I’m not sure if you’ve experienced this, but the COVID pandemic has led me to evaluate my priorities in life. This includes my professional priorities and reflecting on areas of practice that have brought me the greatest joy. At the top of this list for me is community-based infant tube feed weaning, a key practice area of mine for many years.
I wanted to share some key infant tube weaning tidbits I’ve gathered over the years.
Common Reasons WHY Infants Have Tube Feeds in the Community
There is an endless list of possibilities here, but the most common reasons for home infant tube feeds in my experience are:
- Ex-prems, especially those who were born very preterm or with residual respiratory issues
- Neurological issues – hypoxic ischemic encephalopathy (HIE) is a common example
- Unrepaired cleft palates
- Infants awaiting cardiac surgery
- ENT concerns such as severe laryngomalacia with aspiration
- Severe oral aversion, reflux, oral motor delays (all are often linked with other medical concerns)
Questions to Think About When Considering a Wean
With any infant sent home on a tube feeding, the goal is almost always to wean those feeds at some point in the future. There are a few exceptions to this, such as infants with severe neurological concerns, but even in these situations there are often many unknowns with long-term prognosis.
What are some of the questions I ask myself when determining if an infant is ready to start weaning?
- Is the baby receiving gastric or jejunal feeds?
- Are feeds being delivered continuously or via bolus?
- If the infant is on bolus feeds, how long do they take to administer?
- Are there any concerns with tolerance of current tube feeds?
- How are their oral motor skills? Has an OT or SLP assessed this? Is there any aspiration risk?
- Is a specialized infant formula being utilized? Do you anticipate any issues with oral acceptance of this formula?
- Is any portion of the feed currently being taken orally? What percentage? How long does the oral portion of the feed take? Breast or bottle?
- Are there any upcoming procedures or surgeries that could affect their oral intake in the near future?
- How is their growth?
The answers to these questions help guide the decision to start weaning along with discussions with pertinent medical team members and most importantly, the family themselves.
Strategies for Infant Tube Feed Weaning
There is no ‘one size fits all’ strategy for tube weaning. Each patient is different. Each family is different. And each clinician is different with varying previous experiences guiding a family in a tube feeding wean.
In general, I find potential “weaners” fall into three main categories:
1) Natural Weaners
These are the most simplistic weans to achieve. As the infant grows, gets stronger and has more practice with oral feeds, the volumes consumed orally naturally increase and it is quite straightforward to simply reduce the tube feed top-up given.
The biggest decision is typically when to stop those top-ups. In my experience, these infants typically eventually need a “bite the bullet” type of approach where the tops-ups are simply discontinued. Where the line is for stopping those top-ups is different for each situation, but I typically would consider it when the infant is taking 70-80% of their feeds orally. This may mean stopping all the top-ups at the same time or cutting back one-by-one over a period of time.
2) The Threshold Weaners
These little ones present a bit more of a challenge in that they hit a maximum that they will take orally – for example,40-60% of their total feed without any progression. In this situation, I will take a closer look at length of time for their oral feeds, other medical issues influencing feeding and make sure I consult with the medical team members to ensure there is not another medical reason for the lack of progression. From there, I usually will look at a caloric reduction to get them over that hump.
With this strategy, you will usually see a period of weight maintenance and sometimes weight loss. It’s important to prepare the family and medical team for this. Often, families will try this caloric reduction for a few days, not notice an improvement and then revert back. I have found that it can take 1-2 weeks to see changes using this strategy. Your threshold for weight maintenance or weight loss is very patient- specific and needs to be determined in collaboration with the family and medical team.
3) The Borderline Weaners
This category of infant is the one who is taking only 5-10 mL orally per feed. Is it worth a caloric reduction to see if we notice improvement? Typically, with small volumes like these being consumed, it is not the total calories that is hindering the oral feed progression. They may need more time, more growth or it is simply their underlying medical situation holding them back. But I have seen cases where calories were reduced and the infant took off running with those oral feeds!
Take Home Message
The bottom line is that there is no right or wrong when it comes to infant tube feed weans. Each patient calls for a customized approach taking all the factors affecting feeding into consideration.
Don’t be scared to wean! In order to get these infants off their tubes and feeding independently, a leap needs to be taken at some point. I’ve seen many infants in my career who were tube fed much longer than they needed to be because nobody wanted to rock the boat.
As always, we’d love to hear from you! What has your experience been in the realm of infant tube feed weans?
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