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Pediatric Dysphagia Evidence Map
Treatment

Tube Feeding

 


 

External Scientific Evidence

  

Evidence-Based Practice Guidelines
British Thoracic Society

British Thoracic Society Guideline for Respiratory Management of Children with Neuromuscular Weakness
Hull, J., Aniapravan, R., et al. (2012).
Thorax, 67 Suppl 1, i1-40.
Added: April 2013

Description

  • This guideline provides recommendations for the assessment and treatment of children with neuromuscular weakness (NMW). The target audiences of this guideline are healthcare professions who care for these children. The guideline provides graded evidence statements and recommendations. Evidence statements are graded as:

    • Level 1 (1-, 1+, 1++) - Meta-analyses/systematic reviews of randomized controlled trials (RCTs) or RCTs with low (1++) to high (1-) risk of bias.

    • Level 2  (2-, 2+, 2++) - Case control or cohort studies or a systematic review of such studies with a minimal (2++) or high (2-) risk of bias.

    • Level 3 - Non-analytic studies

    • Level 4 - Expert opinion

  • The recommendations included in the guideline are classified based on the strength and quality of evidence.

    • Grade A - Based on 1++ or 1+ evidence directly applicable to the target population and overall consistency of results.

    • Grade B - Based on 2++ evidence directly applicable to the target population or extrapolated evidence from studies classified as 1++ or 1+.

    • Grade C - Based on 2+ evidence directly applicable to the target population or extrapolated evidence from studies classified as 2++.

    • Grade D - Evidence level 3 or 4 extrapolated evidence from level 2 + studies.

    • Good Practice Point - Important practice points for which there is no or likely to be no evidence.

Recommendations
"Gastrostomy feeding can improve and maintain adequate nutrition in children with NMW (evidence level 3)" (p. 27).

» See full summary and quality ratings



Feeding Problems of Infants and Toddlers
Bernard-Bonnin, A. C. (2006).
Canadian Family Physician, 52, 1247-1251
.
Added: July 2011
 
Description
This guideline provides recommendations regarding the diagnosis and management of feeding problems in young children. Populations included, but were not limited to, children with behavioral feeding disorders, craniofacial anomalies and neurodevelopmental disabilities. Levels of evidence are provided for recommendations throughout the text. Level I evidence requires at least one well done randomized controlled trial, systematic review, or meta-analysis. Level II evidence requires at least one (preferably more than one) comparison trial, non-randomized cohort, case-control, or epidemiologic study. Level III evidence is based on expert opinion or consensus statements. 
 
Recommendations
Treatment should focus on the elimination of tube feeding and the increased acceptance of oral feeding. Treatment should incorporate the "behavioural technique of extinction" (Level I Evidence), or "gradual desensitization" (Level II Evidence) (p. 1250). 
 
 
 
 
New York State Department of Health, Early Intervention Program; U.S. Department of Education
 
Clinical Practice Guideline: Report of the Recommendations. Motor Disorders, Assessment and Intervention for Young Children (Age 0-3 Years)
New York State Department of Health, Early Intervention Program. (2006).
Albany (NY): NYS Department of Health, Publication No. 4962, 322 pages.
 
 
Added: July 2011
 
Description
This guideline provides recommendations regarding assessment and intervention for young children with developmental motor disorders and cerebral palsy, a static central nervous system disorder.  The target audiences for this guideline are parents and professionals. The recommendations are classified A, B, C, D1 or D2, based on the strength and quality of evidence. Level A recommendations are considered “strong evidence” based on high quality evidence from two or more efficacy studies. Level B recommendations are considered “moderate evidence" and based on evidence from at least one high quality efficacy study. Level C recommendations are "limited evidence" and based on evidence from at least one efficacy study with moderate quality or applicability to the topic.  Level D1 and D2 are consensus recommendations. Level D1 recommendations are consensus panel opinion based on information not meeting criteria for evidence in systematic reviews and Level D2 recommendations are based on information where a systematic review has not been done. 
 
Recommendations
  • Non-oral feeding should be considered for infants with severe dysphagia, children with persistent swallowing problems, and children who are chronically unable to meet nutritional needs with oral feedings alone (Evidence Level D2).
  • Safe transitions from tube to oral feeding should be facilitated and encouraged (Evidence Level D2) (pp. 156–160). 
 
 
 
Royal College of Speech & Language Therapists; Department of Health (UK); National Institute for Clinical Excellence (NICE)
 
Royal College of Speech and Language Therapists Clinical Guidelines: 5.8 Disorders of Feeding, Eating, Drinking & Swallowing (Dysphagia)
Taylor-Goh, S., ed. (2005).
RCSLT Clinical Guidelines. Bicester, Speechmark Publishing Ltd.
 
Added: July 2011
 
Description
This guideline provides recommendations for the assessment and management of swallowing disorders in children and adults. This guideline is intended for speech-language pathologists. Populations included, but were not limited to, stroke, traumatic brain injury, autism spectrum disorder, cerebral palsy, Parkinson’s disease and head and neck cancer. Each recommendation is graded A (requires at least one randomized controlled trial), B (requires at least one well-conducted clinical study), or C (requires evidence from expert committee reports). 
 
Recommendations
  • Speech-language pathologists should be involved in the clinical decision for non-oral nutrition and hydration as part of the multidisciplinary team (Level C Evidence) (p. 70).
  • Children receiving non-oral feeding should be given oral stimulation as appropriate to "normalise sensation and maintain and promote skills" (Expert Opinion) (p. 70).
 
 
 
 
Evidence-Based Systematic Reviews
Slow Advancement of Enteral Feed Volumes to Prevent Necrotising Enterocolitis in Very Low Birth Weight Infants
Morgan, J., Young, L., et al. (2011).
Cochrane Database of Systematic Review(3), CD001241.

This review meets the criteria for a high-quality evidence-based systematic review.
Added: April 2013

Description
This is a review of randomized controlled trials (RCTs) investigating the slow advanacement of enteral feeds on the incidence of necrotizing enterocolitis, mortaility, and time to establish full enteral or oral feeding in very low birth weight or preterm infants.

Conclusions
"The available trial data do not provide evidence that slowly advancing enteral feed volumes reduces the risk of necrotising enterocolitis

» See full summary and quality ratings


Gastrostomy Feeding in Cerebral Palsy: A Systematic Review
Sleigh, G., & Brocklehurst, P. (2004).
Archives of Disease in Childhood, 89(6), 534-539.

This review meets the criteria for a high-quality evidence-based systematic review.
Added: April 2013

Description
This is a systematic review examining the benefits and risks of tube feeding compared with oral feeding in children with cerebral palsy (CP).

Conclusions
The authors concluded that there was limited evidence regarding the effect of tube feeding for children with feeding or swallowing difficulties due to CP. "Moreover, serious issues are raised about a potential increased risk of death, the necessity for further surgical procedures, and some life threatening complications. In addition there is some evidence that gastrostomy feeding has a negative impact for families" (p. 10). The results of this systematic review did not allow the authors to draw any firm conclusions regarding the relative benefits and harms of tube feeding with this population.

» See full summary and quality ratings



Early Trophic Feeding for Very Low Birth Weight Infants
Bombell, S., & McGuire, W. (2009).
Cochrane Database of Systematic Reviews (3).

This review meets the criteria for a high-quality evidence-based systematic review.
Added: September 2012

Description
This is a meta-analysis of randomized or quasi-randomized controlled trials investigating the effects of early trophic feedings in very low birth weight (VLBW) infants.

Conclusions
"There is insufficient evidence to determine whether feeding very low birth weight infants small quantities of milk during the first week after birth (early trophic feeding) helps bowel development and improves subsequent feeding, growth and development. Analysis of eight trials does not suggest that this practice increases the risk of a severe bowel disorder called “necrotising enterocolitis”. Further trials are needed to provide robust evidence to inform this key area of care" (p. 2).

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Tube Feeding in Infancy: Implications for the Development of Normal Eating and Drinking Skills
Mason, S. J., Harris, G., et al. (2005).
Dysphagia, 20(1), 46-61.
Added: September 2012

Description
This is a review of research literature addressing the impact of tube feeding on the establishment of normal oral eating behaviors in infants who have received tube feeding.

Conclusions
“Further research is needed to compare different methods of weaning children off the tube, including the use of overnight or a daily bolus regimen, gastrostomy or NG feeding, and the effectiveness of intensive versus slower transitions from tube to oral feeding” (p. 60).

» See full summary and quality ratings



 
Feeding Protocols to Improve the Transition from Gavage Feeding to Oral Feeding in Healthy Premature Infants: A Systematic Review
Medhurst, A. (2005).
Evidence in Health Care Reports, 3(1), 1-25.

This review meets the criteria for a high-quality evidence-based systematic review.
Added: September 2012

Description
This is a systematic review of randomized or quasi-randomized controlled trials investigating the use of feeding protocols compared to traditional feeding methods in the transition from gavage to oral feeding in healthy premature infants.

Conclusions
"The results of this review suggest feeding protocols may improve the transition from gavage feeding to oral feeding in the healthy premature infant when compared to traditional feeding methods. When utilising feeding protocols the number of days to transit from gavage feeding to oral feeding may be reduced, growth may be maintained and the length of hospitalisation may be reduced. These results must be interpreted with caution due to the possibility of systematic errors in the design, conduct, analysis and reporting of the two RCTs included in the review" (p. 11).

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Continuous Nasogastric Milk Feeding Versus Intermittent Bolus Milk Feeding for Premature Infants Less Than 1500 Grams
Premji, S., & Chessell, L. (2003).
Cochrane Database Syst Rev(1), CD001819
.
 
This review meets the criteria for a high-quality evidence-based systematic review.
Added: March 2012
 
Description
This is a review of randomized and quasi-randomized trials investigating the impact of continuous nasogastric feeding versus intermittent bolus nasogastric feeding in premature infants with a birth weight of less than 1500 grams. 
 
Conclusions
“There is no difference in time to achieve full enteral feeds between continuous and intermittent bolus tube feeding method regardless of tube feed placement. However, the clinical risks and benefits of continuous and intermittent nasogastric tube milk feeding cannot be reliably discerned from current available randomized trials” (p. 14).
 
 
 
 
Does Enteral Nutrition Affect Clinical Outcome? A Systematic Review of the Randomized Trials
Koretz, R. L., Avenell, A., et al. (2007).
Am J Gastroenterol, 102(2), 412-429; quiz 468
Added: July 2011 
 
Description

This is a systematic review of randomized controlled trials (RCTs) addressing the use of enteral nutrition, parenteral nutrition, or volitional nutrition support for individuals with various stages and types of disease processes. Evidence is divided into five grades:

A- One or more high-quality RCTs demonstrated benefit.

B- Evidence of benefit was limited to low-quality RCTS.

C- Inadequate data to decide if a benefit is present or absent.

D- Limited evidence was not able to define a benefit.

E- One or more high-quality RCTs indicated that the intervention was not effective or if there was any evidence it caused harm. 
 
Conclusions
  • PN trophic feedings reduced time to full feeding by 2.7 days and duration of hospitalization by 15.6 days (Grade B).
  • There was insufficient evidence (Grade C) to determine if enteral nutrition was of benefit to other pediatric conditions besides low birth weight infants.
 
 
Gastrostomy Feeding Versus Oral Feeding Alone for Children with Cerebral Palsy
Sleigh, G., Sullivan, P. B., et al. (2004).
Cochrane Database of Systematic Reviews (2).
 
This review meets the criteria for a high-quality evidence-based systematic review. 
Added: July 2011
 
Description
This is a review of randomized controlled trials investigating the effect of gastrostomy feeding as compared to oral feeding for children with feeding/swallowing difficulties secondary to cerebral palsy. 
 
Conclusions
  • No controlled trials comparing the delivery of nutrition via a tube feeding and oral feeding were found.
  • Lack of evidence does not support or refute the effectiveness of treatment.
 
 
 
Treatment for Swallowing Difficulties (Dysphagia) in Chronic Muscle Disease
Hill, M., Hughes, T., et al. (2004).
Cochrane Database of Systematic Reviews (2).
 
 
This review meets the criteria for a high-quality evidence-based systematic review.
Added: July 2011
 
Description
This is a systematic review of randomized trials addressing dysphagia management in people with chronic muscle disease. 
 
Conclusions
This review examined a number of treatment options including dietary modification, swallowing maneuvers, surgical intervention, and enteral feeding. The authors concluded that "no trials have adequately evaluated treatments in the management of dysphagia for chronic muscle disease. It is therefore not possible to decide the most appropriate treatment for a given individual based on current evidence" (p. 1). 
 
 
 
 
Early Discharge with Home Support of Gavage Feeding for Stable Preterm Infants Who Have Not Established Full Oral Feeds
Collins, C. T., Makrides, M., et al. (2003).
Cochrane Database of Systematic Reviews (4).
 
 
This review meets the criteria for a high-quality evidence-based systematic review.
Added: July 2011
 
Description
This is a review of randomized and quasi-randomized trials that investigated the impact of early discharge home with gavage feeds and health care support versus later discharge home when full sucking feeds are attained in pre-term infants who have not established full oral feeds. 
 
Conclusions
"The home gavage program was not associated with any significant effect on the duration or extent of breast feeding or weight gain" (p. 7). 
 
 
 
 

Clinical Expertise/Expert Opinion

 
Consensus Guidelines  
American Speech-Language-Hearing Association
 
Roles and Responsibilities of Speech-Language Pathologists in the Neonatal Intensive Care Unit: Guidelines
American Speech-Language-Hearing Association. (2005).
Retrieved from: http://www.asha.org/docs/html/GL2005-00060.html
 
Added: July 2011
 
Description
This is a guideline providing recommendations on the roles and responsibilities of speech-language pathologists (SLPs) providing care in the Neonatal Intensive Care Unit (NICU). Recommendations are provided pertaining to assessment and management of communication, feeding, and swallowing of infants. 
 
Recommendations
  • The effects of nasogastric tubes in very low birth weight infants may include:
    • A longer transition from tube to oral feeding
    • Increased duration of desaturation during oral feeding
    • Oxygen saturation is lower before, during, and after feeding in infants receiving oral feeding as opposed to osogastric tube
    • Infants with nasogastric (NG) tubes in place demonstrate decreased nasal airflow, increased airway resistance, and abnormal airflow distribution
    • Insertion of NG tube stimulates the larynx and increases the risk of laryngospasm, apnea, and bradycardia. Pharyngeal and esophageal trauma are also possible.
  • One set of guidelines suggest that infants should not be expected to demonstrate the ability to suckle and swallow until 32 weeks gestation. “Stable 32-week gestation infants can be put to the breast safely for early feeding experiences, while they may not be ready for bottle-feeding until about 34 weeks gestation” (p. 11).
  • Transitioning challenges may relate to limitations in control of flow rate. “It is important to avoid fast flow nipples (e.g., ‘preemie’ nipples and ‘orthodontic’ nipples) (Vadenberg, 1990b)” (p. 12). Alternatively, the free-flow of formula from the nipples has been proposed. It was found that “preterm infants could divert excess formula flow by drooling as an efficient airway protective behavior” (p. 12). Some evidence also supports cheek and jaw support to enhance suckling efficiency in preterm infants.
  • Mixed results have been demonstrated on the use of various alternatives to the breast when the mother is not present for feeding. These include the use of a cup instead of bottle, NG tube supplements, an orthodontic nipple, and a nipple shield.

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Client/Patient/Caregiver Perspectives

 
Gastrostomy Placement in Paediatric Patients with Neuromuscular Disorders: Indications and Outcome
Ramelli, G. P., Aloysius, A., et al. (2007).
Developmental Medicine & Child Neurology, 49(5), 367-371.
Added: April 2013

Description
This is a study of 32 children with neuromuscular disorders and a gastrostomy tube for feeding. This study examines the impact of the feeding tube on nutrition, growth, and quality of life.

Conclusions
"Three of the patients followed-up were not entirely were not entirely satisfied with the intervention because of post-gastrostomy GOR [gastro-esophageal reflux], increased secretions, and poor feed volume toleration. These were complications noted soon after gastrostomy placement and may have been resolved with secondary management" (p. 370).

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Percutaneous Endoscopic Gastrostomy in Cystic Fibrosis: Patient Acceptance and Effect of Overnight Tube Feeding on Nutritional Status
Van Biervliet, S., De Waele, K., et al. (2004).
Acta Gastro-Enterologica Belgica, 67(3), 241-244.
Added: April 2013

Description
This is a study of 11 children with cystic fibrosis and a percutaneous endoscopic gastrostomy tube. The study examines the acceptance of the tube feeding by children and caregivers and the effect of tube feeding on nutritional status.

Conclusions
Ten of the eleven patients were relieved with the placement of the tube since it eliminated concerns and discussions regarding the quantity of food to be consumed. Parents indicated more difficulty accepting the tube than the children.

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Percutaneous Endoscopic Gastrostomy in Children: A Safe Technique with Major Symptom Relief and High Parental Satisfaction
Avitsland, T. L., Kristensen, C., et al. (2006).
Journal of Pediatric Gastroenterology and Nutrition, 43(5), 624-8.
Added: September 2012

Description
This retrospective study looks at the long-term results of percutaneous endoscopic gastrostomy (PEG) in children.  In addition to collecting information on morbidity, indications for PEG, preoperative findings, and perioperative complications, a subset of parents and caregivers were interviewed.

Conclusions
“At long-time follow-up, an overwhelming proportion of parents/caregivers were very satisfied with the gastrostomy and the way it had influenced theirs and their child’s general situation” (pp. 626-627).

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Safety and Caregiver Satisfaction with Gastrostomy in Patients with Ataxia Telangiectasia
Lefton-Greif, M. A., Crawford, T. O., et al. (2011).
Orphanet Journal of Rare Diseases, 6(23), 1-10.
Added: September 2012

Description
This retrospective study was conducted to determine if gastrostomy tube (GT) feeding is tolerated in children with a rare neurodegenerative disease, Ataxia Telangiectasia (A-T). Measures of caregiver satisfaction were also collected. 

Conclusions
Caregivers and patients viewed tube feedings as usually easy to administer and caregivers were almost always satisfied with having the GT’s placed” (p. 6 of 10; in Results section).

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Decision-Making Around Gastrostomy-Feeding in Children with Neurologic Disabilities
Mahant, S., Jovcevska, V., et al. (2011).
Pediatrics, 127(6), e1471-81.

This review meets the criteria for a high-quality evidence-based systematic review.
Added: September 2012

Description
This is a review of qualitative research literature exploring parents’ experiences with tube feeding with their children with neurologic disability.

Conclusions
The major source of decisional conflict relates to the meaning of feeding by mouth and feeding through a tube for parents and the values they place on them. Contextual factors unique to child and family and process factors related to information exchange and support are also important in understanding and improving the decision-making process” (p. e1480).

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The Impact of Child Tube Feeding on Maternal Emotional State and Identity: A Qualitative Meta-Analysis
Wilken, M. (2012).
Journal of Pediatric Nursing, 27(3), 248-55.

This review meets the criteria for a high-quality evidence-based systematic review.
Added: September 2012

Description
This is a meta-analysis of qualitative literature investigating the impact of a child's tube feeding on the emotional state of the mother and maternal identity development.

Conclusions
"Overall, tube feeding is associated more with increased stressful or traumatic experience, a decrease in normalcy, and negative impacts upon the motherhood constellation themes than with improvements in the mother-child relationship, freedom from feeding battles, or improvements in the child's medical situation" (p. 252).

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Early Decision of Gastrostomy Tube Insertion in Children with Severe Developmental Disability: A Current Dilemma
Martinez-Costa, C., Borraz, S., et al. (2011).
Journal of Human Nutrition & Dietetics, 24(2), 115-121
.
Added: July 2011
 
Description
This study provides results from a structured questionnaire administered to the parents of 26 children with severe developmental disabilities fed via gastrostomy tube (GT).  The study results included parent satisfaction with GT feeding. 
 
Conclusions
  • Ninety-one percent of families were very satisfied with GT feeding.  
  • Parents reported improved nutritional status, decreased respiratory infections, and reduced feeding time. 

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Different Priorities: A Comparison of Parents' and Health Professionals' Perceptions of Quality of Life in Quadriplegic Cerebral Palsy
Morrow, A. M., Quine, S., et al. (2008).
Archives of Disease in Childhood, 93(2), 119-25.
 
Added: July 2011
 
Description
This is a study of 21 parents of children with quadriplegic cerebral palsy (CP) attending a multi-disciplinary feeding clinic. The aim of the study was to identify the primary aspects of feeding-related quality of life for the children from the parents' perspective and compare the results with the perceptions of the health professionals. 
 
Conclusions
  • "The majority of parents of children with gastrostomies reported a positive experience due to reduced time impact, decreased burden of care and improved physical comfort for the child" (p. 121).
  • With gastrosotomy, parents reported reduced concern regarding safe, adequate nutrition and hydration and medication administration. They also reported reduced dependence on one caregiver for feeding.
  • Parents with a positive view of tube feeding typically considered it necessary for their child's survival.
  • "Parents with a negative experience of gastrostomy described unacceptable complications (e.g., tube falling/being pulled out, infections), poor follow-up services and resources, and deterioration in the child's health, happiness or socialisation" (p. 121).
  • Some parents felt they were "pressured into accepting a gastrostomy or had not been informed of the potential negative aspects of gastrostomy" (p. 121).
  • Many parents believed that tube feeding meant discontinuing efforts to orally feed.

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The Impact of Percutaneous Endoscopic Gastrostomy Feeding in Children; The Parental Perspective
Brotherton, A. M., Abbott, J., et al. (2007).
Child: Care, Health, and Development, 33(5), 539-46.
 
Added: July 2011
 
Description
This is a cross-sectional qualitative design study of 24 parents of children receiving percutaneous endoscopic gastrostomy (PEG) feedings. This study examines the impact of PEG feeding on daily life for both the parents and the children. 
 
Conclusions
  • "Most parents were happy with their child's regimen and the perceived QoL [quality of life]" (p. 542).
  • Some difficulties with tube feedings were noted. These included extreme fatigue due to night-time feedings, restricted ability to engage in outside activities or family holidays, difficulties in finding a place to feed outside of the home, childcare problems because of others' reluctance to tube feed the child, and attitudes of others toward the tube feedings.
  • Parents reported that tube feedings also brought positive aspects. These included less pressure at mealtimes to make sure the child received adequate nutrition and a safe and effective way to administer medications to the child.
  • Some parents reported that the PEG feedings did not offer the same bonding experience as bottle or breastfeeding.
 
 
 
Mothers' Voice: A Qualitative Study on Feeding Children with Cerebral Palsy
Sleigh, G. (2005).
Child Care Health Dev, 31(4), 373-383.
 
Added: July 2011
 
Description
This is a qualitative study of carers of children with cerebral palsy. This study examines the perceived impact of oral versus non-oral feeding of carers for children with severe feeding/swallowing difficulties. 
 
Conclusions
  • Respondents in both oral feeding and non-oral feeding via gastronomy groups indicated that "professional support for oral feeding should be given a higher priority" (p. 373).
  • A number of respondents indicated frustration when fighting for entitled support.
 
 
Parents' Perspectives on Feeding Medically Compromised Children: Implications for Occupational Therapy
Franklin, L., & Rodger, S. (2003).
Australian Occupational Therapy Journal, 50(3), 137-147.
 
Added: July 2011
 
Description
This is a qualitative study of eight families with children with chronic medical conditions requiring tube feeding. This study examines the impact of feeding difficulties on parenting and family life. 
 
Conclusions
"All families found managing tube feeding stressful, but acknowledged that the tube helped them manage their anxiety by ensuring their child was getting adequate nutrition" (p. 144). 
 




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