Tube Weaning: Transition From Enteral to Oral Feeding

Successful tube feed weaning models have been demonstrated in inpatient, outpatient, and virtual health settings utilizing different approaches, with varying intensity and medical supervision (Lively, McAllister, & Doeltgen, 2019) (Marinschek, Pahsini, & Doeltgen, 2019) (Williams, et al., 2017) (Mirete, et al., 2018) (Lively, McAllister & Deltgen 2020). Results of these programs suggest that with appropriate support and monitoring, successful reduction or complete weaning from tube feeds is possible for certain children (Krom, de Winter, & Kindermann, 2017).

The approaches used to develop tube weaning programs regardless of setting can be characterized as behavioural, child- and family-centred, and biomedical (Lively, McAlister & Deltgen 2020).

A behavioural approach focuses on the psychological aspect of feeding and unlearning the association between food, caregiver, and trauma. Feeding therapists support the child with oral sensorimotor skill building prior to manipulating appetite. Meals are provided by clinical staff during the early stages of weaning. Conditioning tools are used by feeding therapists and caregivers are brought into therapy when aversive behaviours are unlearned.
A child- and family-centred approach focuses on the parent-child relationship, combining developmental, biological, and therapeutic aspects of feeding. Appetite manipulation is started early in the intervention to help the child learn feelings of hunger and regulation.
A biomedical approach focuses on eating as a biological process combining intensive hunger provocation with a behavioural approach. The biomedical approach is often used in inpatient intensive weaning programs, may include medication, and requires close medical monitoring.

Outpatient or home-based tube weaning programs are recommended as first-line therapy to support a child-led approach, while intensive inpatient weaning programs may be used if outpatient weaning attempts are unsuccessful (Silverman, et al., 2013); (Slater, et al., 2021); (Clouzeau, et al., 2021); (Dipasquale, et al., 2021). Outpatient programs build oral sensorimotor skills and food acceptance over a longer period before enteral feed reduction is started. Intensity of therapy and hunger provocation are increased, and are implemented in the child’s home, in-person, via telemedicine, or in an interdisciplinary clinic (Hartforff, et al., 2015); (Wiken, Cremer, Berry, & Bartmann, 2013); (Slater, et al., 2021).

Few specific unique models for tube weaning exist. The Graz model of tube weaning incorporates all three approaches described above, however, with less intensity than an inpatient program. An interdisciplinary team supports the child and family over several weeks implementing hunger provocation (enteral feed reduction), daily play picnics, feeding therapy, music therapy, growth monitoring, and medical monitoring. This model has been successfully applied in a telemedicine format.

Oral stimulation (e.g. non-nutritive sucking or manual touch) prior to initiating oral or enteral feeding reduces time to transition preterm infants from tube to breast or bottle (Fucile, Wener, & Dow, 2021); (da Rosa Pereira, Levy, Procianoy, & Silveira, 2020); (Say, et al., 2019). Infants fed using a developmental and cue-based feeding protocol reach full oral feeding sooner and are often discharged from hospital sooner than those fed with a volume-based protocol (Morag, Hendel, Karol, Geva, & Tzipi, 2019).

Successful tube weaning models are tailored to the child, involve an interdisciplinary team, utilize a combination of approaches, and are characterized by:

Readiness for oral feeding (safe swallow and oral sensorimotor skills)
A positive feeding relationship
Normalization of feeding and eating behaviours
Use of behavioural technique to increase oral intak