Beyond the G -Tube - Amazon S3 · before you ever start decreasing Tube-feedings • Puree might be better than liquid to elicit swallow because of weight, easier control and slowed

Beyond the G-Tube

Jennifer Meyer M.A. CCC-SLP Feeding and Dysphagia Resources, PC

Beyond the G-tubeJennifer Meyer, M.A. CCC-SLP

Disclosure Statements

I have the following relevant financial relationships in the products or services described, reviewed, evaluated or compared in this presentation.• CEU Espresso, Inc.

• Ownership interest, employee, speaker fee • Feeding and Dysphagia Resources

• Ownership interest, employee, speaker fee

I have no relevant non-financial relationships to disclose

Journey To Oral Feeding

NPO Not gag at sight of food

Pleasure Feeds

Supplemental + Oral Oral

NOTES

Don’t see a tube as FAILUREIt’s a way to provide great nutrition while learning to enjoy sensory aspects of eating, gain confidence in eating skills and become internally motivated to eat enough to grow well.

NOTES

Don’t see a tube as FAILUREIt’s a way to provide great nutrition while learning to enjoy sensory aspects of eating, gain confidence in eating skills and become internally motivated to eat enough to grow well.

G-Tube Placement

• Who? – Patients who need long-term alternative feeding route (>3mos.)• Why? (Morris &Klein, 2000)

• Anatomical abnormalities• Neurological Issues• Aspiration• Fatigue• Pending surgeries• Failure to Thrive (allergies?)• Poor appetite

OSHA Conference 2019

Copyright © Jenifer S Meyer M. A. CCC-SLP 2019 All Rights Reserved

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Different ButtonsMic-Key

• most common



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BARD®

• very flat• interior part is hard and

HURTS when going in/out

Mini-One ®

• a bit lower profile inside and outside

Complications

• Inflammation • Gastric juice leakage• Skin irritation• Infection – esp. fungal• Mechanical – tube occlusion• Granulation tissue/hyperplasia

Inflammation Granulation tissue



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Complications (cont’d)

• Nausea – pressure altered• GERD/NERD• Retching/Gagging

Note: Many parents don’t know about “Burping the tube”:- attach 60cc syringe with plunger removed. -Unclamp. - Hold above stomach and allow air to bubble up.

Getting Ready for Tube Weaning

Plan for Weaning from first day of tube

placement!

It is a PROCESS not a “sudden” decision.

Key Concepts We Will Cover:

Oral Sensory

Stimulation

Meal Concept for

Tube Feeding

GI Diversity Oral Motor Capability

Keys for Successful Tube-Weaning

Sensory:

• Reduce negative/aversive oral stimulation

• Facilitate pleasurable experiences and age-appropriate oral exploration

Motor:

• Maintain suck if at all possible

• Work through developmental progression as appropriate

• If you donʼt use it, you lose it

Association of oral activity and satiety

• During tube feeds:• Oral Play • Tastes

Remember: Transition is a PROCESS!! Therapy starts from first day of tube placement. Even if NPO, still work on:

What Happens When NPO?

• Decreased Sensory input to most sensitive area of body (decreases organization, comfort, exploration)

• Decreased stimulation of suck (also decreases organization, comfort, loss of reflexive suck, decreased stomach secretions for digestion)

• Increased GER (Digestion starts at the mouth!)



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What Happens When NPO?

• Don’t make association between oral sensation and satiety

• Loss of socialization and bonding during feedings

Meal Concept

1. Conducive Environment• State – awake, quiet/active alert (watch meds!)• Position

oAge-typical if possibleoSupported; semi-reclinedoAlignment: neutral head flexion, trunk enlongation,

slight anterior tilt at hips (avoid too much trunk flexion – encourages reflux)

A tube-feeding is still a meal.

Meal Concept

2. Bonding• Cuddle, Eye contact, Voice• Family Meals• Talking, modeling, sights/smells

Food is Love!

Meal Concept

3. Oral component - Provide oral SENSORI-motor stimulation prior to and during tube feeding• Decreases irritability, increased weight gain, easier

transition to oral feeding (Field, et al., 1982; McCain, 1995)

• Smell/Taste?• Massage/Vibration• Pacifier• Mouthing (toys)• Nuzzle empty breast

Meal Concept

4. Bolus• Stretches stomach (4oz in 20 min.)• Get used to “meal”• Can experience hunger between feeds• Try to follow age-typical feeding schedule• No gag or retch during feeds

Meal Concept

5. Set up Environmental Cues for eating• Location• Seating• Utensils• Modeling• Socialization



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GI Diversity

• Infants: • Expressed Breastmilk is considered best (varies fat

content, taste, smell)• With RD can add other flavors

• Older children/adults:• Homemade Blended Formulas

• Vita-Mix (Reduced cost w/letter)• Blend Tech (Free w/letter)

Oral Motor Skills

• Liquid vs. Puree vs. Solids?• Beckman:• Increase quantity before increasing variety• Change flavor before texture/consistency• Meals versus Therapy:

• Strengthening / Exercise/ New foods happen in therapy• When able to take 4 oz – move it to mealtime• Practicing already attained skills happens at Meals

Readiness to Wean

Child Readiness

• Original medical condition resolved?• Current medical status• stable, healthy?

• Oral sensorimotor status• Accepting and able to consume 4 ounces at a time?

Child Readiness

• Swallowing skills• No s/s aspiration on target consistencies

• Weight/nutritional status• Not “borderline” or fragile

• GI Status?• No Reflux or Retching• At least 1 BM per day• Tolerating all daytime feeds

• Interested?

Parent/Caregiver Readiness

§ Consistency, Patience, Perseverance (Wolf & Glass, 1992)

§ Have to be able to follow-through on DAILY feeding activities

§ What are their goals?§ It always takes longer than you think it will.§ Note: The child WILL get sick at some point during the

wean and need to go back up on TF temporarily. Just expect it and don’t get discouraged.



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The actual weaning

Starting the WeanNeed Medical Clearance and RD/LD

§When tolerating ~4oz. by mouth in tx:§ Identify best time of day for oral feeding.§ Offer food first and finish with tube§ Often start with Snacks first; Then start on Meals

§Option A: When taking 50 – 75% of the TF meal by mouth, drop another tube feed.

§Option B: Continue until have replaced one whole TF with oral feeding ; then start on another tube feed

§NEED TO WORK WITH A DIETITIAN TO BALANCE KCAL AND FLUIDS!

Example Schedule

Typical Medical• 8:00 TF 8 oz• 12:00 TF 8 oz• 4:00 TF 8 oz• 8:00 TF 8 oz

32 oz

Closer to Oral Schedule• 7:00 TF 6 oz• 10:00 TF 2-4 oz• 12:00 TF 8 oz• 3:00 TF 4 oz• 6:00 TF 8 oz• 9:00 TF 2-4 oz

30-38 oz

THE PACE

“Therapists frequently strive for repeated gains and changes without pause. This often pushes the infant or child to the point where there may be a functional retreat into less mature but familiar behaviors. Natural plateaus must be allowed and encouraged. The child needs these pauses to stabilize a newly learned behavior before moving on.”

(Morris & Klein, 2000, p.617)

Some Thoughts:

• They need “peristaltic practice”• Everything should be in place and set up for success

before you ever start decreasing Tube-feedings• Puree might be better than liquid to elicit swallow

because of weight, easier control and slowed A-P transit.• Some kids swallow (clean) bath water first.

Techniques to Create Hunger

�Double-check the environmental cues�Once consuming 30kcal 5-6x/day, reduce TF by 25-

50%(Toomey)�Delay TF 30 min. then offer food by mouth�Skip a snack entirely and offer oral 30 min. before

next TF meal�Drop one TF by 25-50% (replace some with water)

BEFORE the time you are trying to increase oral intake.



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FINSHING THE PROCESS

When is Tube Removed?

• Not needed for at least 3 mos.• Gotten through at least 1 illness without using

tube.• Maintained their weight curve for 3 consecutive

checks. (Usually 3 mos.)• Not needed for meds.• No upcoming surgeries• Not flu or RSV season.

Is therapy appropriate for children who will never wean off tubes?

• Recreational eating for sensory enjoyment and development and social interaction• Ability to tolerate oral hygeine activities• Saliva control• Speech Development

“He will eat when he is hungry.”

- NOT!!!

“Parents and therapists mustlisten to the child and let the child set the pace. Health, good growth, and positive mealtime experiences are the most important goals.”

(Morris & Klein, 2000, p.616)

Parent HandoutIn appendices



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What Families Need to Know to Facilitate Eventual Tube-Weaning

• Don’t Stop Oral Sensory Stimulation!• Tube-Feeding is still Mealtime!• Go to Feeding Therapy even when your child/family

member can’t have anything by mouth!• Be mindful of the possible complications.• Take care of the tube site.

Jennifer Meyer, M.A. CCC-SLP

Feeding and Dysphagia Resources, P.C.

[email protected]



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What Parents Need to Know to Facilitate

Eventual Tube-Weaning

Don’t Stop Oral Sensory Stimulation!

If a baby is NPO (can’t eat by mouth), he will have:

– Less sensory input to his mouth and missing out on taste, smell, and temperature experiences. This makes it harder for him to stay calm, and explore and learn about his world.

– Decreased stimulation of the reflexive sucking response. This also can make him more agitated, interfere with digestions, and make it harder to “organize” his perceptions of what is going on and learn and grow.

– Difficulty making the association between something in his mouth and feeling full. He will not understand why he should eat later.

– Less time for interaction and bonding during feedings. He’ll miss out on communication and cuddling most babies get during bottle or breastfeeding.

Go to Feeding Therapy even when your child can’t have anything by

mouth! A Feeding Therapist can help you compensate for these issues by teaching you how to provide appropriate sensory stimulation to his mouth such as mouth play and massage, and encourage sucking on a pacifier. This will help him transition to eating more easily, help him gain wait, and learn to calm himself during fussy periods. She will help you work toward eventual eating by mouth.

Tube-Feeding is still Mealtime!

Think of his tube feedings as meals too because they are. Make sure he is

awake and calm when you begin the tube feeding. Encourage him to suck on a pacifier while being tube-fed so that he will make the connection between sucking and feeling full and satisfied. Talk to him and even hold and cuddle him during the tube feeding just as you would if you were bottle-feeding. Be sure to keep his head well above the level of his tummy to discourage reflux. As your child gets older, sit him at the table with the rest of the family during meals so that he does not miss out on this important time.

As a child gets used to taking “meals” through the tube, his stomach stretches to hold “meal-sized” amounts of food and he experiences hunger between feedings. This too can help the transition to eating by mouth eventually.



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Line up your Resources! Some of the professionals who can help you after going home include: • Feeding Therapist – will help with continued Oral Motor therapy; treating the

Dysphagia (swallowing problems); management of related conditions such as retching, reflux, and aversion; improve trunk strength which can improve swallowing safety; development of pre-speech skills; and assist you with family training and support.

• Registered Dietician – will help you find a formula that works for your child and monitor his growth

• Lactation Consultant – will help you with breastfeeding/milk production • Physician – will help you with some of the complications that you might deal

experience with your child’s feeding tube

Jennifer Meyer, M.A. CCC-SLP Feeding and Dysphagia Resources, P.C.

www.FeedingAndDysphagiaResoures.com [email protected]

214-LETS-EAT



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G-Tube Bibliography Blackman, J. & Nelsen, C. (1985) Reinstituting oral feedings in children fed by gastrostomy tube. Clinical Pediatrics, Vol. 24, No. 8, 434-438

Borowitz, S., & Borowitz, K. (1992). Oral dysfunction following Nissen Fundoplication. Dysphagia, 7, 234-237.

Field, T., Ignatoff, E., Stringer, S., Brennan, J., Greenberg, R., Widmayer, S., & Anderson, G.C. (1982). Nonnutritive sucking during tube feedings: Effects on preterm neonates in an intensive care unit. Pediatrics, 70(3) 381—384.

Fraker, C., Fishebein, M., Cox, S. & Walbert, L (2007). Food Chaining. New York: Marlowe & Company.

Hyman, P.E. (1994). Gastroesophageal reflux: one reason why baby won't eat. The Journal of Pediatrics, 125(6), SI03-SI09.

Kindermann, Angelika (2008) Discontinuation of Tube Feeding in Young Children by Hunger Provocation. Journal of Pediatric Gastroenterology and Nutrition 47(1)

Klein, M.D. & Morris, S.E. (2007). Homemade Blended Formula Handbook. Tucson, AZ:

Mealtime Notions, LLC

Lynch, C., & Fang, J. (2004). Prevention and management of compliciations of percutaneous endoscopic gastrostomy. Practical Gastroenterology. November, 2004. 66-76

Mason, S.J., Harris, G. & Blissett, J. (2005). Tube Feeding in Infancy: Implications for the Development of Normal Eating and Drinking Skills. Dysphagia 20(1), pp46-61.

McCain, G.C. (1995). Promotion of preterm infant nipple feeding with nonnutritive sucking. Journal of Pediatric Nursing, 10(1), 3-8.

Measel, C. P. (1979). Non-nutritive sucking during tube feedings: Effect on clinical course in premature infants. Journal of Obstetrical, Gynecologic, and Neonatal Nursing. 8:265-72.

Monahan, P., Shapiro, B., & Fox, C. (1988) Effect of tube-feeding on oral function. Developmental Medicine and Child Neurology, Annual meeting abstracts, 7.

Morris, S., & Klein, M. (2000). Prefeeding Skills (2nd ed.). Tucson, AZ: Therapy Skillbuilders.

Palmer, M.M., & Heyman, M.B. (1993). Assessment and treatment of sensory-versus motor-bases feeding problems in very young children. Infants and Young Children, 6(2), 67-73.

Palmer (1998). Weaning from gastrostomy tube feeding: A commentary on oral aversion. Pediatric Nursing, Sept-Oct. 1998. Sullivan, P., Morrice, J., Vernon-Roberts, A., Grant, H., Eltumi, M., & Thomas, A. (2006). Does gastrostomy tube feeding in children with cerebral palsy increase repiratory morbidity ? Archives of Disease in Childhood 2006;91:478-482



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Toomey, K. Lester, A. (2009). Picky eaters vs. Problem Feeders: The SOS Approach to Feeding. A presentation sponsored by Education resources, Inc. Wolf, L.S. & Glass, R.P. (1992). Feeding and Swallowing Disorders in Infancy: Assessment and Management. Tucson, AZ :Therapy Skillbuilders.. Zamakhshary, M . Jamal, M., Blair, G., Murphy , J., Webber , E . Skarsgard, E. (2003) Laparoscopic vs percutaneous endoscopic gastrostomy tube insertion: A new pediatric gold standard?. Journal of Pediatric Surgery, Volume 40, Issue 5 , Pages 859 – 862

G-Tube Resources

1. http://health.groups.yahoo.com/group/Blenderized-Diet/

2. http://www.marjoriemeyerpalmer.com/ 3. www.KidsWithTubes.com

4. http://www.notube.at/literature

5. Mary C. Tarbell, M.Ed, CCC-SLP . :

http://www.healthsystem.virginia.edu/internet/speech/clinics.cfm#feeding

6. www.Reflux.org – GERD resources

7. www.MyButtonBuddies.com ($5)



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Documents

Beyond the G -Tube - Amazon S3 · before you ever start decreasing Tube-feedings • Puree might be better than liquid to elicit swallow because of weight, easier control and slowed