COMMON BEHAVIOR DISORDER IN CHILDREN AND MANAGEMENT.pptx
Wilken Pediatric Feeding Tube Weaning
1. FEEDING TUBE WEANING
Sydney
Markus Wilken
Saturday 12 Nov.
Germany Novotel Sydney Manly Pacific
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 tube
Most important: Ensure survival of critically ill children
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. BASIC DOMAINS OF ORAL FEEDING
WHAT DO WE NEED TO EAT?
• Oral-motor and sensory development
• Motor development
• Health
• Initiative
• Interactional routines
5. TUBE FEEDING & FEEDING
DISORDER
How does tube feeding result in Feeding Disorder?
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. WHAT IS A FEEDING DISORDER?
…a good question! Because:
There are no universally accepted definitions or validated classifications of
common FDs (Feeding Disorders) of infancy.“
(Benoit, 1999, S. 339)
Symptoms of feeding disorder:
• Food refusal
• Vomiting
• Force feeding
• Pre- oral resistance
• And many more
9. THE DIAGNOSTIC MAINFRAME
A 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)
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. 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. 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?
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. HUNGER INDUCTION
Before day 1 day 2 day 3 day 4 day 5
10. am 130 50
1 pm 130 130 130 120 90 60
5 pm 130 130 130 130 130 130
night 400 400 370 300 250 200
Total 790 710 630 550 470 390
day 1 day 2 day 3 day 4 day 5
Fluidal Intake
Nutrition intake
Urin/Bowl Move
Weight
Sleep Behavior
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. PLAY PICNIC
LET THE CHILDREN PLAY
• Anything goes:
• Children define the rules
• All initiative is in the children's hands
• Nothing has to happen:
• No playing, just observing
• Not touching, just smelling
• Not eating, just playing
• No play picnic
• It is the child's choice
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. PSYCHOLOGICAL FEEDING THERAPY
• If the child doesn't 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 doesn't understand me…
• Adjust my communication to the child
Treatment without words needs more
therapeutic intuition than technique.
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. 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. MAIN FRAMEWORK
• Home-based treatment means:
• Treatment at the child's environment
• In the child's circadian rhythm
• Demand on the therapist:
• Flexibilty (free time schedule)
• Developmental knowledge
• Therapeutic skills
• Intuition
• Feeding tube weaning is hard to predict
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. 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. FEEDING BEHAVIOR
Failed Failed
Successful Successful
P Before After
before treatment after treatmentb
treatment treatmentb
Feeding 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. GROWTH AND TUBE FEEDING
Before After
P
treatment treatment a
Body weight (z-score) 1 -2.5 (1.5) -2.6 (1.1) .24
Body (z-score) 1 -2.8 (2.1) -2.5 (1.5) .49
BMI (z-score)1 -1.1 (1.7) -1.2 (1.1) .77
Feeding 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) .001
Values are either mean (SD) or number (%). Comparisons were done using two-sided t-tests1 for ordinate data or X² test2 for
frequency distributions. aFollow up one to three years after treatment.
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*