Weaning off the Feeding Tube

Indication and contraindication for weaning off the feeding tube
Evaluation of a diagnostic schedule in a pediatric sample

Background: Enteral feeding in pediatric samples has significantly increased. The main factors resulting in higher rates of enteral-fed children are advances in medicine technology and knowledge. These advances lead to a better enteral application technique and to a higher survival rate of children with complex diseases. In some cases tube dependency results from a medical diagnosis, which make oral feeding unsafe, e.g. neurological dysphagia with high aspiration rates. But in most cases oral feeding is considered possible. A common problem is the indication for terminating enteral feeding. A diagnostic schedule to evaluate if oral feeding should be established is lacking.
Methods: The study has been designed to address this topic in three phases.
Phase 1- Literature review: All relevant publications on indications and contraindications for tube feeding and tube weaning have been systematically scanned to identify specific exclusion criteria for feeding tube weaning.
Phase 2- Development: Results from the literature review will be discussed in the study group and with external experts. From this the essential diagnostic areas and the exclusion criteria should be defined. 
Phase 3- Evaluation: An indication and contraindication schedule will be evaluated in all cases where tube weaning may take place.

Published: Wilken, M. & Jotzo, M. (2008). Evaluation eines diagnostischen Leitfadens zur Indikation und Kontraindikation von Sondenentwöhnung. AC Hauer & J Deutsch (Hrsg.) 23. Jahrestagung der Gesellschaft für pädiartrische Gastroenterologie und Ernährung. Abstracts der Vorträge und Posterbeiträge. Heilbronn: SPS Publications. S 24.


Qualitative Analysis of the Tube Weaning Process

The prevalence of enteral feeding in the pediatric population has significantly increased. In the majority of cases it is assumed that oral feeding would be possible. For these cases, a tube weaning therapy has been developed and evaluated. In this article, the tube weaning process is described and qualitatively analyzed.
Case Description: Female very low birth weight toddler (24+6 weeks gestational age, birth weight 390g) who has been 100 % enteral-fed. At the age of 2.5 years a tube weaning therapy was executed.
Methods: A feeding therapist and an assistant kept a daily therapy diary, following the concept of qualitative introspection. The parents and the Castillo Morales therapist added their reflections to the diary.
Discussion: The therapy was successfully completed, in spite of the fact that it has been discontinued due to a severe infection. The therapy process followed a non-linear dynamic. This necessitates a high degree of flexibility, experience and endurance in all involved persons.

Publication: Wilken M, Cremer V, Prüß J, Jotzo M. Sondenentwöhnung als Prozess. Ein qualitativer Einblick in einen Therapieprozess. L.O.G.O.S. Interdisziplinär 2008; 16 (in press).


Feeding Disorder and Development

Feeding Adversity Scale
Granted by: German National Academic Foundation

Objectives: LBW premature infants are at high risk of early onset feeding disorder. The Feeding Adversity Scale (FAS) has been constructed in order to diagnose feeding disorders in premature infants. The goal of this study is to assign cases to early intervention programs.
Patients and methods: 46 of 122 cases born weighing less than 2000g (male: 20, female: 26, Age M=12 mon. +/-2.8) have been included. Mean birth weight was 1307g +/-446. The Feeding Adversity Scale, Child Vulnerability Scale, Developmental Score, symptoms of feeding disorders and psychosocial status were evaluated by parental reports and questionnaires.
Results: The internal consistency was α=.83. The split-half reliability after Spearman-Brown correction was α=.82. The cut-off value of the FAS correctly assigns all cases of food refusal. The FAS showed better validity than the Developmental Score or Child Vulnerability Scale in relation to food refusal. The validity was estimated at r=.72.
Conclusions: The FAS is a useful tool for systematic screening for feeding disorders in premature infants.

Published: Wilken M. The Feeding Adversity Scale (FAS): Development and evaluation of a psycho-diagnostic instrument for early-onset feeding disorders in premature infants. PhD-Thesis, 2008: University of Osnabrueck.


Parental Trauma in NICU

Development and evaluation of an intervention program for parents of preterm infants during the infant’s hospital stay
Martina Jotzo, PhD
Objectives. The intervention study, incorporating a control group design, is aimed at the development and evaluation of a crisis intervention program for parents of preterm babies during hospitalisation in a neonatal intensive care unit (NICU). Theoretical bases are: a model of transition to parenthood (Gloger-Tippelt, 1988); approaches to the parent-infant relationship (preterm birth as an emotional crisis – Caplan, 1960; Kaplan et al., 1960; Owens, 1960; a sensitive period and early contact – Klaus et al., 1978, 1983a,b; interaction analysis – Goldberg 1979; a transactional model of development – Sameroff, 1975); a stress and coping theory (Lazarus, 1981; Lazarus et al. 1981, 1984) as well as a model of psychological traumatization (Fischer et al., 1998).
A preliminary study evaluated whether the preterm birth of a baby causes trauma for the parents. 65 mothers and 13 fathers of premature infants answered retrospective questionnaires. The questionnaires assessed the traumatic impact of the premature birth and the main variables influencing the level of symptomatic response to the trauma. The sample came from a self-help forum for parents of premature babies on the internet. The share of mothers with a clinically significant trauma connected to the preterm birth was 77% in the first month after birth, 49% one year after birth, and 17% more than four years after birth. The share of fathers with a significant trauma was 23% in the first month after birth and 27% one year after birth, compared to 13% more than four years after birth. Despite being significantly limited as to how representative they are, these results show clearly that the preterm birth of a child may have a traumatic impact on parents.
The central questions of the main study are twofold:

  1. An intervention program was developed which contained general trauma-preventative components (Slaikeu, 1990; Fischer et al., 1998) as well as components specifically geared towards premature birth (Meyer et al., 1993; Sarimski, 2000). The intervention effects were evaluated. The question examined was whether parents who had participated in the intervention program differed in substantial outcome variables from parents who did not receive intervention.
  2. On the basis of the theoretical concepts above, a model of the parents’ psychological processes following the premature birth of their baby was developed. This model was evaluated by testing the connections between the variables of the model.

Methods. Data collection took place in an NICU. A total of 53 mothers and 27 fathers participated (26 mothers and 15 fathers in the intervention group, 27 mothers and 12 fathers in the control group). Parents in the intervention group received a one-off intervention in the form of structured crisis intervention in the first few days after the birth, while parents in the control group did not receive any intervention. When the children were discharged, parents of both groups answered a questionnaire, covering key outcome and/or model variables. The questionnaires tested for (1) Previous traumatization, dissociative experience throughout premature delivery; (2) stressors with reference to the NICU, the threat experienced as a result of the premature birth, coping, and resources during the baby’s hospitalization; and (3) symptoms of traumatization, sense of well-being, and parental self-efficacy beliefs at the point of the child’s discharge from hospital. In addition, important sample and control variables were collected.
The results pertaining to the fathers are not discussed since sample size is too small and the data are not independent (all fathers were partners of participating mothers).
Results. The main results of the study are the following:

  1. The intervention had a significantly positive overall effect on mothers. Intervention group mothers showed significantly lower levels of symptomatic response to the traumatic stressor as well as significantly more positive feelings of well-being than control group mothers. In addition, significantly positive single effects show up in intervention group mothers with regard to stressors in the NICU, those related to the threat experienced, as well as aspects of the parental self-efficacy beliefs.
  2. The model assumptions are confirmed by both intervention and control group mothers regarding the prediction of well-being indicated by the level of symptomatic response to the traumatic stressor, as well as the prediction of parental self-efficacy beliefs indicated by the level of social support, the sense of well-being, and the threat experienced as a result of premature birth.
Conclusions. Early crisis intervention for mothers of premature babies in the neonatal inten­sive care unit proved very effective in this study. The results show that an intervention that is oriented to the principles of crisis intervention and geared towards the specific problems in premature birth clearly reduces the symptomatic response to the traumatic stressor. This corresponds to findings from secondary trauma prevention. In addition, the form of intervention evaluated here is very economical, as it consists of a one-off crisis intervention program.