Discontinuation of enterostomy tube feeding by behavioral treatment in early childhood: A randomized controlled trial

doi:10.1067/mpd.2000.108397

The Journal of Pediatrics

Volume 137, Issue 4, October 2000, Pages 498-503

https://doi.org/10.1067/mpd.2000.108397 Get rights and content

Abstract

Objective: To determine whether behavior therapy was more effective than nutritional therapy in obviating the need for enteral feeding in infants with resistance to feeding. Study design: Sixty-four children aged 4 to 36 months who were tube fed for at least 1 month and had resistance to feeding were randomly assigned to either behavioral or nutritional interventions (32 per group). For 7 consecutive weeks subjects and their primary feeders attended a weekly clinic with 1 of 2 dietitians followed by 4 follow-up visits. The nutritional intervention provided structured schedules and routines to stimulate the hunger/satiety cycle. The behavioral intervention provided the same schedules and routines plus behavioral therapy (extinction). The primary outcome measure was the proportion of successes, defined as infants no longer requiring tube feeding at the third follow-up visit in each group (4½ months after start of trial). The decision to discontinue tube feeding was made by an independent observer who used criteria defined before the study commencement. Results: Fifteen (47%) of 32 subjects in the behavioral group versus none in the nutritional group were successes (P <.001). Conclusion: Behavior therapy is more efficacious in eliminating the need for tube feeding than nutritional counseling alone. (J Pediatr 2000;137:498-503)

Section snippets

Subjects

Infants aged 4 to 36 months who were fed by gastrostomy or gastrojejunostomy tubes for ≥1 month and had resistance to feeding were eligible. Resistance to feeding was defined (by parental report) as (1) food refusal ≥25% of the time during each meal for ≥1 month’s duration and ≥1 problem behavior at mealtimes or (2) no attempts at oral feeding for ≥1 month because infants resisted such attempts. Resistance to feeding was then categorized into mild, moderate, or severe based on a trained

Results

At the third follow-up visit, 15 (47%) of 32 patients in behavioral therapy and 0 (0%) of 32 in nutritional therapy were no longer dependent on tube feeding (χ² = 19.6, P =.0001; Table II).

. Successes per group at each follow-up visit

Follow-up visit No.*	No. of successes (%)^†
Follow-up visit No.*	Behavioral intervention	Nutritional intervention	P value
1	4 (13)	0 (0)	.04
2	8 (25)	0 (0)	.002
3	15 (47)	0 (0)	.000
4	15 (47)	2 (6)	.000
^†Defined as enterostomy tube feedings not needed for ≥1 month before the visit and weight maintenance or

Discussion

This study demonstrates that a behavioral intervention is more efficacious than a nutritional intervention alone in eliminating the need for enteral tube feeding in infants with resistance to feeding. An increasing number of infants who survive because of advances in medical technology require enteral tube feeding to meet their nutritional needs but develop resistance to the reintroduction of oral feeds. Thus the availability of this treatment option could have a positive impact on the quality

Acknowledgements

We thank the study participants and Derek Stephens, MSc, statistician in the Division of Clinical Epidemiology, The Hospital for Sick Children, for his assistance with data analysis.

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Nowak-Cooperman & Quinn-Shea state the child must be medically able to sustain a 5–10% weight loss as well as tolerate a period of sub-optimal caloric intake and reduction of optimal fluid intake [33]. Tube weaning programs include inpatient hospital programs, which comprised the majority of articles reviewed [19–21,23–25,27,29,31–36], as well as day treatment or intensive outpatient programs [26,28], less intensive outpatient programs [3,21,22,36–39], home-based or ‘netcoaching’ programs [10,30,40], and outpatient programs with video support [18]. The duration of programs was variable, but our review of studies indicated that many programs lasted 2–4 weeks [10,14,19,21,27,29,31–34,36].
Feeding support via nasogastric or gastrostomy tube is a common feature of care for children with congenital heart disease; however, prolonged tube feeding can lead to tube dependency and related long-term impacts on development and health.
we reviewed the literature in order to characterize the state of the science on tube weaning programs in children with congenital heart disease.
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To determine the effectiveness of intrapyloric botulinum toxin injection (IPBI) for treatment of feeding disorders and associated gastrointestinal symptoms in very young children.
A single-center retrospective study of patients 2 months to 5 years old who received IPBI at Boston Children's Hospital from May 2007 to June 2019 was performed. Charts were reviewed for demographic data, comorbidities, symptoms leading to IPBI, oral and tube feeding data, symptom improvement after IPBI, and need for repeat injections. The primary outcome was symptom improvement at the first gastroenterology clinic visit following IPBI. Secondary outcomes included improvement in oral feeding, decreases in tube feeding, and need for repeat injections. The χ² or Fisher exact tests and multivariate logistic regression were used to identify factors associated with symptomatic improvement.
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IPBI is safe and effective in young children. Children with enteral tubes show improvement in oral feeding and reduction in need for postpyloric feeding after IPBI.
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Children on long-term tube-feeding often need special treatment for oral feeding transitioning. Rapid tube-weaning programs usually result in short-term reductions in food intake and weight loss. This study examined the long-term effects of a “Graz-model” based weaning program on nutritional status and growth.
Children aged 0.5–13.0 years on long-term enteral nutritional support (ENS) participated in a three-week multidisciplinary weaning treatment. Data were collected at baseline, after completing the program, and at six and 12 months. Height/length, weight and BMI z-scores were determined according to the WHO growth standards. Energy and protein intake were assessed and presented as % of recommended daily allowance (RDA) values.
Study participants (n = 58) were 64% male. Four children did not complete the three-week program due to acute illnesses. Complete weaning (from 100% ENS to 100% oral) was achieved in 22 children and partial weaning (at least 80% reduction of ENS) in 23 children. No demographic or clinical success predictors were identified. Thirty of the 45 weaned children completed the 12-month follow-up. A significant reduction in energy intake was observed at the three-week time-point [mean (SE): 56 (5.8)% versus 80 (4.7)%, p = 0.001]. This was followed by improvements in eating skills leading to energy intake at 12 months which did not significantly differ from baseline (p = 0.392). Mean (SE) baseline protein intake was 187 (13.0) %RDA. No significant difference from baseline were noted at 12 months (p = 0.301). Estimated mean (SD) height-, weight- and BMI z-scores at baseline were −2.11(0.28), −1.48(0.25), −0.13(0.31), respectively. No significant differences in growth data were observed over time.
Short-term reductions in nutritional intake and body weight observed after an intensive weaning program were reversible, and growth patterns were stable over 12 months. Further follow-up is recommended to ensure continued positive development in these children.
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A systematic review (SR) by Sharp et al. (2017) [11] reporting on 593 children included 6 studies regarding appetite manipulation with success rates of 44–90% at discharge [5,11,12,24,30,36,37]. Other studies not included in the SR using appetite manipulation showed short-term success rates varying from 47 to 100% [2,3,7,13,14,23,38–42]. Especially considering the high rate of previously unsuccessful other interventions to wean these challenging patients, these short-term efficacy rates may be considered to be high [24].
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^☆: Supported by grants from the Medical Research Council of Canada, The Ontario Mental Health Foundation, and the National Health and Research Development Program.

^☆☆: Reprint requests: Diane Benoit, MD, Department of Psychiatry, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, M5G 1X8, Canada.

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Original ArticleDiscontinuation of enterostomy tube feeding by behavioral treatment in early childhood: A randomized controlled trial☆,☆☆

Abstract

Section snippets

Subjects

Results

Discussion

Acknowledgements

J Am Acad Child Adolesc Psychiatry

J Am Diet Assoc

J Am Acad Child Adolesc Psychiatry

Am J Clin Nutr

J Am Acad Child Adolesc Psychiatry

Feeding problems in infancy and early childhood: identification and management

J Paediatr Child Health

Feeding disorders, failure to thrive, and infant obesity

Post-traumatic feeding disorders in infancy: Behaviors predicting treatment outcome

Infant Ment Health J

Food refusal after an incident of choking: a posttraumatic eating disorder

J Am Acad Child Adolesc Psychiatry

Gastrostomies: indications, management, and weaning

Infants Young Children

Factors associated with the transition to oral feeding in infant fed by nasogastric tubes

Am J Occup Ther

Traumatically acquired conditioned dysphagia in children

Ann Otol Rhinol Laryngol

Feeding resistance and gastroesophageal reflux in infancy

J Pediatr Gastroenterol Nutr

Swallowing training for dysphagic patients

Arch Phys Med Rehabil

Original Article
Discontinuation of enterostomy tube feeding by behavioral treatment in early childhood: A randomized controlled trial☆,☆☆