The Association of Tube Weaning and Oral Skill Development in Infants With Tube Dependency: A Prospective Study.

OBJECTIVE: This study was the first of its kind by assessing oral skills development during and after applying the "Graz Model" of tube weaning. METHODS: This prospective case series study included data of 67 (35 females, 32 males, treated from March 2018 to April 2019) tube dependent children, who participated in the effective "Graz Model" of tube weaning. Parents filled out the standardized Pediatric Assessment Scale for Severe Feeding Problems (PASSFP) prior to and immediately after completion of the program. Paired sample t tests were conducted to examine pre-to-post changes in the children's oral skills. RESULTS: The study showed that oral skills increased significantly during tube weaning PASSFP score of 24.76 (standard deviation, SD = 12.38) prior to versus 47.97 (SD = 6.98) after completion of the program. Furthermore, significant changes in their sensory and tactile perception and in their general eating behavior were observed. Children also showed reduced oral aversion symptoms and food pocketing, could enjoy their meals, and increased their food repertoire. Mealtime duration could be decreased, and parents were less anxious about their infants' intake and less frustrated because of their children's eating behavior. CONCLUSION: The results of this study demonstrated for the first time that tube dependent children can improve their oral skills significantly during and after their participation in the child-led approach of the "Graz model" of tube weaning.

Gut Microbiome Composition and Its Association with Sleep in Major Psychiatric Disorders.

INTRODUCTION: Sleep disturbances are highly prevalent across most major psychiatric disorders. Alterations in the hypothalamic-pituitary-adrenal axis, neuroimmune mechanisms, and circadian rhythm disturbances partially explain this connection. The gut microbiome is also suspected to play a role in sleep regulation, and recent studies suggest that certain probiotics, prebiotics, synbiotics, and fecal microbiome transplantation can improve sleep quality. METHODS: We aimed to assess the relationship between gut-microbiota composition, psychiatric disorders, and sleep quality in this cross-sectional, cross-disorder study. We recruited 103 participants, 63 patients with psychiatric disorders (major depressive disorder [n = 31], bipolar disorder [n = 13], psychotic disorder [n = 19]) along with 40 healthy controls. Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI). The fecal microbiome was analyzed using 16S rRNA sequencing, and groups were compared based on alpha and beta diversity metrics, as well as differentially abundant species and genera. RESULTS: A transdiagnostic decrease in alpha diversity and differences in beta diversity indices were observed in psychiatric patients, compared to controls. Correlation analysis of diversity metrics and PSQI score showed no significance in the patient and control groups. However, three species, Ellagibacter isourolithinifaciens, Senegalimassilia faecalis, and uncultured Blautia sp., and two genera, Senegalimassilia and uncultured Muribaculaceae genus, were differentially abundant in psychiatric patients with good sleep quality (PSQI >8), compared to poor-sleep quality patients (PSQI ≤8). CONCLUSION: In conclusion, this study raises important questions about the interconnection of the gut microbiome and sleep disturbances.

Oxidative Status in Adult Anorexia Nervosa Patients and Healthy Controls-Results from a Cross-Sectional Pilot Study.

Oxidative stress describes an imbalance of reactive oxygen species (ROS) and antioxidative defence systems. Recently, the consequences of oxidative stress have become a central field of research and have been linked to the genesis of multiple psychiatric diseases. Some oxidative stress parameters have not been investigated before in anorexia nervosa (AN) patients, including the gut microbiota-derived metabolite trimethylamine N-oxide (TMAO) and polyphenols (PPm). In this cross-sectional pilot study, we evaluated these markers together with total peroxides (TOC), antioxidative capacity (TAC), endogenous peroxidase activity (EPA) and antibodies against oxidized LDL (oLAb) in serum samples of 20 patients with AN compared to 20 healthy controls. The antioxidative capacity was significantly decreased in AN patients, with a mean TAC of 1.57 mmol/L (SD: ±0.62); t (34) = -2.181, p = 0.036) compared to HC (mean = 1.91 mmol/L (SD: ±0.56), while the other investigated parameters were not significantly different between the two groups. In AN patients, TAC correlated with EPA (rsp = -0.630, p = 0.009). This study suggests that there is an antioxidative deficiency in AN patients. In this respect, there is a demand for interventional studies to determine whether antioxidants can be used as add-on therapy in the treatment of AN.

Efficacy of a standardized tube weaning program in pediatric patients with feeding difficulties after successful repair of their esophageal atresia/tracheoesophageal fistula.

Children born with esophageal atresia (EA) might suffer from significant oral feeding problems which could evolve into tube dependency. The primary aim of the study was to define the outcome of tube weaning in children after successful EA repair and to compare outcomes in children with short gap/TEF (tracheoesophageal fistula) and long-gap EA. Data of 64 children (28 with short-gap EA/TEF with primary anastomosis and 36 with long-gap EA with delayed surgical repair) who participated in a standardized tube weaning program based on the "Graz model of tube weaning" (in/outpatients in an intensive 3-week program, online coaching (Netcoaching) only, or a combined 2-week intensive onsite followed by online treatment "Eating School") from 2009 to 2019 was evaluated. Sixty-one patients completed the program by transitioning to exclusive oral intake (95.3%). Three children (4.7%) were left partially weaned at the time of discharge. No significant differences could be found between short gap/TEF and long-gap EA group regarding outcomes.Conclusions: The study's findings support the efficacy of tube weaning based on the published "Graz model of tube weaning" for children born with EA/TEF and indicate the necessity of specialized tube weaning programs for these patients. What is Known: • Children with esophageal atresia/tracheoesophageal fistula often suffer from feeding problems and tube dependency. • Different tube weaning programs and outcomes have been published, but not specifically for children with EA. What is New: • Evaluation of a large sample of children referred for tube weaning after EA repair. • Most children with EA can be weaned off their feeding tubes successfully after attending a specialized tube weaning program.

Long-term Outcomes of an Interdisciplinary Tube Weaning Program: A Quantitative Study.

BACKGROUND AND OBJECTIVES: Children who become tube-dependent need specialized treatment in order to make the transition to oral feeding. Little is known about long-term effects of tube weaning programs. This study analyzes long-term effects (outcome, growth, and nutrition data) in a large sample of formerly tube-dependent children 1 to 6 years after participation in tube weaning programs, based on the "Graz model of tube weaning." METHODS: Parents of children who completed a tube weaning program between 2009 and 2014 (N = 564) were asked to complete a questionnaire on their child's growth and nutrition. Data was analyzed using SPSS V22.0 for Windows (SPSS, Chicago, IL). RESULTS: Response rate was 47.16% (N = 266). Seven children had died between completion of the program and the long-term follow-up. Two hundred and thirty-nine children (92.3%) were still exclusively orally fed 1 to 6 years after completion of the weaning program, 17 children (6.6%) were partially tube-fed. Three children were completely tube-fed (1.1%). Growth data showed no significant changes in zBMI (World Health Organization standards z values for body mass index) between completion of weaning and long-term follow-up. Provided data on nutrition of fully orally fed patients showed that most children (N = 162, 68%) were eating an age-appropriate diet, whereas a small percentage (N = 10, 4%) were fed with a high-caloric formula, a selective diet (N = 12, 5%), or a liquid/pureed diet (N = 55, 23%). CONCLUSIONS: Many children who undergo a tube weaning program based on the "Graz model of tube weaning" are able to stay on full oral feeds in the years after completion of the wean without deterioration of growth.

Tube dependency as a result of prematurity.

BACKGROUND: Enteral nutrition support (ENS) is a standard of care in all NICUs. As a result of long-term ENS, tube dependency can develop. Tube dependency is an inability to make the transition from tube to oral feeds despite the absence of medical reasons for ENS and might lead to symptoms like oral aversion and food refusal. This study aims to evaluate the prevalence of prematurity in a large cohort of tube dependent children. METHODS: Prospectively collected data on tube dependent children who participated in a program based on the "Graz Model of tube weaning" from January 2009 to December 2015 was analysed quantitatively. RESULTS: The study cohort consisted of 711 tube dependent children. Using ICD-10 classification, 378 children (53.2%) were born prematurely, with 103 extremely preterm infants (EPI; including children <29 weeks of gestational age and 275 preterm infants (PI; between 29 and 36+6 weeks of gestational age). More than half (55.4%) of all included patients were female, 51.8% were tube fed via a percutaneous endoscopic gastrostomy (PEG-) tube, 45.8% had a nasogastric (NG-) tube and 2.4% were tube fed via Jejunal (J-) tube. 66% of all EPI and 63.3% of all PI were tube fed since birth. 83.5% of all EPI had no additional diagnoses beyond their extreme prematurity. No differences in tube weaning outcomes between preterm and full term infants were shown. CONCLUSION: Prematurity, especially extreme prematurity, is associated with an increased risk for development of tube dependency. Preventive measures for this specific group of children should be considered.

Nutritional/Growth Status in a Large Cohort of Medically Fragile Children Receiving Long-Term Enteral Nutrition Support.

OBJECTIVE: The aim of the present study was to assess the nutritional status and growth of medically fragile children receiving long-term enteral nutritional support (ENS). METHODS: A retrospective cross-sectional survey was conducted at a tertiary-level pediatric hospital. Growth features and nutritional intake of children (n = 287) receiving ENS were evaluated. During a period of 5 years (2009-2013), study patients in the age group of 1 to 36 months had been referred for the explicit reason of tube weaning. Data were documented with the help of ARCHIMED (version 46.2) and analyzed using SPSS for Windows version 21. Nutritional/growth status was determined by using World Health Organization growth standard tables. RESULTS: Anthropometric parameters of children were compared with World Health Organization standards, and the prevalence of underweight, wasting, and stunting was very high despite being exclusively or predominantly on ENS. Results revealed that the age of a child, inadequate amount of caloric supply/day, the diagnosis of small-for-gestational age, and the type of tube (nasogastric tube) were significantly associated with growth/nutritional status (P < 0.05). Duration of ENS in the percentage of the cohort's lifetime and the main diagnosis were not associated with nutritional/growth outcomes. CONCLUSIONS: In medically fragile children, ENS does not ensure adequate growth per se. ENS requires highly specialized and individually tailored management and in many cases regular adjustments. Long-term tube feeding plans often seem unable to ensure the required amount of nutritional support, which surely compromise the individual efficacy of ENS.

Unintended Adverse Effects of Enteral Nutrition Support: Parental Perspective.

OBJECTIVES: The present study highlights the occurrence of unintended adverse effects of enteral nutrition in infancy and childhood, as viewed and reported from a parental perspective. METHODS: Quantitative analysis of a standardized questionnaire, filled out online by parents of enterally fed children. The questions focused on the nutritive and nonnutritive adverse effects, and other medical and biometric data. Data were collected from January 1, 2009 to December 31, 2013. RESULTS: The study cohort consisted of 425 infants and children with different underlying medical conditions and an average age of 2.17 (median = 1.63) years. Nasogastric tubes were used in 44.2% of all the patients, and 55.8% of the children were fed by percutaneous endoscopic gastrostomy tube. Nearly all of the children have been tube-fed since birth. A total of 56.0% of all tube-fed children showed regular gagging and retching episodes, 50.0% vomited frequently, 14.8% experienced nausea, 7.5% experienced extreme nervous perspiration during the feeding, 45.2% showed loss of appetite, 5.2% experienced local granulation tissue, and 1.9% had other skin irritations. No significant correlations could be found between age, sex, medical diagnoses, type of feeding tube, feeding schedules (bolus or continuous), and parental and child's behavior regarding the feeding situation and duration of tube feeding. CONCLUSIONS: Enteral nutrition affects the child and the whole family system on more than just nutritional level. It is suggested that children and their families should be followed-up by health professionals periodically for nutritional optimization, growth documentation, and other aspects of tube management.

Weaning children off enteral nutrition by netcoaching versus onsite treatment: a comparative study.

AIM: The Graz model of tube weaning has been internationally recognised as a successful and rapid tube weaning program. Beside the onsite treatment option, a telemedical counselling was specifically developed in 2009. This study aims to show outcomes of this newly invented treatment in a large sample of patients. METHODS: Our retrospective open-label study compared success of onsite versus telemedical Graz-based weaning methods for patients with diverse clinical diagnoses with either nasogastric, gastric or jejunal tubes. Outcome variables were successful transition to oral feeds, partial transition to night tube feeds, and failure or interruption of intervention. Patients and physicians chose the intervention method. RESULTS: Complete weaning was achieved in 153 of 169 (90.5%) children in the netcoaching group versus 170 of 209 (81.3%) of those opting for onsite treatment (no significant differences, P > 0.05). Higher partial weaning rates were observed in the onsite group (15.3% vs. 4.7%, P < 0.01, degrees of freedom = 3, χ(2) = 22.76). There were no significant differences regarding the outcomes 'weaning trial without success' (netcoaching: 0% vs. onsite: 2.9%, P > 0.05) and 'interruption of programme' (netcoaching: 4.7% vs. onsite: 0.5%, P > 0.05) between the two groups. CONCLUSION: Despite limitations of study design, we have demonstrated similar efficacy of Graz-based less expensive netcoaching versus more expensive onsite intervention in a large referral population with chronic tube dependency with the majority transitioning to complete oral feeds.