Long term nutritional and growth outcomes of children completing an intensive multidisciplinary tube-feeding weaning program

  • Tal Sadeh-Kon
    Affiliations
    Pediatric Gastroenterology and Nutrition Unit, Edmond and Lily Safra Children's Hospital, Tel Hashomer, Ramat Gan, Israel

    The School of Nutritional Sciences, The Robert H. Smith Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem, Rehovot, Israel
    Search for articles by this author
  • Akiva Fradkin
    Affiliations
    Pediatric Gastroenterology and Nutrition Unit, Edmond and Lily Safra Children's Hospital, Tel Hashomer, Ramat Gan, Israel

    Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
    Search for articles by this author
  • Marguerite Dunitz-Scheer
    Affiliations
    Medical University of Graz, Department of General Pediatrics, Austria
    Search for articles by this author
  • Tali Golik-Guz
    Affiliations
    Pediatric Gastroenterology and Nutrition Unit, Edmond and Lily Safra Children's Hospital, Tel Hashomer, Ramat Gan, Israel

    Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
    Search for articles by this author
  • Ronit Sarig-Klein
    Affiliations
    Pediatric Gastroenterology and Nutrition Unit, Edmond and Lily Safra Children's Hospital, Tel Hashomer, Ramat Gan, Israel
    Search for articles by this author
  • Mirta David
    Affiliations
    Pediatric Gastroenterology and Nutrition Unit, Edmond and Lily Safra Children's Hospital, Tel Hashomer, Ramat Gan, Israel
    Search for articles by this author
  • Batia Weiss
    Affiliations
    Pediatric Gastroenterology and Nutrition Unit, Edmond and Lily Safra Children's Hospital, Tel Hashomer, Ramat Gan, Israel

    Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
    Search for articles by this author
  • Tali Sinai
    Correspondence
    Corresponding author. School of Nutritional Sciences, Robert H. Smith Faculty of Agriculture, Food and Environment The Hebrew University of Jerusalem POB 12, Rehovot 76100, Israel. Fax: +972 8 9363208.
    Affiliations
    The School of Nutritional Sciences, The Robert H. Smith Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem, Rehovot, Israel

    Israel Center for Disease Control, Israel Ministry of Health, Tel Hashomer, Ramat Gan, Israel
    Search for articles by this author
Published:February 15, 2020DOI:https://doi.org/10.1016/j.clnu.2020.02.006

      Summary

      Background & aims

      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.

      Methods

      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.

      Results

      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.

      Conclusions

      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.

      Keywords

      Abbreviations:

      BMI (body mass index), ENS (enteral nutrition support), RDA (recommended dietary allowances), WHO (world health organization)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Clinical Nutrition
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Braegger C.
        • Decsi T.
        • Dias J.A.
        • et al.
        Practical approach to pediatric enteral nutrition: a comment by the ESPGHAN committee on nutrition.
        J Pediatr Gastroenterol Nutr. 2010; 51: 110-122
        • Lochs H.
        • Allison S.P.
        • Meier R.
        • et al.
        Introduction to the ESPEN guidelines on enteral nutrition. Terminology, definitions and general topics.
        Clin Nutr. 2006; 25: 180-186
        • Pahsini K.
        • Marinschek S.
        • Kahn Z.
        • Dunitz-Scheer M.
        • Scheer P.
        Unintended adverse effects of EN support: the parental perspective-A quantitative analysis.
        J Pediatr Gastroenterol Nutr. 2016; 62: 169-173
        • Dunitz-Scheer M.
        • Marinschek S.
        • Beckenbach H.
        • Kratky E.
        • Hauer A.
        • Scheer P.
        Tube dependence: a reactive eating behavior disorder. Infant Child Adolesc.
        Nutrition. 2011; 3: 209-215
        • Gottrand F.
        • Sullivan P.B.
        Gastrostomy tube feeding: when to start, what to feed and how to stop.
        Eur J Clin Nutr. 2010; 64: 17-21
        • Kindermann A.
        • Kneepkens C.M.
        • Stok A.
        • et al.
        Discontinuation of tube feeding in young children by hunger provocation.
        J Pediatr Gastroenterol Nutr. 2008; 47: 87-91
        • Hartdorff C.M.
        • Kneepkens C.M.
        • Stok-Akerboom A.M.
        • et al.
        Clinical tube weaning supported by hunger provocation in fully-tube-fed children.
        J Pediatr Gastroenterol Nutr. 2015; 60: 538-543
        • Wright C.M.
        • Smith K.H.
        • Morrisin J.
        Withdrawing feeds from children on long term enteral feeding: factors associated with success and failure.
        Arch Dis Child. 2011; 96: 433-439
        • Clawson E.P.
        • Kuchinski K.S.
        • Bach R.
        Use of behavioral interventions and parent education to address feeding difficulties in young children with spastic diplegic cerebral palsy.
        NeuroRehabilitation. 2007; 22: 397-406
        • Byars K.C.
        • Burklow K.A.
        • Ferguson K.
        • et al.
        A multicomponent behavioral program for oral aversion in children dependent on gastrostomy feeding.
        J Pediatr Gastroenterol Nutr. 2003; 37: 473-480
        • Benoit D.
        • Wang E.E.
        • Zlotkin S.H.
        Discontinuation of enterostomy tube feeding by behavioral treatment in early childhood: a randomized controlled trial.
        J Pediatr. 2000; 137: 498-503
        • Senez C.
        • Guys J.M.
        • Mancini J.
        • et al.
        Weaning children from tube to oral feeding.
        Child's Nerv Syst. 1996; 12: 590-594
        • McGarth Davis A.
        • Bruce A.S.
        • Mangiaracina C.
        • Schulz T.
        • Hyman P.
        Moving from tube to oral feeding in medically fragile nonverbal toddlers.
        J Pediatr Gastroenterol Nutr. 2009; 49: 233-236
        • Silverman A.H.
        • Kirby M.
        • Clifford L.M.
        • et al.
        Nutritional and psychosocial outcome of gastrostomy Tube-Dependent children completing an intensive inpatient behavioral treatment program.
        J Pediatr Gastroenterol Nutr. 2013; 57: 668-672
        • Trabi T.
        • Dunitz-Scheer M.
        • Kratky E.
        • et al.
        Inpatient tube weaning in children with long-term feeding tube dependency: a retrospective analysis.
        Inf Ment Health J. 2010; 31: 664-681
        • Sharp W.G.
        • Stubbs K.H.
        • Adams H.
        • et al.
        Intensive manual-based intervention for pediatric feeding disorders: results from a randomized pilot trial.
        J Pediatr Gastroenterol Nutr. 2016; 62: 658-663
        • Williams K.E.
        • Riegel K.
        • Gibbons B.
        • Field D.G.
        Intensive behavioral treatment for severe feeding problems: a cost-effective alternative to tube feeding?.
        J Dev Phys Disabil. 2007; 19: 227-235
        • Wilken M.
        • Cremer V.
        • Berry J.
        • Bartmann P.
        Rapid home-based weaning of small children with feeding tube dependency: positive effects on feeding behavior without deceleration of growth.
        Arch Dis Child. 2013; 98: 856-861
        • Dunitz-Scheer M.
        • Scheer P.
        • Tappauf M.
        From each side of the tube. The early autonomy training (EAT) program for tube dependent infants and parents.
        Signals. 2007; 15: 1-9
        • Dunitz-Scheer M.
        • Levine A.
        • Ruth Y.
        • et al.
        Prevention and treatment of tube dependency in infancy and early childhood.
        Infant Child Adolesc Nutr. 2009; 1: 73-82
        • Marinschek S.
        • Dunits-Scheer M.
        • Pahsini K.
        • Scheer P.
        Weaning children off EN by net coaching versus onsite treatment: a comparative study.
        J Paediatr Child Health. 2014; 50: 902-907
        • Shalem T.
        • Fradkin A.
        • Dunitz-Scheer M.
        • Sadeh-Kon T.
        • et al.
        Gastrostomy tube weaning and treatment of severe selective eating in childhood: experience in Israel using an intensive three weeks program.
        Isr Med Assoc J. 2016; 18: 331-335
        • De Onis M.
        • Onyango A.W.
        • Van den Broeck J.
        • Chumlea W.C.
        • Martorell R.
        Measurement and standardization protocols for anthropometry used in the construction of a new international growth reference.
        Food Nutr Bull. 2004; 25: S27-S36https://doi.org/10.1177/15648265040251S104
        • World Health Organization
        Child Growth Standards.
        http://www.who.int/childgrowth/standards/en/
        Date accessed: February 20, 2020
        • Baranowski T.
        24-h recall and diet record methods.
        in: Willett W. Nutritional epidemiology. 3rd ed. Oxford University Press, New York2013: 49-69
      1. Tzameret [computer program]. Version 2. Israeli Ministry of Health, Jerusalem2010
      2. Recommended dietary allowances. 10th ed. The National Academies Press, Washington1989
        • Ishizaki A.
        • Hironaka S.
        • Tatsuno M.
        • Mukai Y.
        Characteristics of and weaning strategies in tube-dependent children.
        Pediatr Int. 2013; 55: 208-213
        • Lively E.J.
        • McAllister S.
        • Doeltgen S.H.
        Variables impacting the time taken to wean children from enteral tube feeding to oral intake.
        J Pediatr Gastroenterol Nutr. 2019; 68: 880-886
        • Marinschek S.
        • Pahsini K.
        • Scheer P.J.
        • Dunitz-Scheer M.
        Long-term outcomes of an interdisciplinary tube weaning program: a quantitative study.
        J Pediatr Gastroenterol Nutr. 2019; 68: 591-594
        • Brown J.
        • Kim C.
        • Lim A.
        • et al.
        Successful gastrostomy tube weaning program using an intensive multidisciplinary team approach.
        J Pediatr Gastroenterol Nutr. 2014; 58: 743-749