Feeding and Venting Part 1- Comfort and connection during feeding

This video is the first in a three-part series on feeding and venting children with feeding tubes. This video gives a fundamental overview of maintaining comfort and connection during a tube feedings and developing a clear Plan B when there's an indication that your child is not tolerating a tube feeding, which can be followed consistently by everyone feeding the child. Included are some tips for what to look for (in a non-verbal child) and considerations for how to optimize the success of a feeding.

We are not specifically covering feeding for infants less than a year old or children who use feeding pumps, but there are similar concepts and ideas so even if you are feeding an infant or using a feeding pump I encourage you to watch anyway.

Being aware of a child’s comfort and connection during feeding is so important because it sets the tone for your child’s experience and happiness during the feeding process and putting some thought in this area can really optimize a tube feeding experience.

Whenever someone feeds a child through a feeding tube, making sure the child is comfortable and that it is a positive experience (or at least not a negative experience) is very important.  Sometimes a tube feeding can be stressful for the parent and child, particularly if the child has a history of vomiting or gagging and retching.  When your child is verbal (speaks), it is much easier to understand whether they are comfortable or if they are starting to feel pain or nausea because they can communicate that to you.  Many feeding therapists will advise that it is often counterproductive to continue feeding when a child feels uncomfortable or sick, yet parents can feel enormous pressure to keep going because they want their child’s basic nutrition and hydration needs to be met or they may be wanting to closely follow the instructions of their doctor or therapist.  This can cause a negative feedback loop with a child that can make feeding issues worse.  I would urge you to consult your feeding therapist to find ways to make your child more comfortable. Maybe you need to explore what you are feeding your child with a dietitian to see if something in the food could be causing discomfort.  For example, my son doesn’t tolerate certain foods and they cause intestinal distress which causes gas and bloating, which is uncomfortable.  Sometimes children have less issues with blenderized food than commercial formula so that could be something to explore.  Sometimes positioning during feeding is the issue, sometimes the feeding speed, or amount of food, or excess air can be the issue. Sometimes the parent is so agitated that the child picks up on that stress and becomes stressed themselves.  All of these issues should be examined if your child is uncomfortable. If you suspect something more serious is going on, of course, involve your child’s medical team.  For example in cases of chronic reflux, where food and stomach acid come up into the esophagus, there are medications, positioning techniques, and even surgery that can mitigate that condition.

The bottom line is that there are a lot of things a parent can explore to make feeding a positive and comfortable experience for the child.

Suzanne Evans Morris (who I interviewed in my video on considerations for a blended formula) gives some wonderful advice and guidance on this in her book Homemade Blended Formula Handbook in Chapters 12 and 13. 

If your child is non-verbal, it can take a little more observation to know whether your child is doing ok with a feeding.  You will have to be aware of non-verbal cues, such as body movements, facial expressions or other changes that equate to pain or discomfort.

To give you an example, when we feed our son, we are conscious of his normal baseline state.  He is typically happy and engaged, he often smiles and laughs, he rarely cries or winces. We understand his normal body movements and facial expressions when everything is ok.

Some signs that he is NOT doing ok with a feeding are:

• He goes from being happy and engaged to quiet
• The corners of his mouth turn down (pre-gagging nausea)
• His breathing rate may increase (from discomfort)
• He starts salivating a lot (from nausea)
• His face may become slightly discolored- either pale or reddish
• He may start whining or wincing
• His tongue pushes out of his mouth and he may start gagging; his tongue can be discolored, like a little purplish.  This usually indicates he is seconds away from vomiting.

 
Take a minute to think about the last time you felt sick during or after eating or right before you vomited.  We’re you salivating?  Did the corners of your mouth turn down?  Did you start breathing a little heavier because you were so uncomfortable? 
 
What can you do if this happens?
 
Every parent should have a Plan B for feeding in place.  This may be something you create with your GI or feeding therapist or you may develop it on your own over time.  Plan B’s are very individualized because children are different.  If anyone else is feeding your child, like a nurse or caregiver or family member, they should know about the Plan B as well.  It is very important that the Plan B is communicated and applied consistently to everyone feeding your child.
 
To give you an example, this is our Plan B:
 
A. Be aware of the signs that the feeding is not going well (we’ll talk about this in another video, but continuous observation is one of the key elements of tube feeding) 

B. If ANY of the signs are observed, Immediately stop feeding- hoping that things will get better and continuing to feed is typically not a good idea, for us anyway.   It will almost always lead to vomiting. Also, don’t wait for multiple signs.  One sign is enough to take a break. 

C. Immediately vent the stomach, which we will talk about in more detail in another video in this series.  By venting the stomach you will do two things: 

              1) release any excess air which could be taking up room in the stomach and leading to                  feeding overly full, which can cause nausea or pain; and/or
 
               2) allowing any excess food to come back out of the stomach to relieve some of the                       pressure. 

If a lot of food comes back out into the syringe, you may want to throw some of that away and allow the stomach time to digest with the smaller amount of food. You may need to quickly reposition the child to vent effectively.  For example, the child may do well eating while sitting up but may vent more effectively by being reclined. Quickly taking these steps can not only relieve discomfort, but you may be able to prevent vomiting and losing the meal.  The key is being observant and have a Plan B that you can quickly fall back on.
 
D. Restarting the feeding. You’ll want to allow some time to pass.  You’ll want to also take into consideration where you were in the feeding. If you’re close to the end of the feeding, you may want to stop the meal altogether. It is normal for all children, tube fed or not, to require more or less food on different days or at different times. Sometimes when our son is in a growth spurt, we notice his stomach motility is increased, his stomach may growl more often, and when we vent him we see very little stomach contents (i.e., food) remaining in his stomach.  Other times, we can see that he has more stomach contents (i.e., food) left than usual and fills up faster, which means he’s not requiring as much food at a certain meal.   
If you were in the beginning or middle, you may want to keep going with caution after a break.  In our case, if we decide to continue the feeding, we typically allow 15-20 minutes before restarting a feeding to allow time to digest, particularly if a lot of food came out of the stomach when we vented (which tells us that the motility may be a little slow and/or we fed too much too fast). Then we will go at least twice as slowly as we did in the beginning, venting frequently and continuing to watch for signs of discomfort. 
 
E. Investigate.  Whether or not you decide to restart the feeding, if you have had to engage in Plan B, it is also a good idea to do a little investigating.  If your child does not normally become uncomfortable or nauseated during mealtimes, what was different about this one?  Was there something different about the food?  Was there more food or was the food fed at a faster pace?  Was this meal closer to other meals or free water than usual? Have any medications changed? Could your child be constipated?  Was your child in a different position than usual?  For example, our son has cerebral palsy and has very low tone through his midsection.  If we feed him while he is upright or seated, he slouches and it decreases his stomach volume which can lead to being uncomfortable or nauseated when we feed him.  We have learned that he does best being fed laying down on a wedge.  Some children need to be more upright, like being reclined in a wheelchair, due to reflux.  So being aware of a child’s optimal position is important.  Again, we’ll talk about this in the venting section, but some children don’t release air as well in certain positions and that air buildup can make children nauseated, so thinking about positioning not only for feeding but for venting is important. And be aware that sometimes those positions are different.
 

Environment

Lastly, it is important to take into consideration the environment where the feeding is taking place.  Basically, you want to feed a child in an environment where they can be happy and relaxed; feeling stress while eating can be counterproductive to any child’s eating habits.
 
Think about the elements type of environment in which you like to eat and in which you
don’t like to eat.  Noisy or quiet?  Messy or clean?  Rushed or relaxed?  With people who are happy or people who are stressed?  With people ignoring you, or interacting with you and noticing how you feel?   Children often have the same preferences.
 
If child feels like their signs of discomfort are routinely ignored, it may be hard to them to relax.  Consider whether it possible to feed the child with the family at times? Or at least with a family member or caregiver who can positively interact with them during the feeding, and observe any signs of difficulty. Even if a child is non-verbal, assuring them that you are noticing how they are feeling during the feeding can be comforting. Maybe the child likes listening to music or singing?  Or with young children, maybe they can be held while tube feeding?  If your child can safely take some food by mouth, offering bites of food they can play with or taste while tube feeding can make the meal more enjoyable. 
 
 
I hope this has given you some ideas to think about as you tube feed your child.  The other videos coming up in this Feeding and Venting Series will focus on the specific techniques for feeding and venting.
 
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Thanks for visiting!
 
Mentioned in this video: Homemade Blended Formula Handbook Chapters 12 and 13