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To (tube) feed or not to (tube) feed: how to decide?

To (tube) feed or not to (tube) feed: how to decide?. Charlotte M Wright Honorary Consultant Paediatrician, RHSC Yorkhill Professor of Community Child Health Glasgow University. Yorkhill Feeding Clinic. Psychologist, Dietetician, Paediatrician Set up in 2002 to:

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To (tube) feed or not to (tube) feed: how to decide?

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  1. To (tube) feed or not to (tube) feed: how to decide? Charlotte M Wright Honorary Consultant Paediatrician, RHSC Yorkhill Professor of Community Child Health Glasgow University

  2. Yorkhill Feeding Clinic • Psychologist, Dietetician, Paediatrician • Set up in 2002 to: • Wean children ‘stuck’ on tube feeding • Work with weight faltering children at risk of tube feeding • Assess need for tube feeding where there is doubt • Assessment • Review full medical, dietary and behavioural history • Detailed growth and body composition assessment • Video’d meals • Dietary assessment

  3. Three children referred for assessment for possible tube feeding • Quadriplegic cerebral palsy • Community staff recommending tube feeding because of • Feeding disco-ordination • Poor weight gain • Parents unwilling or unhappy to start tube feeding

  4. Assessing growth in cerebral palsy • Children with cerebral palsy tend to • Be very short • Have low BMI (low muscle mass) • Using SD scores to assess growth • 0 = 50th centile • -2 = 2nd = 2% of all children • -4 = very tiny = <1in a thousand children • A child who is proportionate will have roughly same weight and height SD score

  5. Case study one: SM Boy aged 7.4 years • Functional level • At level of 6 week old baby • Eating • Enjoys being fed • Very slow, small amounts • Health • No major illnesses • Growth and fat stores • Emaciated +++ • 1.1 kg lighter than in 18m ago • Weight 11.3 kg (-8 SD) • Height -4 SD, BMI -6SD

  6. SM Progress • Tube feeding started slowly with close monitoring and mineral supplements to prevent refeeding syndrome • Good initial weight gain, but then some re-loss, feeds increased further • Less interested in foods, otherwise fine • 20% heavier after 8m

  7. Case study 2: AM Boy aged 16 years • Major difficulties feeding at school • Videofluoroscopy showed silent reflux • Family told to stop all oral feeding • Tube feeding started • Referred to feeding clinic for 2nd opinion

  8. AM assessment • Functional level • Limited cognition, no voluntary movement • Eating • Enjoys food++; Little choking when fed at home • Health • No chest infections or other ill health • Growth • Has grown steadily till now, height 0.4th centile • Fat stores • Weight 30 kg (-5 SD) BMI -5SD • Weight loss (3kg) since stopped oral feeding • Body fat 9th centile (~25th before weight loss) • Lean mass 0.4th centile

  9. AM progress • Continued full tube feeding • Depressed ++ • No change in health • Family eating in secret so as not to upset him • Regained lost weight • Gradual improvement in mood • Family give tastes of favourite foods as a treat

  10. Case study 3: CF Girl aged 15 years • Functional level • Lively and cheerful • In wheelchair • Voluntary movement of arms, poor coordination • Eating • Loves her food but makes mess when eating • Health • Excellent health • Growth and fat stores • Stable growth pattern for 4 years • Weight -3-4SD, Height -3, BMI 2nd centile • Fat 9-25th, lean 9-25th centile

  11. Progress • No need for artificial feeding • Support family and advise school on how to minimise mess • Continued well at follow up

  12. Pros and cons of tube versus oral feeding

  13. Monitoring subsequent progress • Is child happier and in better health? • Are feeds well tolerated? • Weight gain • Sufficient? • Excessive? • Has their growth improved?

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