 Transition to Oral Feeding Is Not Always Easy . . . page 2 Steps for initiating the transition to oral feeds (1,2,8,9,10) a) Promoting a positive feeding relationship between the caregiver and child Children who are tube fed from birth may have missed the parent-child bonding that occurs around feeding, impairing their ability to form a good interpersonal relationship. Parents who are given anticipatory guidance about common feeding problems may be able to better respond and prevent them from becoming major problems. Parents who have not been taught what to expect during feedings may begin to dread mealtimes, or become abrupt with the infant or toddler who cries or exhibits other feeding misbehaviors. Caregivers need to be made aware of the time required and the behavioral feeding techniques likely to be needed. b) Normalizing the feeding schedule and environment The feeding schedule should be adjusted to more closely resemble a normal eating pattern. A structured schedule of consistent feeding times should be established. For toddlers, the tube feedings should be given at the family's regular meal times in order to familiarize them with the social nature of eating. Continuous feeds should be changed to an intermittent bolus schedule that approximates normal oral feedings in timing and quantity. Energy intake via the tube feeding should be decreased by 10-25%, depending on the age and nutritional status of the child, to allow a sense of hunger to develop. No food or drinks should be given between. Water may be given if the child is thirsty, but not within the 2 hours before a feeding. Feeding time should be limited according to age (approximately 20-30 minutes.) Feedings should take place in a quiet place with few distractions and the feeder should have a calm positive attitude. The young infant should be fed in a comfort able, upright position, while the older infant or toddler should be positioned comfortably in a developmentally appropriate seat. c) Choosing what to offer first Premature infants at 32 weeks gestation have demonstrated the ability to coordinate sucking with swallowing and breathing when fed at the breast. Breastfeeding offers a distinct advantage over bottle-feeding when it comes to effective swallowing, as the breastfed infant often sucks 2-3 minutes before the let down of milk delivers fluid to the pharynx. This gives the infant time to prepare for swallowing. (7) Although the initial feedings may be brief in duration, success should not be measured by the volume consumed, but by the enjoyment of the baby and mother and the opportunity to practice oral motor skills. When the infant is not yet ready to be exclusively nourished at the breast, additional expressed breastmilk given by bottle or tube feed may be required. In circumstances where expressed breastmilk is not available, commercial formulas for preterm, or full-term infants are the next best alternatives. When the infant feeds vigorously, nurses from both breasts at each feeding, and gains weight steadily, bottle-feeding may be discontinued. For bottle-fed infants, a variety of nipples should be tried. High flow rate nipples should be avoided during weaning to oral feedings as they may allow milk to flow without active sucking. This by passes the oral phase of swallowing, flooding the nasopharynx and catching the infant unprepared for the passage of milk through the pharynx into the esophagus. For older infants or toddlers with no history of oral intake, foods/fluids that are developmentally appropriate, rather than age appropriate, should be chosen. For children who have fed orally before, choose from foods that have been liked or accepted in the past. A thicker food consistency gives the child more time to coordinate oral-pharyngeal movements for the suck-swallow sequence. Thicker textures also give more tactile feedback, reducing the chance of choking. d) Presenting food to the older infant and toddler Before introducing food on a spoon, it may be helpful to allow the child to first taste the food by placing a small amount on the gums, lips, or tongue. Start with very small quantities to avoid overwhelming the child. The feeder should offer the food in a neutral manner; attention in the form of positive reinforcement (e.g. praise, clapping) should be provided immediately following desired eating behaviours (e.g. accepting the spoon in the mouth). Toddlers should be given 15-30 seconds to accept offered foods or fluids. If the child demonstrates food aversion or feeding misbehavior, care should be taken not to provide positive reinforcement through increased attention such as coaxing or playing games. It may be necessary to stop and try again at the next feed. e) Establishing criterion for success Oral intake should be increased slowly. As the child begins to demonstrate consistent oral intake, resolving feeding problems, and maintenance of weight or weight gain, tube feeding can be decreased by an additional 25%. When approximately 75% or more of calories are taken orally, tube feeding can be discontinued. However, the gastrostomy tube should remain in place until the child has demonstrated consistent oral feeding for a minimum of six weeks. If the comprehensive assessment suggests that the child with eating problems is able to feed orally, it should be suspected that the problem is an unwillingness to eat. If the previous steps for establishing oral feeding have been unsuccessful, a behavioural approach to the treatment of food aversion may be more effective. (1,5,9,10) An approach that breaks down eating into small, learnable steps or components may be an effective means of introducing eating skills and desensitizing patients to eating fears. For children who have used food refusal to manipulate or control their environment, a behavioral approach can focus on improving the existing parent-child interactions. As a result, appropriate eating behavior is reinforced by the providers of care, and attention is withheld for behaviour such as crying, choking, or struggling, which often occur as the child attempts to terminate feeding efforts. The transition to oral feeding can occur quickly (within weeks ) or be protracted (months to years). Success requires confidence and 'tough-love' from the caregivers feeding the child; reluctance to be firm and push the child sufficiently hinders progress in many instances. Success is most likely to occur when there is good collaboration between the family and multidisciplinary team, and a positive feeding relationship between the children and their caregivers. (10) Conclusion The transition to oral feeding is often uneven. Early identification, assessment and treatment of feeding difficulties is required to help parents and caregivers cope with these stressful problems and prevent them from becoming more complex. Health care professionals working with tube-fed infants and children should seek to become familiar with the causes of oral feeding problems and recommendations regarding their prevention and management. |
