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FEEDING TUBE WEANING                SydneyMarkus Wilken                Saturday 12 Nov.Germany         Novotel Sydney Manl...
PEDIATRIC TUBE FEEDING:                       THE BENEFITS•   Protection from aspiration in children with dysphagia (2)•  ...
PEDIATRIC TUBE FEEDING:                                 THE PROBLEMS•   Major (5%) and minor (73%) complications (5)    • ...
BASIC DOMAINS OF ORAL FEEDING                   WHAT DO WE NEED TO EAT?•   Oral-motor and sensory development•   Motor dev...
TUBE FEEDING & FEEDING       DISORDER How does tube feeding result in Feeding Disorder?
IMPACT OF FEEDING DISORDER   ON FEEDING BEHAVIOR•   Oral-motor and sensory development     • Reduces swallowing activity, ...
WHAT IS A FEEDING DISORDER?…a good question! Because:There are no universally accepted definitions or validated classificati...
DIAGNOSTICPROTOCOLReady for the wean?
THE DIAGNOSTIC MAINFRAMEA feeding behavior does not become a “feeding problem“  until it does not meet the expected perfor...
EXPECTED PERFORMANCE FOR…                      None   Minimal     Medium    Normal   High     Swallowing         □       □...
INTAKE•   Phone conference with parents    •   Tell me about your child!    •   What is the problem?    •   Medical condit...
QUESTIONNAIRE•   Tube and oral feeding characteristics•   Feeding Schedule•   Weight, length, BMI•   Feeding Disorder Symp...
FEEDING VIDEO ANALYSIS    What we need:•   Feeding Situation (ca. 5 Minutes)•   Child and Parent are visible    Assessment...
ANALYSIS OF MEDICAL REPORTS•   Indication for tube feeding?•   Possible medical complication during weaning    •   Hypogly...
WHAT IS THE PROBLEM?•   How can the problem be explained?•   Is it a feeding disorder/tube dependency?•   How much varianc...
PREPARATION• Assessment interview• Regular Follow-ups• Interventions   • Play   • Enjoy   • Adapted tube feeding   • The G...
Treatment
THEORETICAL ASSUMPTIONS•   Eating and drinking is self-regulated•   The self-regulation capacity is suppressed by tube fee...
HUNGER INDUCTION                 Before     day 1     day 2    day 3   day 4   day 510. am            130        50       ...
WHERE TO START?•   Playing, playing, playing…simply playing    •   Child shows competencies and deficits    •   Child leads...
PLAY PICNIC                       LET THE CHILDREN PLAY•   Anything goes:    •   Children define the rules    •   All initi...
IN THE FEEDING SITUATION•   Where? Everywhere:    •   on the floor, in the high chair, in the park, in the restaurant, in t...
PSYCHOLOGICAL FEEDING THERAPY•   If the child doesnt speak…    •   Communicate with gestures, mimicry, body    •   Answer ...
WHEN CHILD REFUSE COMPLETELY•   Acceptance of food refusal to reduce stressful feeding situations•   Observe and discuss t...
WHEN FEEDING STARTS•   Rearrange the feeding situation to avoid refusal triggers•   Make the feeding situation more comfor...
MAIN FRAMEWORK•   Home-based treatment means:    •   Treatment at the childs environment    •   In the childs circadian rh...
FOLLOW-UP & EVALUATION         12   11        Diagnostic                        Preparation                        Intensi...
FOLLOW UP (SIX MONTHS)•   Regular contact by phone for 4 weeks    •   One conference per week•   Daily contact possible fo...
TUBE WEANING IN EARLY              CHILDHOOD                    LONGITUDINAL OUTCOME•   Involved N=57/Excluded from the pr...
FEEDING BEHAVIOR                                                                                          Failed          ...
GROWTH AND TUBE FEEDING                                                         Before                      After         ...
COMPARISON HOME-BASED INPATIENT          TREATMENT                            Home-based          Inpatient Treatment grou...
FURTHER INFORMATION:Markus WilkenHohlweg 4D-53721 Siegburgmail@markus-wilken.dewww.spectrumpediatrics.com
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Wilken Pediatric Feeding Tube Weaning

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Wilken Pediatric Feeding Tube Weaning

  1. 1. FEEDING TUBE WEANING SydneyMarkus Wilken Saturday 12 Nov.Germany Novotel Sydney Manly Pacific
  2. 2. PEDIATRIC TUBE FEEDING: THE BENEFITS• Protection from aspiration in children with dysphagia (2)• Ensure caloric/fluid supply and weight gain (3)• Gives families a break from stressful feedings(4)• Non-palatable medication can supplied via tubeMost important: Ensure survival of critically ill children
  3. 3. PEDIATRIC TUBE FEEDING: THE PROBLEMS• Major (5%) and minor (73%) complications (5) • Major: Septicemia, /Minor: Tube leakage (60 %)• Decreased swallowing activity (6)• Frequent vomiting (7)• Overweight and failure to thrive (8)• Reduced hunger-driven motivation to eat (9)• High economic costs (10)• Emotional stress for the parents (11)• Higher mortality risk (12)
  4. 4. BASIC DOMAINS OF ORAL FEEDING WHAT DO WE NEED TO EAT?• Oral-motor and sensory development• Motor development• Health• Initiative• Interactional routines
  5. 5. TUBE FEEDING & FEEDING DISORDER How does tube feeding result in Feeding Disorder?
  6. 6. IMPACT OF FEEDING DISORDER ON FEEDING BEHAVIOR• Oral-motor and sensory development • Reduces swallowing activity, vomiting, over-stimulation (16)• Motor development • Refuse to crawl with a PEG, bind the hands (NG-tube)• Health • Complications, hospitalization, feeding intolerance (5,17)• Initiative • No Hunger, no thirst, no initiative to eat (9)• Interactional routines • Food refusal (14), parental stress (11), conflicting recommendations
  7. 7. WHAT IS A FEEDING DISORDER?…a good question! Because:There are no universally accepted definitions or validated classifications ofcommon FDs (Feeding Disorders) of infancy.“  (Benoit, 1999, S. 339) Symptoms of feeding disorder:• Food refusal• Vomiting• Force feeding• Pre- oral resistance• And many more
  8. 8. DIAGNOSTICPROTOCOLReady for the wean?
  9. 9. THE DIAGNOSTIC MAINFRAMEA feeding behavior does not become a “feeding problem“ until it does not meet the expected performance for that infant. For a “normal” baby without any medical diagnosis or complications, we expect that the infant will take the required amount efficiently, without colour change or other physiologic compromise, and will gain weight. (Wolf & Glass, 1992, p. 165)
  10. 10. EXPECTED PERFORMANCE FOR… None Minimal Medium Normal High Swallowing □ □ □ □ □ Oral Motor Status □ □ □ □ □ Gastric Transport □ □ □ □ □ Feeding tolerance □ □ □ □ □ Weight gain □ □ □ □ □ Growth □ □ □ □ □Motoric Development □ □ □ □ □ Eating behavior □ □ □ □ □ Initiative □ □ □ □ □ Trauma symptoms □ □ □ □ □ Healthy child Cerebral Palsy Esophageal Atresia
  11. 11. INTAKE• Phone conference with parents • Tell me about your child! • What is the problem? • Medical conditions? • Developmental status?
  12. 12. QUESTIONNAIRE• Tube and oral feeding characteristics• Feeding Schedule• Weight, length, BMI• Feeding Disorder Symptoms• Psychosocial Situation
  13. 13. FEEDING VIDEO ANALYSIS What we need:• Feeding Situation (ca. 5 Minutes)• Child and Parent are visible Assessment• Structured video analysis• Functional swallowing evaluation• Classification of feeding disorder
  14. 14. ANALYSIS OF MEDICAL REPORTS• Indication for tube feeding?• Possible medical complication during weaning • Hypoglycemia, Feeding intolerance, Failure to Thrive• Swallowing Evaluation: • MBSS/ FEES• Traumatic impact of medical treatment • Recurrent intubation, suctioning • Nasogastric tube placement• Tube Weaning possible?
  15. 15. WHAT IS THE PROBLEM?• How can the problem be explained?• Is it a feeding disorder/tube dependency?• How much variance is explained by the: • Medical • Behavioral/psychological • Functional status?• Is a feeding tube or a tube weaning indicated?
  16. 16. PREPARATION• Assessment interview• Regular Follow-ups• Interventions • Play • Enjoy • Adapted tube feeding • The Goal:• Reduce Feeding Disorder Symtoms
  17. 17. Treatment
  18. 18. THEORETICAL ASSUMPTIONS• Eating and drinking is self-regulated• The self-regulation capacity is suppressed by tube feeding• Tube feeding must be terminated to establish oral eating• Feeding disorder becomes visible once tube feeding is terminated…• …and then it can be treated.
  19. 19. HUNGER INDUCTION Before day 1 day 2 day 3 day 4 day 510. am 130 50        1 pm 130 130 130 120 90 605 pm 130 130 130 130 130 130night 400 400 370 300 250 200Total 790 710 630 550 470 390 day 1 day 2 day 3 day 4 day 5Fluidal IntakeNutrition intakeUrin/Bowl MoveWeightSleep Behavior
  20. 20. WHERE TO START?• Playing, playing, playing…simply playing • Child shows competencies and deficits • Child leads through play • Play playfully (more childish than educational) • You can play dyadic or triadic, parents always welcome • Play may last from 10-120 minutes• Daily re-occurring: Start with play
  21. 21. PLAY PICNIC LET THE CHILDREN PLAY• Anything goes: • Children define the rules • All initiative is in the childrens hands• Nothing has to happen: • No playing, just observing • Not touching, just smelling • Not eating, just playing • No play picnic• It is the childs choice
  22. 22. IN THE FEEDING SITUATION• Where? Everywhere: • on the floor, in the high chair, in the park, in the restaurant, in the car• When? According to the child’s rhythm: • In the morning, at lunch, in the afternoon• How to work with the child? • Intuitive, slow, sensitive • Let the parents feed: feed the child only in exceptions
  23. 23. PSYCHOLOGICAL FEEDING THERAPY• If the child doesnt speak… • Communicate with gestures, mimicry, body • Answer with gestures, mimicry, body• If the child is hard to understand… • Empathize and observe • Interpret and reflect• If the child doesnt understand me… • Adjust my communication to the child Treatment without words needs more therapeutic intuition than technique.
  24. 24. WHEN CHILD REFUSE COMPLETELY• Acceptance of food refusal to reduce stressful feeding situations• Observe and discuss the signals of food refusal and acceptance with the parents.• Focus on the specific cues that trigger refusals• Go back to play when the child is afraid to eat.• For post-traumatic feeding disorder: Enable the child to cope with negative affects during play.
  25. 25. WHEN FEEDING STARTS• Rearrange the feeding situation to avoid refusal triggers• Make the feeding situation more comfortable for the child.• Help regulate feeding according to hunger and thirst signals.• Encourage parents to feed slowly.
  26. 26. MAIN FRAMEWORK• Home-based treatment means: • Treatment at the childs environment • In the childs circadian rhythm • Demand on the therapist: • Flexibilty (free time schedule) • Developmental knowledge • Therapeutic skills • Intuition• Feeding tube weaning is hard to predict
  27. 27. FOLLOW-UP & EVALUATION 12 11 Diagnostic Preparation Intensiv Treatment Aftercare 10 45
  28. 28. FOLLOW UP (SIX MONTHS)• Regular contact by phone for 4 weeks • One conference per week• Daily contact possible for 6 months• Counseling in special situations: • Infection • Short term food refusal • Growth and thriving • Removal of g-tube
  29. 29. TUBE WEANING IN EARLY CHILDHOOD LONGITUDINAL OUTCOME• Involved N=57/Excluded from the program=18• Drop out= 7 Success Rate• Evaluation before treatment follow-up 9 % (1-3 years later)• AQFT- Questionnaire: Weaned • Nutrition and tube feeding Not Weaned 91 % • Frequency of symptoms • Growth
  30. 30. FEEDING BEHAVIOR Failed Failed Successful Successful P Before After before treatment after treatmentb treatment treatmentbFeeding Aversion Scale 2.7 (0.6) 1.9 (0.6) .001 2.4 (0.8) 2.7 (0.1)Food refusal a 75 (64) 2.4 (6.5) .001 11 (16) 11 (17)Regurgitation a 44.9 (65.1) 1.2 (3.0) .002 40 (45) 3 (2)Gagginga 46 (59.9) 4.7 (11.4) .001 113 (163) 17 (10)Force Feeding a 33.8 (70) 6.4 (23.6) .08 13 (16) -Bizarre eating habits a 20.7 (63.4) 18.5 (38.1) .89 69 (40) 0.6 (0.3)Swallowing resistance 27.8 (51.4) 24.8 (51.4) .81 60 (79) 20 (17)Sum of Symptoms a 243.4 (201) 56.4 (100.1) .001 277 (235) 54 (47) a Frequency of occurrence of symptoms per month b Follow up one to three years after treatment Values are means (SD). Comparisons were done using paired t-tests1.
  31. 31. GROWTH AND TUBE FEEDING Before After P treatment treatment aBody weight (z-score) 1 -2.5 (1.5) -2.6 (1.1) .24Body (z-score) 1 -2.8 (2.1) -2.5 (1.5) .49BMI (z-score)1 -1.1 (1.7) -1.2 (1.1) .77Feeding Tube2 31 (100) 6 (19.3) .05 Nasogastric Tube² 16 (51.6) 1 (3.2) Gastrostoma² 12 (38.7) 4 (12.9) Jejustoma² 3 (9.7) 1 (3.2)Percentage fed via Tube1 86.2 (18.0) 11.6 (29.5) .001Values are either mean (SD) or number (%). Comparisons were done using two-sided t-tests1 for ordinate data or X² test2 forfrequency distributions. aFollow up one to three years after treatment.
  32. 32. COMPARISON HOME-BASED INPATIENT TREATMENT Home-based Inpatient Treatment groups 1-3* 4-12 Infection rate 1/25** (year 2007) 15/50 (2010) Treatment hours per day 4-10 h* 2-6 h Treatment costs 4-8.000 €** 8,5-20.000 € Medical consultation 1-5 per week 24 h** Team size medium high* Duration of treatment 7-10 days** 4-6 weeks Children per year N=20-40 N=40-60*
  33. 33. FURTHER INFORMATION:Markus WilkenHohlweg 4D-53721 Siegburgmail@markus-wilken.dewww.spectrumpediatrics.com

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