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Nursing guidelines

Sham feeding for infants with unrepaired long-gap oesophageal atresia


  • Introduction

    Sham feeding is used to enable the infant to learn to feed orally either by breast or bottle prior to repair of long-gap oesophageal atresia.  
      
    A sham feed is a feed given to an infant with unrepaired long-gap oesophageal atresia, with a Replogle tube in the upper oesophageal pouch connected to suction, which drains the milk to prevent aspiration.   
      
    The feed is removed from the oesophageal pouch by suction, collected in a trap and re-fed to the infant via the gastrostomy tube to associate oral feeding with satiety, with the milk entering the stomach at the same time.   

    Sham feeding principles  

    • Breast or bottle feed (maternal preference) to develop suck/swallow ability  

    • Replogle tube in upper oesophageal pouch, low suction (-40 to -60mmHg) to remove swallowed milk with salivary enzymes  

    • Collected milk re-fed via gastrostomy to associate oral feeding with satiety  

    Rationale for sham feeding  

    • Neonatal suck/swallow develops in a narrow time window  

    • Inability to feed orally leads to failure to develop this skill  

    • Oral aversion and feeding tube dependence are well described in infants with repaired long-gap OA  

    • Sham feeding has been reported to reduce time to full oral feeding post definitive repair of long-gap OA  

    Aim  

    To provide clinicians with guidance on supporting infants with unrepaired long-gap oesophageal atresia to learn to feed orally.  

    Definition of terms  

    • Oesophageal atresia (OA):  A congenital anomaly in which the oesophagus ends in a blind upper pouch. Most neonates with OA also have an abnormal connection between the trachea and oesophagus; this is called a tracheo-oesophageal fistula (TOF).
    • Long-gap oesophageal atresia: Variants of OA with a large gap (wider than ~4cm between the two ends of the oesophagus). This includes pure OA (Figure 2) and OA with a proximal TOF. An infant with OA and distal TOF may also have a large gap between the ends of the oesophagus.  
    • Replogle tube:  A double lumen tube which is placed into the oesophageal pouch and connected to continuous low-pressure suction (-20 to -35 cmH2O), allowing the pouch to be kept clear of saliva and secretions which can spill into the lungs.  
    • Traction suture techniques: involves the placement of sutures under tension in the upper and lower ends of the oesophagus. The infant will return to theatre after approximately 4-8 weeks for a delayed repair of the oesophageal atresia if the oesophageal ends are close enough.     

    Indications for sham feeding  

    • >35 weeks corrected age, stable, requiring no respiratory support and able to coordinate sucking, swallowing and breathing  

    • Stable on continuous low-pressure Replogle tube suction of the upper oesophageal pouch 

    • Tolerating more than 100mls/kg/day of bolus enteral feeds via gastrostomy  

    • Replogle tube Fg10 ideally positioned in oesophageal pouch via nare (to promote positive oral association with feeding)  

    • An order from the Surgeon and Neonatologist  

    • Sham feeding may be by breast or bottle (maternal preference) 

    • The Oesophageal Atresia nurse is available to be present for the first 5 days of sham feeding 

    Assessment  

    The infant requires:  

    • Continuous cardio-respiratory and oxygen saturation monitoring  

    • Ensure correct position of the Replogle tube in the oesophageal pouch by ensuring it is secured/taped at the correct/ordered length.  

    • Ensure patency of the Replogle tube prior to commencing a sham feed by aspirating and flushing the suction lumen as per the Replogle Management Guideline   

    • Ideally, a sham feed is performed by two RNs for safety purposes. 

    Ongoing Assessment  

    1. Ongoing assessment of cardio-respiratory status during and post sham feed   

    • The infant requires continuous cardio-respiratory and oxygen saturation monitoring  

    • Observation for respiratory compromise 

    2. Assessment of feeding including:  

    • Coordination of sucking, swallowing and breathing  

    • Management of feed volume with no coughing, choking or aspiration episodes  

    • Cease the feed immediately if there are any signs of respiratory distress or oral aversion  

    3. Drainage and flow of Replogle 

    • If there is any pink or blood-stained aspirate, cease the sham feed immediately and check the suction pressure is not higher than -60mmHg.  

    • Flush the Replogle tube gently with 2mL sodium chloride 0.9% to assess for continued active bleeding and patency of Replogle tube.  

    • Contact the neonatal and surgical teams (and the Oesophageal Atresia Nurse if available) and withhold sham feeds until reviewed 

    • Document any problems with sham feeding in the EMR (Progress Notes).  

    Procedure 

    Equipment  

    • New specimen trap (40mL) for each sham feed  

    • 20 mL oral syringe  

    • 10 mL syringe  

    • 10 mL ampoules of sodium chloride 0.9%  

    • New enteral feed set for each sham feed – only if re-feeding via pump set   

    • 10 Fr suction catheter for oesophageal pouch suction as required  

    Technique  

    1. Perform hand hygiene and ensure appropriate PPE.  

    1. Disconnect Replogle tube from Atrium Underwater Seal Drain (UWSD). Ensure Replogle tube is in correct position (correct length) in the oesophageal pouch and remains patent. 

    1. Gently aspirate the suction lumen. 

    1. Flush with 2mL sodium chloride 0.9% and gently aspirate the 2mL sodium chloride 0.9% back from the oesophageal pouch (repeat to remove any tenacious secretions until clear) 

    1. Attach a new specimen trap to the Replogle tube and suction tubing. The specimen trap is used to collect the milk during the feed. Ensure the specimen trap is positioned down towards the floor to ensure milk drains into the specimen trap. This will reduce the risk of milk being suctioned back into the suction tubing.  

    1. When ready to commence the sham feed, ensure wall suction set to -40 to -60mmHg (as per the order).  

    • Ensure wall suction pressure does not excess -60mmHg during a sham feed. 

    • Observe frequently during the sham feed for fluctuations in the wall suction and alter the regulator dial as required to maintain -40 to -60mmHg.  

    1. Infant may commence breast or bottle feed (see additional notes and figures below for more information) once the RN has moved the Replogle from the USWD to wall suction with appropriate pressures and parent and baby are comfortable. 

    1. Feed will collect in the specimen chamber, and this is re-fed into the gastrostomy via a syringe under gravity or via a feeding pump.   

    • This re-feeding gives the infant the sensation of satiety while the stomach is filling with feed during a sham feed and prevents waste of salivary enzymes.

    • If using expressed breast milk or pre-heated formula, this feed needs to be re-fed during the sham feed and not used for a later feed.  

    1. Burp infant, as this gets the infant used to burping which will be necessary post repair of oesophageal atresia 

    1. Following completion of the sham feed:   

    a. Aspirate the suction lumen of the Replogle tube,  

    b. Flush the Replogle tube with 2mL sodium chloride 0.9% slowly  

    c. Gently aspirate the 2mL sodium chloride 0.9% back from the oesophageal pouch to clear the Replogle tube  

    d. Repeat flushes (as above) until return is clear and no longer milk tinged   

    e. Disconnect and discard the specimen trap    

    f. Reconnect Replogle tube to the Atrium UWSD Unit (suction set between -20 to -35cmH2O, as set/ordered prior to sham feed) to the Replogle tube  

    g. Ensure wall suction is reset at -80 mmHg  

    1. Record sham feed in EMR Flowsheets as a comment in Enteral Feeding section (enter breastfeed and volume taken by sham) to provide a reference for how sham feeding is progressing. 

    • Once tolerating sham feeds well, aim to grade infant up over several weeks to 3-4 sham feeds per day, dependent on appropriate staffing  

    Breastfeeding notes:    

    • Oral feeding may start when suck/swallow/breathing is well coordinated.  
    • If the parents’ long term feeding preference is to breastfeed this should be actively encouraged as the preferred option for sham feeding. 

    • During breastfeeding infant should be positioned head up with infant’s trunk at least 45 degrees upright.  

    • Mother to offer breastfeed. Initially commence feeds on a partially expressed breast to reduce aspiration risk.  

    • Initially to offer only 1 breast  

    • If breastfeeding well and volumes tolerated over first 2 days, mother can then offer breastfeed without expressing first; increasing sham feeding as tolerated to offering both breasts at each feed (when infant on 150mL/kg/day bolus gastrostomy feeds)

    • When an appropriate volume is taken or the infant is no longer interested in breastfeeding or the specimen trap is nearly full, re-feed the breast milk taken by sham feeding into the infant’s gastrostomy by slow gravity feeding.  

    Breastfeeding Sham

    Figure 1. Sham breast feed. RCH photo taken with consent. 

    Bottle feeding notes:  

    • Offer bottle feed only if mother does not wish to breastfeed. 
    • Initial bottle feed should be 10mL volume or less  

    • Warm entire volume of feed to be given, pouring amount for sham feed into the bottle  

    • First sham bottle feed to be given with ultraslow flow, extra small white Sepal teat  

    • Sepal teat size & flow must be ordered as part of the sham feeding order on EMR  

    • Increase bottle feed by 10mL every 12 hours as tolerated up to total feed volume  

    • While holding infant in a comfortable upright position – place a few drops of EBM/formula on lips to initiate feed. Pace bottle feed as required by infant  

    • If parent wishing to mix feed, ideally aim to establish sham breastfeeding first prior to introducing sham bottle feeds, unless parent wanting to offer a bottle feed first  

    Figure 2. Bottle sham feed. RCH photo taken with consent.  

    Family Centred Care  

    It is the responsibility of the clinician caring for the infant receiving sham feeding to ensure that the parents/caregivers understand the rationale for the intervention, as well as potential complications. Sham feeding aims to encourage positive oral experience in an extremely high risk cohort for oral aversion. As with all oral feeding methods, sham feeds should be offered only when infants are awake and cueing and accepting of stimulus in and around the mouth. 

    Companion Documents  

    Links  


    Evidence Table 

    Reference 

    Source of Evidence 

    		 Key findings and considerations 
    Alberti D, Boroni G, Corasaniti L & Torri F. (2011). Esophageal atresia: pre and post-operative management. Journal of Maternal-Fetal and Neonatal Medicine. 24, S(1): 4-6.   Systematic review
    • Suggested a method of “sham feeding” when surgical repair is delayed 
    • The patient is allowed to “eat” by mouth while the material swallowed is immediately aspirated from the Replogle tube and re-fed 
    • This allows the development of sucking and swallowing and a more rapid recovery of the oral feeding after correction of the atresia 
    • Requires optimum care to prevent aspiration. 
    Bairdain, S., Hamilton, T.E., Smithers, C.J., Manfredi, M., Ngo, P., & Gallagher, D., Zurakowski, D., Foker, J.E., & Jennings, R.W.  (2015). Foker process for the correction of long gap esophageal atresia: Primary treatment versus secondary treatment after prior esophageal surgery. Journal of Pediatric Surgery, 50(6): 933-937. doi: 10.1016/j.jpedsurg.2015.03.010   RCT
    • Comparison of outcomes between Foker repair versus secondary treatment after prior esophageal surgery.  
    • 63% of the primary Foker process cases had reached full oral nutrition versus 9% of the secondary repair 
    • Individual times to full oral feeding data not provided.  
    Golonka, NR, & Hayashi, AH. (2008). Early “sham” feeding of neonates promotes oral feeding after delayed primary repair of major congenital esophageal anomalies. The American Journal of Surgery. Vol. 195, pp. 659-662.
    		Case report
    • All infants successfully completed the sham feeding protocol before undergoing delayed primary esophageal repair. After repair, they had a shortened time to full oral feeding.  
    • “Our ‘sham’ feeding protocol is safe and very effective in early development of oral feeding mechanisms and shortens time to complete oral feeding after delayed esophageal repair."
     Hawley, A.D, Armstrong, R.K, Brooks, J-A, E, Pellicano, A, Nightingale, M.G, Crameri, J, & Teague, W.J.  (2019). Sham feeding promotes oral feeding success in long-gap esophageal atresia, even with traction sutures in situ. Diseases of the Esophagus, 32(supplement 1), pp. 22  
    Retrieved November, 11, 2019 from https://academic.oup.com/dote/article/32/Supplement_1/doz047.64/5518460
    		 Longitudinal case study
    • Time to full oral feeding (FOF) was significantly reduced in those 12 patients with successful sham feeding (medium FOF 75 days IQR 57-227; compared to those in the group not sham fed FOF 730 days, IQR 125-1100 vs P = 0.03).  
    • In long gap OA, successful sham feeding improves time to full oral feeding post definitive repair and was not associated with aspiration.  
    • Reported success with sham feeding even in patients undergoing staged repair with traction suture techniques, including in those following traction suture placement.    
    Hawley, A, McLeod, EJ & Hunt, RW. (2011). Tube feeding dependence in infants with repaired oesophageal atresia and distal tracheo-oesophageal fistula.  Journal of Paediatrics and Child Health.  47 (S1): 86 (April).  
    		  
    • Infants with OA and distal TOF have a number of factors that influence the post-operative establishment of oral feeding and contribute to reliance on tube feeding at the time of discharge. 
    • These factors include associated surgical issues, postoperative complications related to TOF/OA repair, neonatal issues, associated congenital anomalies and respiratory issues. 
    • The use of ‘sham’ feeding may be applicable to our population undergoing a delayed repair or replacement as this practice would support the early development of oral feeding, allowing the baby to breast or bottle feed in the first few weeks of life, thus facilitating oral feeding following OA repair.
    Lemoine, C, Faure, C, Villeneuve, A, Barrington, K, Desrosiers, C, Thiboutot, L & Aspirot, A. (2016). P-21: Feasibility and safety of sham feeding in long gap esophageal atresia. Diseases of the Esophagus, Volume 29, Issue 3, 1 April 2016, Page 294, https://doi.org/10.1093/dote/29.3.294b   Retrospective chart review
    • 27 patients were included in this study. 9 patients were offered sham feeding. 
    • Glucose water was most often offered at the time of gavage feeds. Quantities varied from 5 cc to 30 cc.  
    • Sham feeds were pursued until time of delayed primary anastomosis in 8 out of 9 patients. 
    • There were no medical contra-indications to sham feeding, as there were no complications derived from sham feeding.
    • The two patients who benefited from the protocol seemed to have a decreased tendency to oral aversion while parents greatly appreciated the experience.” 
    Lemoine, C., Faure, C., Villeneuve, A., Barrington, K., Desrosiers, C., Thiboutot, L., Beaunoyer, M., & Aspirot, A. (2014). Feasibility and safety of sham feeding in Long Gap Esophageal Atresia. 3rd International Conference on Esophageal Atresia, Rotterdam (October, 2014). Retrieved October 31, 2019 from www.we-are-eat.org/wp-content/uploads/2014/10/181.pdf  Retrospective chart review
    • 9/27 33% of patients with long-gap oesophageal atresia offered sham feeds (5-30cc glucose water +/- milk).  
    • Sham feeding is feasible and safe in LGEA.  
    • High parental satisfaction  
    Soyer, T., Arslan, S. S., Boybeyi, Ö., Demir, N., & Tanyel, F. C. (2023). The role of oral feeding time and sham feeding on oropharyngeal swallowing functions in children with esophageal atresia. Dysphagia, 38(1), 247-252.   Retrospective study

    The retrospective study identified patients from 2013-2020 that had various methods of oesophageal anastomosis. The study investigated the role of sham feeding for patients with delayed primary repair and found a statistical significance in promotion of sham feeding in these individuals. The research highlighted that the earlier oral feeds are introduced, less longer-term complications arise for this patient population.  
      Vancouver Island Health Authority – Special Care Nursery Unit Manual. (2010). Guidelines for sham feeding infants with esophageal atresia.   Hospital guideline
      • Developed by nursing staff at Victoria General Hospital, Vancouver & Golonka & Hayashi as above.  
      • Sham feeding sessions are considered if primary repair in infants with esophageal atresia is delayed to enable further growth of the infant and additional esophageal growth 
      • Infants who are deprived of oral feeding may develop oral defensiveness or other behaviors that make the eventual transition to oral feeding difficult. 
      • Introduce sham feedings via Replogle tube and collect contents (milk and mucous) with a mucous collection trap or syringe withdrawal prior to re-feeding via gastrostomy  
      Weems, M. (2018). Pilot study on sham feeding in post-operative gastrointestinal surgery infants.  ClinicalTrials.gov Identifier: NCT03350022.  NIH. U.S National Library of Medicine. ClinicalTrials.gov  

      https://clinicaltrials.gov/ct2/show/NCT03350022  
      		 Cohort study
      • Pilot study to evaluate sham feeding “to promote adequate oral skills in order to prevent oral aversion and/or poor oral skills due to the delay in oral feeds for surgical reasons. 
      • Sham feeding is intended for infants who are expected to have a prolonged course without normal enteral feeding by mouth. 
      • Sham feeding has been shown to be safe and shorten time to oral feeding in infants with esophageal atresia with delayed esophageal repair.  
      • Anecdotal evidence from Le Bonheur suggests that sham feeding in post-operative gastroschisis patients improves parental satisfaction and engagement.



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        The revision of this nursing guideline was coordinated by Brooke Smith and Julia McKeown, CNS, Butterfly and approved by the Nursing Clinical Effectiveness Committee. Updated August 2024.