeding. If a child has underlying motility problems, they may be more comfortable on continuous feedings or slow bolus or a combo of the two. The child has to be comfortable with tube feeds to want to eat by mouth.
Medicines and Formulas. We manipulate medicine, formula and rate to establish “gut comfort”. The choice of formula and use of GI medicines can increase success with the tolerance of tube and oral feeds. This can assist with transition back to oral feeds. Medical management can help with motility, comfort and boost appetite. We also tend to choose predigested formulas which can reduce reflux and improve motility as well as now having the option of the often better tolerated real food blenderized formulas (either homemade or now 2 options are available pre-made and packaged). We also look at the rate at which tube feeding is delivered. In some cases we also consider different types of tubes or placement of tubes.
Allowing time to orally feed. This can be difficult to establish but many children need to have periods of time off the tube to successfully feed by mouth. We often call this developing “hunger” but some of our patients do not know true hunger and I think of of it as a period of being empty and then feeling comfortable with oral feedings. This could involve a variety of different schedules:
- continuous tube feeds at night and off during the day.
- bolus tube schedule, offering oral feeds first.
- bolus tube schedule with a longer break between feeds to allow oral feeding.
- continuous tube feeds at night and reduced day bolus or slow bolus.
- some children will feed on top of a tube feed as well.
A few final thoughts. Most of what I have described above can be done with a feeding therapist and physician or dietician support. Other options would include some type of more intensive program that can assist with transition to oral feeding. Intensive feeding programs allow the child to work with a team multiple times per day over a period of weeks or months. They are all different and should be researched and chosen based on the program’s philosophy. Some use primarily a behavioral approach while others combine sensory therapy, appetite manipulation and/or behavioral techniques. Some therapists consider them to be aggressive or harsh and the truth is some are and some are not. There are also programs and plans that involve rapid tube weaning where the feeds are cut in large volumes under supervision of a medical team as the child transitions to oral feeding.
Lastly, there are some children who will never come off their feeding tubes because of medical issues or severe dysphagia and if tolerated their plan may include “therapeutic feeds” or oral feeding in small amounts for pleasure.
Take home points:
- Weight and growth come first in the feeding plan even if that involves using a feeding tube.
- Use the tube thoughtfully to promote not only weight gain but comfort.
A feeding tube can provide support to ease the child’s need to take in calories and allow the child time to work toward oral feeds.
- If possible, allow the child some time off the tube to work on oral feeding.
- Medical and Nutritional strategies can greatly assist with comfort and desire and transition off the tube.