Ideas for Transitioning off of a G-tube

When a child is referred for feeding therapy to transition off of a feeding tube, what is the best intervention strategy?

 

The best answer is the one that works in the most efficient way possible! In all honesty, there is no standard approach to transitioning off of a feeding tube. There are many different approaches that range from:

 

• reducing tube feeding volumes to encourage hunger

• using medical and nutritional strategies

• manipulating tube feeding schedules

• oral-motor/sensory therapy techniques to encourage intake

• behavioral feeding techniques to encourage intake

 

In these blog post, I will discuss some techniques that we have used successfully in our feeding clinic using a medical,motor, and behavioral philosophy to help children wean from their feeding tubes.

 

Thoughts before you begin therapy:

 

Why did the child receive the feeding tube?

 

It is important to understand why the child received the feeding tube initially. Many children require a feeding tube because they do not eat or drink enough to meet their caloric needs. Many of these children had difficulty taking in the volume of calories needed and ended up with a diagnosis of failure to thrive which is the point a feeding tube is often recommended. There are other reasons for children to require a feeding tube that might include; poor weight gain and growth, periods of non-oral feeding due to medical issues, needs for medication administration or secondary to dysphagia and inability to protect their airway during swallowing.

 

Determining if a child can safely swallow to work on oral food acceptance. When to order a modified barium swallowing study (MBSS)?

 

Prior to starting feeding therapy, the clinician must complete a thorough medical history and oral motor/swallowing assessment to determine if the child can swallow safely and if there is risk for aspiration. Important information can be gained from looking at how well the child handles his or her saliva, observing the child swallow water or a thin liquid and foods, and listening to the child’s vocal quality. The child’s pulmonary history should also be considered and assessed for pneumonia, bronchitis, asthma-like symptoms, and congestion which can (but not always) indicate aspiration.

 

Many children have intact swallowing function and have received g-tubes simply because they have difficulty taking in volume or simply put do not eat enough. If the child appears to have a functional swallow, then therapy to increase acceptance of food can begin.

 

If a child has clinical signs of aspiration during the swallowing exam, is at risk based on their medical history, or is medically fragile, then a referral for a MBSS should be initiated. Examples, might include a child with vocal cord dysfunction or prolonged intubation or a child with a tracheostomy. In those cases, we would proceed with the MBSS knowing that the test may not be completely accurate if the child is upset and refuses to accept food or liquid orally but it will give us some information about the child’s oral pharyngeal function.

 

I would not recommend a modified barium swallow study (MBSS) before starting feeding therapy for the sole reason that the child is not eating. I have been on the receiving end of these referrals and it is very difficult to do a MBSS on a child who does not eat. Again, a MBSS is for the child at risk for aspiration or for a child presenting with signs of aspiration. For some children, we anticipate needing a MBSS but work with them first with a goal of acceptance of small volumes orally. This is done in hopes of getting better cooperation from the child during the MBSS for improved accuracy.

 

Once it has been determined that the child can swallow and is ready to begin therapy, where should you start?

The strategies we utilize to encourage the transition from tube feeding to oral feedings promote “gut comfort” and the idea of making eating easier for the child. If a child feels good from a GI standpoint, the child will have a better response to therapy that encourages oral feeding. Here are some of the strategies we have utilized:

 

1) The use of continuous tube feeding to promote gut comfort.

 

• Many of the children we work with have feeding tubes because they had difficulty eating enough or another way to say it is difficulty handling volume. These are children who have a history of grazing behavior or volume limiting. We often see that some of these children, who ate prior to having their feeding tubes placed, stop eating after the tube simply because they are now being fed either too much volume or fed at a rate that is too fast.

• Manipulation of tube feeding schedules to allow the child a portion of time off the feeding tube to allow the child time to practice oral feeding.

• It is difficult to practice oral feeding when a child is being fed every 3-4 hours. It is a common therapeutic strategy to offer oral feeds prior to the tube feeding. Many of the children we see have failed that trial before they come to us.

   
  

Strategy:(tube feedings are always manipulated with the medical team including a dietician).

 

• Feed through the tube using continuous feeds allowing a period of time off the tube feeding to work on oral feeds. Caloric needs will be individual to the child. This might be 12, 14, 16, or even 24 hours feeds. Some children will benefit from a combination of slow feeds at night and small boluses spread throughout the day. Or slow feeds at night and small oral feeds during the day.

• Our goal is tolerance of the tube feeds and to allow a portion of time off during the day to work on oral feeding (if possible).

• Many parents feel they are going backward by going to continuous feeds or slower feeds. We explain the rationale of the recommendations. As in any therapy feeding interventions are trial and error. Some children can remain on bolus feeds but if a child has tried bolus feeds and therapy is not progressing, continuous feeds may be an option.

   
  

* Some times parents will say they are told that continuous feeds are not “normal” and that by achieving bolus feeds, the child is on a more “normal” schedule. That is fine if it is working toward the goal of oral intake. I point out that it is “not typical” to require a feeding tube. I would speculate that the motility and GI function and sensitivity of many of our tube feeders is also “not typical”.

 

2) The use of predigested formulas to promote comfort, efficient gastric emptying, reduce intolerance.

• Many of our tube fed patients have a history of reflux, constipation, motility problems, or intolerance. Some ate a little bit before they received their g-tubes.

 

Strategy: (formulas are always manipulated with the medical team including a dietician).

 

• Use predigested or hydrolyzed formulas that often are better tolerated through the tube. These formulas often reduce reflux, improve motility and/or tolerance, and may promote stooling.

 

3) The use of medical management to promote comfort, appetite, efficient gastric emptying, reduce intolerance.

 

• You can look back at some of my posts on GI strategies to get more info here. This involves medications for GERD, stooling, motility, pain, and appetite.

 

Strategy: (medications are always manipulated with the medical team).

 

• I will highlight one medical strategy that can be very helpful in improving intake which is the use of an appetite stimulant. There are several medications used to stimulate appetite but the one we use most often is periactin or cyproheptidine (http://en.wikipedia.org/wiki/Cyproheptadine) This is an antihistamine that has a side effect of stimulating hunger. I plan on writing an entire post dedicated to this strategy.

• I’ll summarize here by what I have learned from our GI team. They feel it is best used after establishing comfort. It may be contraindicated to stimulate appetite if a child is vomiting, retching or feeling pain in the GI tract. And because one of the most common side effects is sleepiness, our GI practitioners typically start the medication at night before adding in day time doses or the child may be too sleepy during the day. We have seen children double their intake with the use of periactin. Like all medication there are side effects. It does not work for every child but many have favorable responses to it.

 

4) The use of behavioral feeding strategies to increase food acceptance.

 

• After the child is comfortable from a GI standpoint, swallowing has been cleared, and weight and growth is stable, then feeding therapy can begin to address intake. When the goal is to move from tube feedings to oral feedings, one can assume the child has limited or decreased experiences with eating. Therefore therapy should operate with the ideas that feeding should be easy, successful, and something to build upon.

 

Strategy: (the most efficient was to move children off of a feeding tube is to work on liquid and puree intake).

 

• In therapy, use behavioral reinforcement strategies to improve acceptance of liquids and food.

• Emphasize acceptance of formula (what is going into the tube feeds of possible or the equivalent) and purees or mashed foods. If the child can orally drink the formula, that is a direct caloric and nutrient equivalent to the tube feeds and can be subtracted from tube feedings (if weight is stable and medical team agrees).

• Puree acceptance is typically easier for children to manipulate with a faster oral transfer allowing the child to take more volume in less time. This can mean jarred purees or homemade pureed foods.

• Therapy can address chewing as well, however, it can take many months to years for a child to develop the strength and coordination required for chewing an entire meal of table foods. If the goal is to reduce dependence on the tube, work on liquids and purees, and a little chewing on the side.

• Finally, if the child is stuck, consider an intensive feeding program where a team can work with child daily for a period of time to improve acceptance. More to come on intensive feeding team in another post.

 

Summary

 

There are many philosophies and strategies to move children from tube feeding dependency to oral feeds. The right one is the one that works for that child and family. These ideas are based on the use of a medical, motor, and behavioral approach. Consider these ideas to help you:

 

• GI comfortable through the use of slow feeds, predigested formulas, and medications to promote comfort and appetite.

• Therapy to improve consistent acceptance.

• Know the caloric, nutrient, and hydration needs of the child to help formulate goals.