Tube dependency in the infant

from Wikipedia, the free encyclopedia

Under special dependency or tube dependency refers to an unintended long-term consequence for exclusive enteral nutrition via feeding tube in babies and young children. This leads to a physical and emotional dependence of the child on a probing originally planned as only temporarily in the absence of a medical indication. Tube dependency is therefore an iatrogenically influenced new disorder, which causes a great deal of suffering in children and their families, but is still little noticed in medical circles. Many feeding tubes are placed for a few months with a clear indication (nasogastric tube, gastrostomy tube, jejunal tube), but often without a specific therapeutic support or a precise exit strategy.

causes

Infants and toddlers are affected who have received a temporary feeding tube due to their mostly acute medical situation and who remain dependent on it after the medical necessity has expired, as they cannot make the transition to oral nutrition due to food aversion or disinterest. In most cases, these are premature babies or postpartum surgical patients who have been tube-fed for months. Due to the long duration of the tube and the severity of the underlying disease, the children cannot learn how to eat themselves. With regard to their main medical diagnoses, the children are an extremely heterogeneous group, whereby children with mentally age-appropriate development as well as children with massive developmental delays and complex disabilities are equally affected.

consequences

There are both advantages and disadvantages to tube feeding a child. It is important to wean the children as soon as possible after the medical necessity has expired (usually a desire to gain weight in the absence of the ability to oral nutrition), as the risk of dependence increases the longer it takes.

Advantages of temporary tube feeding are:

  • especially the life-sustaining function of tube feeding ,
  • Improvement of the quality of life at the beginning of the indication,
  • easy controllability of food intake.

Disadvantages are:

  • Excessive vomiting, vomiting, and gagging of food
  • Reflux , probe dislocations, skin irritation and inflammation
  • decreased development of oral autonomy, lack of learning to eat independently
  • Impairments in language, social and motor development, no feeling of hunger
  • active resistance to feeding attempts and active refusal to eat
  • strong defense against any contact with liquid, mushy and solid foods
  • interactive family, social and financial burdens.

Diagnosis

Since probe dependency is a recent disorder / disease and is unknown as such to many medical professionals or not yet recognized as a problem in its own right, there is still no valid diagnostic inventory to classify it. In practice, therefore, the revised form DC 0-3 R is used as a multiaxial diagnostic system for babies and toddlers aged 0-3 years, with the focus on eating disorders. It consists of five axes that are compatible with those of the DSM-IV and allows the division into currently six, previously five, feeding disorders, each with different causes.

  1. Feeding Disorder of State Regulation: Post-traumatic eating behavior disorder (feeding disorder due to regulatory disorder), 601 DC: 0–3 R
  2. Feeding disorder associated with attachment problems, 602 DC: 0–3 R
  3. Infantile anorexia (individuation disorder, infantile anorexia), 603 DC: 0-3 R
  4. Sensory Food Aversions, 604 DC: 0–3 R
  5. Feeding Disorder Associated with Concurrent Medical Condition, 605 DC: 0–3 R
  6. Feeding Disorder Associated with Insults to the Gastrointestinal Tract (Eating Disorder Associated with Disorders of the Gastrointestinal Tract), 605 DC: 0–3 R.

Overall, the behavioral observation of the child is the main focus of the diagnosis.

Tube weaning options

The earlier the feeding tube is removed and the younger the child, the sooner the transition to self-directed eating can take place. Tube weaning must thus an intrinsic part and the aim of the temporary probe indication be the tube dependency should be avoided per se. The tube weaning process requires diet modification under medical supervision and a team that supports the child and parents in the transition to oral nutrition. Accordingly, the following points are essential in the tube weaning process:

  • medical decision to stop tube feeding,
  • Learning process of the child to eat enough orally,
  • Change of attitudes, role understanding and tasks of the parents in the transition phase.

In contrast to the high number of children with long-term probes, only a few research approaches / programs on tube weaning can be found in the literature. McGrath Davis, Schurle Bruce, Mangiaracina, Schulz and Hyman assume a "pain rehabilitation approach". The children who are fed through a tube are treated with medication (by adding neuroleptics), since, according to the researchers' assumption, they may experience pain when taking food. Of the total of nine tube-fed patients examined, who were between seven and 52 months old, 89% were successfully weaned using this method.

In comparison, Benoit, Wang and Zlotkin assume a behavioral approach to tube weaning. In their study, Benoit et al. 15 (47%) of the total of 32 tube-fed children were successfully weaned.

Another important weaning program is the Graz model . The treatment of the Graz model draws on more than 20 years of experience and takes place with a short but intensive multidisciplinary approach:

  • physically-conditioned level (somatic approach): allowing hunger and on
  • Developmental psychological level: development of the child's oral autonomy.

In addition to outpatient and inpatient therapy at the focus center of the University Clinic in Graz, there has been a telemedical treatment alternative of online weaning via a NetCoaching program since 2009.

Overall, the topic is becoming increasingly relevant in (research) literature and there is a strong presence in the media. All over the world there is a large number of newspaper articles and video contributions on the phenomenon of babies and toddlers “not wanting to eat” or “being able to eat”.

Individual evidence

  1. ↑ a b c M. Dunitz-Scheer et al .: Prevention and Treatment of Tube Dependency in Infancy and Early Childhood. In: Infant, Child, & Adolescent Nutrition. 1 (2), 2009, pp. 73-82.
  2. ↑ a b c d e M. Dunitz-Scheer et al .: Tube weaning. In: Pediatrics. 4 + 5, 2010, pp. 7-13.
  3. ↑ M. Dunitz-Scheer, M. Tappauf, K. Burmucic, P. Scheer: Early childhood eating disorders: children are not vessels. In: Monthly Pediatrics. 155 (9), 2007, p. 795.
  4. ↑ a b c S. Oberleitner: Fogopedic intervention in the context of tube weaning using the example of the "Graz model". Graz: unpublished diploma thesis FH Johanneum, 2009.
  5. ↑ a b M. Dunitz-Scheer et al .: Eating or not eating, that is the question here. In: Pediatrics and Pedology. 6, 2004, pp. 1-11.
  6. ↑ M. Dunitz-Scheer et al .: Tube weaning in early childhood. In: Monthly Pediatrics. 149, 2001, pp. 1348-1359.
  7. ↑ a b c d e f Diagnostic classification of mental health and developmental disorders of infancy and early childhood. Revised edition (DC: 0-3R). ZERO TO THREE Press, Washington, DC 2005, ISBN 0-943657-90-3 .
  8. ↑ Davis McGrath, A. Schurle, A. Bruce, C. Mangiaracina, T. Schulz, P. Hyman: Moving from tube to oral feeding in medically fragile nonverbal toddlers. In: Journal of Peadiatric Gastroenterology and Nutrition. 49, 2009, pp. 233-236.
  9. ^ A b D. Benoit, E. Wang, SH Zlotkin: Discontinuation of enterostomy tube feeding by behavioral treatment in early childhood: A randomized controlled trial. In: The Journal of Pediatrics . 137, 2000, pp. 498-503.

Web links