There is a continuum from non-oral feeding to oral feeding. Some children are totally tube feed dependent, others progress to eating small amounts. Some children can eat solids but receive all liquids by tube. Some children eat by mouth but need extra calories via the tube to grow. Other children progress to oral feeding and are able to grow and thrive without the tube.
Moving from tube feeds to normal oral intake is often guided by the underlying medical reasons for needing the tube in the first place. For example, a child with a brain injury may need a much slower careful transition than a premature infant with no other medical problems.
To decide if your child is ready to transition towards oral feeling, think about the following readiness factors:
- Has the medical condition that led to tube feeding in the first place, been resolved?
- How well is your child in terms of general health and growth?
- Can your child swallow safely? (If there has been any history of aspiration, a speech pathology assessment involving a modified barium swallow study should be conducted before larger amounts and varieties of food or liquid are given)
- Does your child have the available oral skills to eat the volume of food needed to support nutrition? (A speech pathologist and dietitian will help to decide this)
- Does your child show a sense of hunger?
Opportunities for oral stimulation should be given to your child before the introduction of oral feeding.
A program of suitable activities should be decided by a speech pathologist to meet your child’s individual needs. Oral activities can increase the amount of saliva your child produces and it is important to monitor while doing the activities to make sure they are able to swallow and manage their saliva safely. A speech pathologist should assess your child’s ability to swallow when beginning a program of oral activities and especially before any food or liquid is introduced. Some activities your speech pathologist may suggest to help you prepare include:
- Offering positive touch experiences to your child’s face and lips e.g. cheek to cheek cuddles.
- Bringing their hands and fingers: to their mouth / between their lips / inside their lips.
- Mouth toys of assorted shape and firmness.
- Swiping food on the lower lips and gum followed by tastes to the tongue (initially in very small amounts)
- Making associations between tube feeds and oral stimulation e.g. mouthing a toy and smelling a food prior to and while being tube fed to create a positive link between the feeling of hunger and the oral area.
Your child’s feeding tube may have been inserted because your child could not swallow safely. If their skills for oral feeding improve, then your child’s ability to swallow safely may also improve. However taking small amounts of food and liquid is quite different from taking full meals orally. Close monitoring and management by your child’s speech pathologist is needed to check the ongoing safety and efficiency of your child’s swallowing mechanism. A Modified Barium Swallow study may be needed to test your child’s swallowing skills.
Signs of swallowing difficulty
Signs that your child is having difficulty swallowing may include (but not be limited to):
- Coughing, gagging with eating
- Vomiting during eating
- Excessive drooling.
- Increased congestion.
- Gurgly voice.
- Food refusal.
- Mealtimes lasting longer than 30 minutes.
- Feeling of food getting stuck behind breast bone
- Drinking a lot of water between mouthfuls to wash food down
Textures and food types
Children transitioning to oral intake may need a modified diet. Your child’s speech pathologist will assess your child’s oro-motor and swallowing skills and make recommendations.
Modifications can be made to fluids and foods so that they are easier and safer to swallow. If your child is put on a modified diet by your speech pathologist, it is important that the recommended modifications are followed closely.
Children, who are transitioning from tube to oral feeds, may increase the variety of foods in their diets more slowly and more cautiously than other children. It is important to offer foods regularly as tastes change and develop.
Example: Fluid modifications:
Fluid runs freely from the spoon but leaves a mild coating
Fluid slowly drips in dollops off the end of the spoon
Fluid sits on spoon and does not flow off it
Example diet modifications:
Food may be naturally soft or is cooked/cut to alter its texture
Minced and moist
Food is soft, moist & easily mashed with a fork; lumps are smooth and rounded
Food is smooth, moist and lump free; may have a grainy quality
Access to utensils/equipment
Modified or specialist equipment may be recommended for your child when they start their oral intake. This will be decided by your speech pathologist and or occupational therapist. Specialist equipment may include special teats/bottles, cups, utensils, oral-facial stimulation materials and seating systems. Many of these products are available commercially or alternatively your therapist will help you source these items.
Multidisciplinary team approach
Children who are transitioning from tube to oral feeds will need help from a team of health professionals. Your team may include some or all of the following:
- nurse consultant
- speech pathologist
- occupational therapist
Removal of the feeding tube
A feeding tube should stay in place until your child can consistently eat and drink enough food and fluid, even in times of illness. Removing the tube too early may result in extra long mealtimes for you and your child and place your child at risk of malnutrition and poor growth.
- To check how ready your child is to transition towards oral feeling, consider the readiness factors.
- A speech pathologist may need to assess your child’s ability to swallow when beginning a program of oral activities and especially BEFORE any food or liquid is introduced.
- Close monitoring and management by your child’s speech pathologist is necessary to evaluate ongoing safety and efficiency of the swallowing mechanism.