Evaluating Hunger Manipulation During Feeding Intervention

The recognized standard of care for children dependent on feeding tubes is intensive multidisciplinary feeding intervention (IMFI) involving a professional team that includes psychologists, physicians, nurse practitioners, registered dietitian nutritionists, and speech-language pathologists/occupational therapists working together in inpatient or day hospital settings. A meta-analysis of 11 studies involving intensive, multidisciplinary intervention reported that 71% (95% CI, 54%-83%) of 454 patients successfully weaned from feeding tube dependence at discharge from inpatient or intensive day treatment programs. Treatment gains were maintained following discharge, with 80% (95% CI, 66%-89%) of 414 patients successfully weaned from tube feedings at last follow-up. The most common treatment approaches documented by the meta-analysis involved behavioral intervention and tube weaning (hunger manipulation - evoking a state of hunger to encourage oral consumption by rapidly weaning from the tube). The review highlighted the lack of consensus among clinicians and researchers regarding the criteria for, rate of, and timing of weaning from enteral feedings.

As a result, the authors concluded that the relative contribution of aggressive tube weaning as a standalone or adjunctive therapy to behavioral intervention remains uncertain.

The primary objective of this study is to determine to what extent hunger provocation, via rapid weaning from enteral feedings, is acceptable and feasible and to evaluate the effect of this intervention when used as an adjunct to our standard model of behavioral intervention within the study team's IMFI program, for individuals with Avoidant Food Intake Disorder (ARFID) who are dependent on enteral feedings to meet their daily caloric needs.

Inclusion criteria

• Be between the ages of 18 months and 6 years of age;
• Present with dependence on enteral feeding for at least 80% of their daily caloric needs; - Have some prior experience consuming food orally;
• Demonstrate safe and functional swallowing;
• Present without neuromuscular conditions who are non-ambulatory (such as cerebral palsy);
• Have a body mass index in the 15th percentile, or greater;
• Present with no evidence of moderate or severe malnutrition (weight for age or BMI of age z-score < -1) or recent weight loss;
• Engage in no severe problem behavior outside of mealtimes;
• Have a stable sleep schedule that will not interfere with therapeutic meals throughout the day;
• Caregivers must be English-speaking;
• Caregivers must be present for and participate in all treatment sessions.

Exclusion criteria

• Individuals with significant active medical conditions requiring oversight from a physician;
• Subjects who display severe problematic behaviors outside of the mealtime, necessitating intervention to specifically address those behaviors; -
• Subjects with medical, structural, or functional limitations preventing safe oral intake of pureed foods;
• Subjects with documented evidence of moderate to severe malnutrition or recent weight loss;
• Individuals with avoidance/restrictive food intake disorders who are not dependent on enteral feedings for at least 80% of their daily caloric needs.