Transitioning to oral feeding: A retrospective cohort study of a family-centered, hunger-based tube weaning program

BACKGROUND

We investigated the effectiveness of a novel, hunger-based outpatient tube weaning program for children with feeding-tube dependency.

METHODS

This interdisciplinary program induced hunger via rapid reduction in tube-fed calories, followed by 2 weeks of daily outpatient mealtime support and regular follow-up. Forty-one children (6.9 months to 12.8 years) participated in this retrospective cohort study.

RESULTS

Before the program, children received a median of 90.0% (interquartile range [IQR]: 75.0%-100%) of caloric intake via tube feeds. At the end of the 2-week program, children received 16.0% (IQR: 0.0%-30.0%) of caloric intake via tube feeds, which further reduced to 1.5% (IQR: 0.0%-33.0%) at 6-months, and 0.0% (IQR: 0.0%-35.0%) at 1-year follow-up. The percentage of participants who ate >30 different foods increased from 4.9% at baseline to 81.5% at 1-year follow-up. The baseline median weight z score of -1.24 (IQR: -1.69 to -0.69) decreased to -1.81 (IQR: -2.77 to -1.02) at 1-year follow-up. A linear mixed-effects model demonstrated that weight z score was significantly higher at baseline and 2-weeks compared to the 1-year follow-up (P < 0.001 and P = 0.001, respectively), but was not significantly different between 6 months and 1 year (P = 0.44). Age was not associated with percentage of caloric intake via tube feeds or number of foods eaten.

CONCLUSION

Children who participated in the hunger-based tube-weaning program had increased and more varied oral intake 1 year following the intervention. The median weight z score decreased over the year after intervention but did not significantly decrease between 6 and 12 months after the program.

Cost Analysis of Avoiding Gastrostomy Tube in Robin Sequence Neonates that Undergo Mandibular Distraction

OBJECTIVES/HYPOTHESIS

To evaluate costs associated with perioperative gastrostomy tube (G-tube) placement for neonates with Robin sequence (PRS) that undergo mandibular distraction osteogenesis (MDO).

METHODS

Retrospective chart review was performed to examine the medical records of neonates with RS who received treatment at our institution between 2012 and 2021. Patients under 6 months of age that underwent MDO for RS were included. Billing records of hospital costs over a 2-year period were analyzed.

RESULTS

The study included 26 total patients with 11 in the MDO-only group, 9 in G-tube after MDO group, and 6 in G-tube before MDO group. There was a significant difference (p < 0.001) in total hospital costs between groups with MDO-only group averaging $119,532 (SD ± 33,503), the G-tube after MDO group averaging $245,315 (SD ± 102,327), and G-tube before MDO group averaging $252,300 (SD ± 84,990). Multiple linear regression was performed controlling for genetic syndrome and birth weight, which still showed a statistically significant difference in total cost between the MDO-only group and G-tube after MDO (p = 0.006), and between the MDO-only group and G-tube prior to MDO (p = 0.01). There was a significant difference in costs between all three groups for total inpatient/outpatient costs with MDO-only group averaging $78,502 (SD ± 30,953), the G-tube after MDO group averaging $176,125 (SD ± 84,315), and the G-tube prior to MDO group averaging $156,309 (SD ± 95,746).

CONCLUSIONS

MDO performed without perioperative G-tube placement may reduce charges by >$100,000. The associated improvement of dysphagia after MDO surgery and potential for avoiding a G-tube has tremendous downstream cost and social benefits for families.

LEVEL OF EVIDENCE

NA Laryngoscope, 135:1192-1198, 2025.

Development of a toolkit to help parents/caregivers manage feeding problems in autistic children: A protocol for a realist synthesis and toolkit co-design

Many autistic children have feeding problems, typically eating a limited range of foods. Feeding problems affect quality of life, health, and development. Research suggests that parents are often unsure when to or whether to seek help. When they do, local provision of help across the UK is often lacking. A toolkit could offer a tailored, accessible, and scalable early intervention to support parents. We aim to develop the blueprint of a toolkit to help parents/caregivers manage feeding problems in their autistic children. Medical Research Council guidance on developing complex interventions informs three successive work packages: Realist review: a literature search and analysis using realist theory of logic to construct programme theory(s) in line with RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidance.Realist evaluation: interviews of three groups: autistic children, young people and adults (experts), parents/caregivers of autistic children (parents), and professionals who help parents manage feeding problems (professionals) across the UK. Analysis of verbatim interview transcripts using realist theory of logic to refine programme theory(s).Co-design of the toolkit blueprint: behaviour change theory applied to the programme theory(s) will generate candidate components for the online tool. A blueprint (a detailed textual outline) will be co-designed. A participatory research team of experts, parents, and professionals will be involved in each work package. Where consensus is needed it will be reached by asynchronous nominal group technique. A PPI (public and patient involvement) advisory group of experts and parents will ensure the project is relevant, respectful, and accessible. Findings of each step will be disseminated via journal publications, conferences, social media, as well as PPI-co-produced webinars and a dissemination event. On completion, this project will provide the foundation for the subsequent development and refinement of the prototype toolkit.

A natural history of temporary tube feeding care at a children's hospital: A prospective audit of medical records

This chart audit characterized the natural history of temporary tube feeding use at a children's hospital between 1 November 2018 and 30 November 2019. Data were collected from the decision-making phase until tube removal or 4 months post-tube insertion. Children's tube feeding journeys were described, and associations determined between patient and service-related variables and outcomes of tube feeding duration and being discharged with a feeding tube. Four hundred and 94 patients were followed with a median age of 1.0 years (IQR 3.6). Many had respiratory illnesses (n = 213, 43%) and received feeding tubes for inadequate oral intake related to acute illness (n = 279, 57%). Seventy-one new feeding tubes were inserted per month (SD 27.63). Fifty-nine per cent of patients (n = 290) received allied health consults. Although 40% of patients (n = 199) experienced complications, most patients (n = 460, 93%) ceased tube feeding within 4 months. Outcomes were associated with age, medical condition, reflux, primary reason for tube feeding, allied health consult, complication type, tube weaning plans and referral for longer-term feeding devices. Results highlighted a critical need for risk identification from the decision-making stage and standardization of practices during all phases of temporary tube feeding care.

Rehabilitation Outcomes in Children With Acute Flaccid Myelitis From 2014 to 2019: A Multicenter Retrospective Review

BACKGROUND

Acute flaccid myelitis (AFM) is a childhood illness characterized by sudden-onset weakness impairing function. The primary goal was to compare the motor recovery patterns of patients with AFM who were discharged home or to inpatient rehabilitation. Secondary analyses focused on recovery of respiratory status, nutritional status, and neurogenic bowel and bladder in both cohorts.

METHODS

Eleven tertiary care centers in the United States performed a retrospective chart review of children with AFM between January 1, 2014, and October 1, 2019. Data included demographics, treatments, and outcomes on admission, discharge, and follow-up visits.

RESULTS

Medical records of 109 children met inclusion criteria; 67 children required inpatient rehabilitation, whereas 42 children were discharged directly home. The median age was 5 years (range 4 months to 17 years), and the median time observed was 417 days (interquartile range = 645 days). Distal upper extremities recovered better than the proximal upper extremities. At acute presentation, children who needed inpatient rehabilitation had significantly higher rates of respiratory support (P < 0.001), nutritional support (P < 0.001), and neurogenic bowel (P = 0.004) and bladder (P = 0.002). At follow-up, those who attended inpatient rehabilitation continued to have higher rates of respiratory support (28% vs 12%, P = 0.043); however, the nutritional status and bowel/bladder function were no longer statistically different.

CONCLUSIONS

All children made improvements in strength. Proximal muscles remained weaker than distal muscles in the upper extremities. Children who qualified for inpatient rehabilitation had ongoing respiratory needs at follow-up; however, recovery of nutritional status and bowel/bladder were similar.

Changes in Medical Charges Following Intensive Multidisciplinary Intervention for Pediatric Gastrostomy Tube Dependence

OBJECTIVE

Intensive multidisciplinary intervention (IMI) is the most evidence-based approach to treat pediatric feeding disorders. The goal of this exploratory study was to assess changes in health care charges for patients with gastrostomy tube dependence following participation in IMI compared to a waitlist control.

METHODS

Medical charges were assessed for 9 families who participated in IMI compared to 6 control families on a multi-year waitlist for IMI. The IMI and control groups were compared on raw charges submitted as well as individual year-over-year changes in medical charges.

RESULTS

The IMI group decreased health care charges by 71% on average in the year following IMI compared to the control group increasing charges by 22% over the same period.

CONCLUSIONS

IMI also holds potential cost-savings in the year following treatment compared to children who do not receive treatment and adds to previous research focusing on long-term cost effectiveness of IMI.

Multidisciplinary Tiered Care Is Effective for Children and Adolescents With Rumination Syndrome

OBJECTIVES

Rumination syndrome (RS) can be challenging to treat and data on treatment outcomes in children are limited. The objective of this study was to evaluate outcomes of children with RS treated with tailored outpatient and inpatient strategies.

METHODS

We performed a retrospective cohort study of children <18 years old with RS evaluated at our institution from 2018 to 2020. At our institution, we use a multidisciplinary, tiered approach to treatment based on presentation severity. Children with RS either undergo outpatient treatment program (OP) or participate in an intensive outpatient program (IOP) or an intensive inpatient program (IP). We reviewed baseline characteristics and assessed severity (including frequency of regurgitation/vomiting, route of nutrition, and weight loss) at baseline, at completion of treatment, and at a follow-up time point.

RESULTS

We included 171 children with RS (64% female, median age 13 years, interquartile range (IQR) 10-15), 123 of whom had post-treatment data after completing OP, IOP, or IP. At baseline, 66% of patients were vomiting daily and 40% were losing weight. After treatment, 72% of OP, 95% of IOP, and 96% of IP patients reported that symptoms were better or fully resolved compared to baseline. In all 3 treatment groups, patients were vomiting, losing weight, and skipping meals significantly less after treatment compared to baseline. At follow-up (median 5.3 months), 86% of IOP and 66% of IP patients had symptoms that remained better or resolved.

CONCLUSIONS

RS can cause severe symptoms, impacting nutritional status and school participation. However, multidisciplinary care in a tiered approach leads to significant symptomatic improvement.

Characterisation of hospital-produced guidelines regarding management of temporary tube feeding care in general paediatric patients

Background/Aims

There is significant variation in the implementation of temporary tube feeding management in children and a paucity of associated clinical practice guidelines covering all phases of care, from decision making regarding tube insertion through to tube weaning. Development of clinical practice guidelines should consider levels of evidence other than randomised control trials. Examining hospital-produced guidelines used by frontline health staff, for example, could distinguish areas of application of evidence-based recommendations, as well as domains of care in need of increased implementation. This article describes the content of existing hospital-produced guidelines relating to tube feeding care in a general paediatric population.

Methods

Hospital-produced guidelines were sought by mailing 200 health services worldwide and searching Queensland Health's Electronic Publishing Service in Australia and Google. A content analysis was then performed.

Results

The 13 collected hospital-produced guidelines from Australia, the UK and Canada generally comprehensively reported on processes related to the decision-making, tube placement and tube maintenance phases. However, reporting on oral feeding while tube feeding, tube feeding dependency, tube feeding exit planning, and the social and emotional aspects of tube feeding were areas within these phases that had limited coverage. Recommendations for the phase of tube weaning were also infrequently included.

Conclusions

Development of formal clinical practice guidelines covering all tube feeding phases should assist in optimising patient and health service outcomes.

Oral Nutritional Supplementation Improves Growth in Children at Malnutrition Risk and with Picky Eating Behaviors

The problem of poor nutrition with impaired growth persists in young children worldwide, including in India, where wasting occurs in 20% of urban children (<5 years). Exacerbating this problem, some children are described by their parent as a picky eater with behaviors such as eating limited food and unwillingness to try new foods. Timely intervention can help prevent nutritional decline and promote growth recovery; oral nutritional supplements (ONS) and dietary counseling (DC) are commonly used. The present study aimed to determine the effects of ONS along with DC on growth in comparison with the effects of DC only. Enrolled children (N = 321) were >24 to ≤48 months old, at malnutrition risk (weight-for-height percentile 3rd to 15th), and described as a picky eater by their parent. Enrollees were randomized to one of the three groups (N = 107 per group): ONS1 + DC; ONS2 + DC; and DC only. From day 1 to day 90, study findings showed significant increases in weight-for-height percentile for ONS1 + DC and for ONS2 + DC interventions, as compared to DC only (p = 0.0086 for both). There was no significant difference between the two ONS groups. Anthropometric measurements (weight and body mass index) also increased significantly over time for the two ONS groups (versus DC only, p < 0.05), while ONS1 + DC significantly improved mid-upper-arm circumference (p < 0.05 versus DC only), as well. ONS groups showed a trend toward greater height gain when compared to DC only group, but the differences were not significant within the study interval. For young Indian children with nutritional risk and picky eating behaviors, our findings showed that a 90-day nutritional intervention with either ONS1 or ONS2, along with DC, promoted catch-up growth more effectively than did DC alone.

Weaning children from temporary tube feeding: Staff survey of knowledge and practices

AIM

To explore the understanding of and practices of health-care workers in weaning children from feeding tubes.

METHODS

An electronic survey of doctors, nurses, and allied health professionals at Children's Health Queensland obtained demographic information and awareness of various areas of tube feeding management particularly tube weaning.

RESULTS

The 155 health-care providers formed three well-matched groups in terms of number and years of experience. Only 18 had formal training in tube weaning. Participants had high levels of knowledge regarding reasons for commencing and possible complications associated with tube feeding. However, health-care providers generally were found to have limited to no knowledge of tube weaning practices. Nearly half of participants (46%) did not know the best time to plan for a tube wean and only 16 indicated that they or their work units documented tube exit plans, regardless of type of feeding tube, in children's medical charts. Time frames were rarely included as part of tube exit plans. Participants ranked medical stability and presence of a safe swallow most highly as important indicators for successful tube weaning. Multidisciplinary management was also identified as valuable. Tube weaning was predominately managed by children's primary health unit/service and largely involved a medical officer and dietician.

CONCLUSIONS

Poor awareness of tube weaning practices such as tube exit strategies may be impacting on the quality of care received by children who are tube fed. Future research should be directed towards developing and evaluating guidelines accompanied by educational resources to further advance tube weaning practices.

An Economic Analysis of Intensive Multidisciplinary Interventions for Treating Medicaid-Insured Children with Pediatric Feeding Disorders

Background. Intensive multidisciplinary intervention (IMI) represents a well-established treatment for pediatric feeding disorders (PFDs), but program availability represents an access care barrier. We develop an economic analysis of IMI for weaning from gastronomy tube (G-tube) treatment for children diagnosed with PFDs from the Medicaid programs' perspective, where Medicaid programs refer to both fee-for-service and managed care programs. Methods. The 2010-2012 Medicaid Analytic eXtract claims provided health care data for children aged 13 to 72 months. An IMI program provided data on average admission costs. We employed a finite-horizon Markov model to simulate PFD treatment progression assuming 2 treatment arms: G-tube only v. IMI targeting G-tube weaning. We compared the expenditure differential between the 2 arms under varying time horizons and treatment effectiveness. Results. Overall Medicaid expenditure per member per month was $6814, $2846, and $1550 for the study population of children with PFDs and G-tube treatment, the control population with PFDs without G-tube treatment, and the no-PFD control population, respectively. The PFD-diagnosed children with G-tube treatment only had the highest overall expenditures across all health care settings except psychological services. The expenditure at the end of the 8-year time horizon was $405,525 and $208,218 per child for the G-tube treatment only and IMI arms, respectively. Median Medicaid expenditure was between 1.7 and 2.2 times higher for the G-tube treatment arm than for the IMI treatment arm. Limitations. Data quality issues could cause overestimates or underestimates of Medicaid expenditure. Conclusions. This study demonstrated the economic benefits of IMI to treat complex PFDs from the perspective of Medicaid programs, indicating this model of care not only holds benefit in terms of improving overall quality of life but also brings significant expenditure savings in the short and long term.

Improvements in Children's Feeding Behavior after Intensive Interdisciplinary Behavioral Treatment: Comparisons by Developmental and Medical Status

This study examined changes in child mealtime behavior, diet variety, and family mealtime environment after intensive interdisciplinary behavioral treatment (IIBT) for 52 children referred to a day treatment feeding program. Children fell into three developmental status groups including autism spectrum disorder (n = 16), other special needs (n = 19), and no special needs (n = 17), with some having no known medical problems (n = 22) and some having gastrointestinal, cardiopulmonary, and/or endocrine-metabolic problems (n = 28). At pre-intervention and post-intervention, caregivers completed the About Your Child's Eating scale, the Brief Assessment of Mealtime Behavior in Children, and a food preference inventory of 70 common foods (20 fruits, 23 vegetables, 12 proteins, 8 grains, 7 dairy). Mixed-factor 2 × 3 ANOVAs compared each of the 11 feeding outcomes across the two study phases (pre-, post-intervention) for the three developmental status groups. All feeding outcomes except fruit acceptance showed significant improvements from pre- to post-intervention, with no main effects for developmental status, and no interaction effects. Additionally, mixed-factor 2 × 2 ANOVAs compared each of the 11 feeding outcomes across the two study phases (pre-, post-intervention) for children with and without medical problems. All feeding outcomes except fruit acceptance showed significant improvements from pre- to post-intervention, with no main effects for medical status, and no interaction effects. Present results suggest that IIBT is effective for improving a number of children's feeding problems, regardless of their developmental or medical status.

The Autism Managing Eating Aversions and Limited Variety Plan vs Parent Education: A Randomized Clinical Trial

OBJECTIVE

To assess the feasibility and initial efficacy of a structured parent training program for children with autism spectrum disorder and moderate food selectivity.

STUDY DESIGN

This 16-week randomized trial compared the Managing Eating Aversions and Limited variety (MEAL) Plan with parent education. MEAL Plan (10 core and 3 booster sessions) provided parents with nutrition education and strategies to structure meals and expand the child's diet. Parent education (10 sessions) provided information about autism without guidance on nutrition, meal structure, or diet. In addition to feasibility outcomes, primary efficacy outcomes included the Clinical Global Impression - Improvement scale and the Brief Autism Mealtime Behaviors Inventory. Grams consumed during a meal observation served as a secondary outcome.

RESULTS

There were 38 eligible children (19 per group, 32 males). For MEAL Plan, attrition was <10% and attendance >80%. Therapists achieved >90% fidelity. At week 16, positive response rates on the Clinical Global Impression - Improvement scale were 47.4% for the MEAL Plan and 5.3% for parent education (P < .05). The adjusted mean difference (SE) on Brief Autism Mealtime Behaviors Inventory at week 16 was 7.04 (2.71) points (P = .01) in favor of MEAL Plan. For grams consumed, the adjusted standard mean difference (SE) was 30.76 (6.75), also in favor of MEAL Plan (P = .001).

CONCLUSIONS

The MEAL Plan seems to be feasible, and preliminary efficacy results are encouraging. If further study replicates these results, the MEAL Plan could expand treatment options for children with autism spectrum disorder and moderate food selectivity.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02712281.

Long-term Follow-up of Adolescents Treated for Rumination Syndrome in an Inpatient Setting

OBJECTIVES

Although several studies have demonstrated the short-term benefit of the behavioral treatment of rumination syndrome, few have investigated the long-term outcomes. Studies reporting long-term benefit have involved combined pediatric and adult samples or have examined outcomes of patients involved in various types of treatment. The purpose of the present study was to examine several aspects of long-term outcome in adolescent patients who took part in the same intensive, interdisciplinary, inpatient behavioral treatment approach.

METHODS

Self-report measures were completed by 47 adolescent patients (mean age = 15.9) around 1 year or more from discharge from our inpatient program. Measures indexed changes in rumination, medical outcomes (eg, use of supplemental nutrition), somatic symptoms, and quality of life.

RESULTS

Most patients reported continued improvement in their rumination over time, with 20% reporting cessation of rumination for at least 6 months. The majority of patients no longer required supplemental nutrition and reported improvements in somatic symptoms and quality of life. Patients who reported greater improvement in rumination also reported more significant improvements in their somatic symptoms and quality of life.

CONCLUSIONS

Intensive behavioral treatment of rumination syndrome leads to long-term improvement in rumination as well as other related factors, including somatic symptoms and quality of life.