TRANSITIONING TUBE FED TODDLERS TO ORAL FEEDINGS 1

Transitioning Tube Fed, Special needs,

Medically Fragile Toddlers, to Oral Feedings.
Brandi Johnson
Jackson College
TRANSITIONING TUBE FED TODDLERS TO ORAL FEEDINGS 2

Transitioning Tube Fed, Special needs,

Medically Fragile Toddlers, to Oral Feedings.
Many people go their entire lives on tube feedings without ever being able to take in

nutrition orally. At Lyle Torrant, a school for special needs children who are medically fragile,

they strive to give their children the most normal life possible. If we can transition these children

to oral feedings, it would just be one less way they are different especially within their home

environments. After seeing one child who was successful in her transition to only oral feedings,

I could not help but wonder, how would you transition patients who are non-verbal and so

medically fragile, who have never physically eaten, to oral feedings? After doing research, I

found two different methods that were successful in their practices.

The first method for transitioning patients from tube to oral feeding was a five-step

program focused on positive reinforcement and behavioral implications and took place only in a

school setting until the patient was fully transitioned in the school setting. The second method

was out patient and focused on the pain associated with the transitional patients. In both settings,

an extensive care team was there to aid in the process and to make sure the patients were

tolerating the entire process. These teams included, speech language pathologist, occupational

therapists, teachers, nurses, caregivers, parents, doctors, a certified cardiovascular perfusionist,

and a social worker. In both methods, the patient had to be evaluated to see if they could tolerate

feedings. They did this with a Modified Barium Swallow. “A physical evaluation was completed

of each child’s oral and oral–pharyngeal anatomy; a review of each child’s oral motor function

and breath control in vocal and swallowing behaviors; and a look at each child’s oral postural

control, saliva control, and behavioral and oral motor response to the introduction of small, test

boluses of liquid and or/puree” (McKirdy, 2008). Once these evaluations were completed and the

doctor approved, the patients then had to be evaluated for their behaviors towards feeding. The
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parents and facilities would work with the patients to ensure that they were showing signs of

readiness, for instance, they would get them used to sitting at a table for meal times without

complaining, they would use a toothbrush to stimulate the patient to get them used to the feeling

and would look for the gag reflex as well. Once all behaviors were demonstrated, they could

then start the second phase of the process.

For the positive reinforcement group, they would feed them bolus feedings for 20

minutes for meal times and 10 minutes for snack times. The bolus was ordered by the doctor

with the max intake per feeding and updated as progress was made. They would reinforce good

behaviors with a peg board and each time the behavior was demonstrated they would take a peg

out and have positive facial and verbal reinforcement. When the patient was deemed ready for

food, they would then introduce them first with water and then slowly introduce feedings. To

move forward, they would still have to show certain behavioral changes that showed the patient

was tolerating and learning. Once the patient was fully on oral foods in the school, they would

then integrate this into the home and community setting. For this method, it took the participants

around a year to complete with four months of additional therapy to maintain.

In the pain method, all patients were given gabapentin, and patients that did not have

seizures or heart disease were given amitriptyline for pain management. These patients went

through oral stimulation as well and before oral foods were introduced at 8 weeks the patients

would then take megestrol to stimulate their appetite. Once started on megestrol, they would

ween from tube feedings and introduce more oral foods for 24 days until the tube feedings were

completely discontinued. The megestrol would only be given for 6 weeks and the other

medications would be given for 6 months. Weights would be measured to verify the patient was

progressing well and tolerating the oral feedings.

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Although the sample size for each of these methods were small, both proved to be

successful. In the pain-controlled group, after 14 weeks all 9 patients were able to tolerate oral

feedings. Eight of the patient were 100% orally fed and one was successful tolerating feedings,

however, could not maintain their weight at 100% oral but was able to maintain weight at a 50%

oral feeding and 50% tube feeding rate. In the positive reinforcement group, there were two

patients only and both were 100% successful in a little over a year to transition the patients to

oral feedings only. In conclusion, there are different methods to transitioning these patients,

however, all patients must be worked with before actually being introduced to oral foods. Each

patient should be examined to see if they can physically and behaviorally tolerate the feedings as

well. There are many steps to take before starting therapy and it will require both time and

patience as this is a big learning process for these patients.

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References

Davis, A. M., Bruce, A. S., Mangiaracina, C., Schulz, T., & Hyman, P. (2009). Moving from

Tube to Oral Feeding in Medically Fragile Nonverbal Toddlers. Journal of Pediatric

Gastroenterology and Nutrition, 49(2), 233–236.

http://doi.org/10.1097/MPG.0b013e31819b5db9

McKirdy, L., Sheppard, J., Osborne, M., & Payne, P. (2008). Transition from tube to oral

feeding in the school setting. Language, Speech & Hearing Services In Schools, 39(2),

249-260.