Caring for Tube‐Fed Children

Enteral nutrition is the practice of delivering nutrition to the gut either orally or through a tube or other device. Many children are reliant on enteral feedings to either supplement their nutrition or as a complete source of their nutrition. Managing children on tube feedings requires a team of providers to work through such dilemmas as feeding schedules, weaning from tube feeding, sensory implications of tube feeding, treatment of pain or nausea associated with eating, oral‐motor issues, and behavioral issues in the child and family. The purpose of the current review is to summarize the multidisciplinary aspects of enteral feeding. The multidisciplinary team consists of a variable combination of an occupational therapist, speech‐language pathologist, gastroenterologist, psychologist, nurse, pharmacist, and dietitian. Children who have minimal oral feeding experience and are fed via a nasogastric or gastrostomy tube often develop oral aversions. Limited data support that children with feeding disorders are more likely to have sensory impairment and that early life pain experiences contribute to feeding refusal. There are inpatient and outpatient programs for weaning patients from tube feeding to eating. The parent‐child interaction is an important part of the assessment and treatment of the tube‐fed child. This review also points out many information gaps, including data on feeding schedules, blenderized tube feedings, the best methods for weaning children off enteral feedings, the efficacy of chronic pain medications with tube‐fed children, and, finally, the necessity of the assessment of parental stress among all parents of children who are tube fed.     

Establishing Early Enteral Nutrition With the Use of Self‐Advancing Postpyloric Feeding Tube in Critically Ill Children

Introduction: Early nutrition support is an integral part of the care of critically ill children. Early enteral nutrition (EN) improves nitrogen balance and prevents bacterial translocation and gut mucosal atrophy. Adequate EN is often not achieved as gastric feeds are not tolerated and placing postpyloric feeding tubes can be difficult. Spontaneous transpyloric passage of standard feeding tubes without endoscopic intervention or use of anesthesia can range from 30%?80%. The authors report on their experience with a 14Fr polyurethane self‐advancing jejunal feeding tube in a pediatric population. These tubes have been used in the adult population with success, but to the authors’ knowledge, there have been no reports of its use in the pediatric age group. Case Series: The authors present 7 critically ill patients 8–19 years old, admitted to the pediatric intensive care unit, in whom prolonged recovery, inability to tolerate gastric feeds, and dependence on ventilator were predicted at the outset. The jejunal feeding tube was successfully placed on first attempt at the bedside in all 7 patients within the first 24 hours without the use of a promotility agent or endoscopic intervention. Nutrition goal achieved within 48 hours of feeding tube placement was reported for each patient. This case series demonstrates that children fed via the small bowel reached their nutrition goal earlier and did not require parenteral nutrition. Conclusion: The self‐advancing jejunal feeding tube can be used effectively to establish early EN in critically ill children.     

Percutaneous Gastrojejunostomy Placement in a Heart Failure Patient With Biventricular Assist Devices

Heart failure patients who require a ventricular assist device often present a nutrition challenge. A 39‐year‐old woman suffering from an acute ST elevated myocardial infarction and severe cardiogenic shock underwent implant of left and right ventricular assist devices (BiVAD). Neurologic deficits prevented her from safely resuming oral intake, and long‐term feeding access was required. The decision was made to insert a percutaneous gastrojejunostomy under fluoroscopic guidance. Patients implanted with ventricular assist devices may require enteral nutrition support. Placement of feeding access other than through the nasoenteric route can be rendered more challenging because of anatomical constraints related to BiVAD positioning; however, whenever enteral nutrition support is required for extended periods, percutaneous or ostomy access offers easier delivery of nutrition. Although technically difficult, successful placement of the enteral feeding tube allowed for continuous 24‐hour feeds to optimize nutrition intake. This is the first time that a percutaneous enteral feeding access was obtained for a ventricular assist device patient at the authors' institution, and it has proven valuable in providing long‐term nutrition in a safe and efficient manner.     

The young handicapped child in the community

Despite recent improvements in services for young handicapped children, families still find themselves without adequate information and support. Fundamental to family support is the planning of joint services and the development of the concept of family support. Assessment must be linked to ongoing programmes of management and the setting of long-term goals. Parent/professional collaboration should ensure the more effective use of resources. Parents need encouragement and detailed support and guidance if they are to play a therapeutic role in caring for their child. They also need practical help, both financial and in the form of respite care. Since the family is the major caring agency for a handicapped child, it is essential that expertise and services are pooled in a more flexible and imaginative way. It is therefore essential that children who have a disability should enjoy positive discrimination from health, education and social services to maximise ability and to ensure that they can enjoy a meaningful life within the home and the community.     

How to support parents and healthcare professionals in the decision-making process of tube feeding in children?

BackgroundTube feeding in children has a severe psychosocial impact on children and their families. Parents also feel that they have limited communication with healthcare professionals (HCPs) about decision-making and the implications of tube feeding.ObjectiveThis study focussed on the parents’ experiences and expectations about tube feeding of children and a solution to improve the management and communication of it.MethodsWe applied a design thinking method in two parts. First, focus groups and individual interviews were conducted with parents of children aged 0–10 years who are or had been tube fed and HCPs. Thereafter, two sounding boards with HCPs and parents were convened to discuss improvements in the management of tube feeding.ResultsIn total, 17 parents participated in the study. Two main topics derived from the focus groups and interviews: psychosocial impact and communication with HCPs. The sounding boards (five HCPs and two parents) divided the challenges of tube feeding into three stages: the moment tube feeding is considered, the insertion of the tube in the hospital, and transfer to the domestic environment and follow-up. Interview topics were used to develop a communication sheet to support the decision process of tube feeding.ConclusionsThe empowerment of parents in the process of tube feeding is important. More attention should be paid to alternatives, consequences, and planning for the long term. The developed communication sheet offers suggestions for issues to discuss and could support communication between parents and HCPs about tube feeding.     

The young handicapped child in the community

Despite recent improvements in services for young handicapped children, families still find themselves without adequate information and support. Fundamental to family support is the planning of joint services and the development of the concept of family support. Assessment must be linked to ongoing programmes of management and the setting of long‐term goals. Parent/professional collaboration should ensure the more effective use of resources. Parents need encouragement and detailed support and guidance if they are to play a therapeutic role in caring for their child. They also need practical help, both financial and in the form of respite care. Since the family is the major caring agency for a handicapped child, it is essential that expertise and services are pooled in a more flexible and imaginative way. It is therefore essential that children who have a disability should enjoy positive discrimination from health, education and social services to maximise ability and to ensure that they can enjoy a meaningful life within the home and the community.     

Enteral tube feeding in a cohort of chronic hemodialysis patients.

Malnutrition affects up to half of all chronic dialysis patients and is an important predictor of mortality, but the efficacy of interventions designed to improve the nutritional status of dialysis patients has been poorly studied. Specifically, although enteral tube feeding is often cited as an important option in the treatment of malnourished dialysis patients, there are few studies examining the effectiveness and complications of enteral tube feedings in adults on dialysis. We performed a retrospective analysis of a small cohort (n = 10) of chronic hemodialysis patients who received enteral tube feeding as all or part of their nutrition between January 1 and May 1, 1999, with follow-up through May 1, 2000, to assess the efficacy and complications of enteral tube feeding. Six patients received feeding via a peritoneoscopically placed (PEG) tube, 3 via nasogastric (NG) tube, and 1 patient was switched from PEG to NG feeding after an exit site infection developed at her PEG site. Seven patients received enteral feeding because of swallowing difficulties occurring after a cerebrovascular accident. Four patients were fed via enteral tube temporarily (相似文献   

Stress levels experienced by the parents of enterally fed children

BACKGROUND: The stress levels of parents of children with chronic illness/disability who were also involved in an enteral feeding programme were examined and compared to the stress levels of parents of healthy children and parents of children with other chronic illnesses reported in previous research. METHODS: Sixty-four parents who had a child with an enteral feeding tube completed the Parenting Stress Index (PSI). RESULTS: Based on criteria developed by Abidin (1995), 42.18% (n = 29) of these parents displayed high stress levels. T-tests revealed that Total Stress scores on the PSI of the parents of children involved in the enteral feeding programme were significantly higher than those reported in the sample of parents used to norm the PSI (P < 0.001), and comparison samples of parents of children with growth deficiencies (P < 0.001) and parents of children with insulin-dependent diabetes mellitus (P < 0.01). Compared to a sample of parents of children with Rett syndrome, the parents of children involved in the enteral feeding programme reported similar levels of stress on the Parent Domain of the PSI and significantly less stress on the Child Domain (P < 0.001). CONCLUSIONS: Factors associated with the stress reported by parents of children with an enteral feeding tube were severity of their child's illness/disability, the constant caretaking demands placed on the parent, and the level of support provided by the parents' social network.     

Home enteral tube feeding in patients with inherited metabolic disorders: safety issues

BACKGROUND: Many children with inherited metabolic disorders (IMD), at risk of hypoglycaemia and metabolic decompensation, are dependent on long-term home overnight enteral tube feeding but its safety issues have not been evaluated. OBJECTIVE: To identify common safety issues and carer pressures for patients with IMD on home enteral tube feeds (HETF). METHODS: Thirty-four patients (53% male; median age 4.1, range: 1.2-15.8 years), with IMD on home continuous overnight tube feeds were recruited. They were all following specialized feeding regimens. A questionnaire, administered by face-to-face interview with carers identified family members involved in feeding, training they received; child safety issues; equipment reliability and carer night time disturbance. RESULTS: The principal problems were: carer sleep disturbance (100%); tube entanglement (71%); untrained secondary carers (71%); faulty pumps (50%); tube blockages (45%); faulty equipment (32%); and child tampering with pumps and feeding equipment (29%). CONCLUSIONS: Significant risks for children on HETF with IMD were identified, potentially leading to metabolic decompensation and hospitalization. The safety of feeding equipment, lack of training of extended family members and practical support for carers requires urgent attention.     

Home enteral feeding audit 1 year post-initiation

OBJECTIVE To determine the practical problems that families of children on home enteral tube feeds (HETF) experience in the first year post-hospital discharge. METHODS Thirty parents/carers of children (0-16 years) completed a multiple choice/short answer questionnaire by interview 12 months after discharge from hospital. Issues addressed included: home delivery of feed and equipment; pump usage; tube changes; and overnight feeding. RESULTS: The main problems identified were: sleep disturbance (75%); frequent tube dislodgement (46%); tube blockages (41%); inability of some home delivery companies (HDC) to provide all the paediatric special feeds required (43%); and pump inaccuracy (23%). Conclusions Children on long-term HETF and their families experience significant problems with sleep disturbance, tube dislodgement and tube blockage. In addition, accuracy of pumps and obtaining feed and equipment was a source of stress. Dietitians and community nurses urgently need to explore solutions to the common problems associated with overnight feeding. Furthermore, regular home reviews are necessary in long-term HETF to continue to identify and minimize problems.     

Infection control issues of enteral feeding systems

Enteral feeding systems provide a mechanism for nutritional support for patients who may be unable to tolerate oral dietary sustenance. This review takes into account recent infection control issues relating to enteral feeding systems. The review is organized into the following areas of emphasis: infections associated with enteral tube feeding, the stability and contamination of enteral tube feeding, the risk:benefit analysis of enteral tube feeding, and the protective effects of enteral tube feeding.     

Helping Families Meet the Nutritional Needs of Children With Disabilities: An Integrated Model

Children with disabilities need adequate nutritional intake to survive and thrive. Many are at risk and in need of nutritional intervention. In this study we evaluated the outcomes of nutrition services for children with disabilities and their families using an integrated model of feeding and nutrition. Thirty-five children and families who received nutrition intervention services participated in the study. Children with disabilities and inadequate nutrition significantly benefited from nutrition interven- tion services. Children increased in weight-for-height ratios. Families reported in- creased alertness for their children with improved nutritional status. Families of children with greater feeding difficulties experienced increased stress and decreased social support. These findings can help families and professionals work in partnership to meet the nutrition needs of children with disabilities and chronic health care problems before a child becomes severely malnourished or a family becomes dys- functional.     

Is it prudent to add n-3 long-chain polyunsaturated fatty acids to paediatric enteral tube feeding?

Nutritional support, as complete enteral tube feeding, is needed by many paediatric patients and must provide sufficient nutrients for normal growth and development. Enteral feeds contain the parent essential fatty acids, linoleic acid and α-linolenic acid, but often do not contain n-3 long-chain polyunsaturated fatty acids. Available data suggest that biosynthesis of eicosapentaenoic acid and docosahexaenoic acid from α-linolenic acid is low in humans and varies between individuals. Long-term enteral feeding with formulae devoid of eicosapentaenoic acid and docosahexaenoic acid may result in low levels in plasma and tissues, potentially affecting immune and neurological function. Currently there is insufficient evidence to define the quantitative eicosapentaenoic acid and docosahexaenoic acid requirements for healthy children, or those with various disease states. Nevertheless, it appears prudent to supply children on long-term enteral nutrition with a dietary source of eicosapentaenoic acid and docosahexaenoic acid. A reasonable approach would be to provide amounts matching intakes of healthy children complying with the advice to consume 1-2 portions of oily fish per week. Further studies are needed to investigate the effects of different amounts of eicosapentaenoic acid and/or docosahexaenoic acid in enteral nutrition on polyunsaturated fatty acid status and the functional and clinical consequences in children.     

The impact of home enteral tube feeding in everyday life: a qualitative study

Advances in clinical and technical areas, combined with developments in community support services, have enabled people to receive enteral tube feeding at home in the UK. Research has focused on clinical and technical aspects, and people's experiences have largely been explored through the audit of after-care services. The research reported in the present paper consisted of a qualitative study in which a small number of people under going enteral tube feeding at home and their carers were interviewed. The study took place in one area of northern England. The interviews explored aspects of daily life, focusing on decision-making and adaptation, and revealed positive feelings about the process of tube feeding, as well as areas of difficulty and concern. Opportunities to improve practice and services are identified from these accounts.     

Enteral tube feeding in the community: survey of adult patients discharged from a Dublin hospital

BACKGROUND AND AIMS: No previous study has examined the state of patients on enteral tube feeding in the community in the Republic of Ireland. METHODS: Fifty adult patients discharged from a Dublin hospital on enteral tube feeding were assessed retrospectively. RESULTS: Sixty-six per cent of the sample were over 65 years of age. Patients required enteral tube feeding as a consequence of swallowing difficulties caused by stroke (46%) or cancer of the head and neck (24%). Most patients were on full nutritional support and, in total, had spent over 49 years tube feeding in the community. Geriatric stroke patients were found to have poor functional ability and nutritional assessment proved difficult to carry out on many of these patients. Problems encountered with feeding included blocked tubes (30%), infected stoma sites (16%), and logistical problems regarding feed and equipment. Nutritional follow-up was not routine in patients with poor mobility, and 55% of patients on long-term tube feeding had not been reviewed by a dietitian in over 1 year. Patients had little faith in their general practitioner's knowledge of enteral feeding. CONCLUSIONS: While patients and families appear to cope remarkably well with tube feeding in the community, more support is necessary to ensure appropriate feeding and to monitor the nutritional status of these patients.     

Psychosocial care in complementary feeding of children: a comparative study of the urban and rural communities of Osun State,Nigeria

This study investigated psychosocial care in complementary feeding of children under two years of age. The cross‐sectional study was carried out in Osun State of Nigeria within Sub‐Saharan Africa, and 450 mothers were interviewed of which 337 were from the urban and 113 from the rural communities. Results revealed that 37.4% of the respondents work outside their home while 46.7% work for more than eight hours in a day. About 77% care for their children all the time while only 23.1% used care alternatives. Complementary feeds are usually introduced as early as one month (2.6%) and those who started at six months were only 37.3%. Mothers combined the use of feeding bottles and cups and spoons for feeding (37.4%) while 15.2% exclusively used feeding bottles for feeding. About 75.1% of children cried before they were fed while mothers observed refusal of food as a sign of fullness when children were fed. The number of mothers who pet children to eat was only 58.7% while the number who force‐feed their children was 23.6%. About 76.2% of mothers claimed that their children have their own separate bowls for eating; 76.4% sit with their children while feeding; and 5.3% talk with their children when they are eating. The study revealed that the psychology and culture of people influenced the respective care in complementary feeding for children. It is recommended that studies on complementary feeding should emphasise psychosocial care for optimum nutritional outcome.     

Clinical trial of a paediatric enteral feed

A paediatric enteral feed, Paediasure, was given to children aged 1–8 years needing nutritional support. Those who had more than 60% of their energy from Paediasure were included in the trial which ran for 1–3 months. Anthropometric measurements were done at the start and at the end of the trial. Nutritional evaluations of Paediasure were made and compared with other enteral feeds.
It was found that children's growth was satisfactory on Paediasure, that it was well tolerated and palatable if given orally. Paediasure has a high-nutrient density so when given at low volumes (which are required for overweight and some very underweight patients) the recommended nutrient intakes (RNI) are more likely to be met than if other enteral feeds are used.