Clinical Guidelines (Nursing)

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 the oesophageal atresia.

    A sham feed is a feed given to an infant with unrepaired long-gap oesophageal atresia, with a Replogle Tube connected to suction, which drains the milk from the upper oesophageal pouch to prevent aspiration. 

    The feed is removed from the oesophageal pouch by suction and re-fed to the infant via the gastrostomy tube to enable oral feeding to be associated with milk entering the stomach at the same time.


    Aim

    To enable 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
    Infants with:

    • Pure OA
    • OA with proximal TOF
    • Other variants of OA/TOF with a large gap where an oesophageal anastomosis is unable to be performed immediately.

    Infants with long-gap OA are often managed with a delayed oesophageal repair, a growth induction procedure or oesophageal replacement surgery. 

    Replogle tube: A double lumen tube which is placed into the oesophageal pouch and connected to continuous low pressure suction (-15 to -35 cmH20), allowing the pouch to be kept clear of saliva and secretions which can spill into the lungs.

    Foker Procedure: Involves growth induction of the oesophagus. The Foker process uses tension-induced growth to enable primary oesophageal reconstruction in patients with long gap oesophageal atresia. Sutures are placed on the upper and lower ends of the oesophagus and brought out onto the neonate's chest wall.  Tension is applied to the sutures by placing short pieces of silastic tubing under the suture loops, with the tension usually increased each day over a 1-3 week period.  When enough growth in the oesophageal ends has been achieved, the infant returns to theatre for an oesophageal atresia repair (oesophageal anastomosis). The Foker procedure may also include the placement of internal sutures on the upper and lower oesophageal segments.
     
    Growth induction procedures: Other growth induction procedures may also be undertaken, involving internal sutures on the oesophageal ends, prior to full repair of the OA.


    Indications for sham feeding

    • Infants with long-gap OA awaiting a delayed repair by oesophageal anastomosis or oesophageal replacement surgery
    • Infant is stable postoperatively following insertion of a gastrostomy tube and tolerating more than 100ml/kg/day of bolus enteral feeds via gastrostomy 


    Assessment

    Assessment of suitability of infant for sham feeding:

    • Infants should be more than 35 weeks corrected age, stable, requiring no respiratory support and able to coordinate sucking, swallowing and breathing
    • Infants should be stable on continuous low pressure Replogle tube suction of the upper oesophageal pouch
    • Sham feeding should only be commenced with consent from the infant’s Surgeon and Neonatologist
    • A proximal TOF should have been excluded prior to commencing sham feeds in infants with long gap OA
    • Infants with OA and proximal TOF should have recovered from the initial TOF repair prior to commencing sham feeds
    • The Oesophageal Atresia Nurse should be present for the first sham feed

    Special Circumstances

    • Occasionally the infant’s surgeon may request for an infant with growth induction sutures in-situ to have sham feeding commenced.  Sham feeding in this situation should be discussed with the Neonatal Consultant and the Oesophageal Atresia Nurse prior to commencing sham feeds.

    Initial Assessment

    1. The infant requires:
      - continuous cardio-respiratory and oxygen saturation monitoring
      - assessment of cardio-respiratory status, with oxygen saturation, heart rate and respiratory rate within normal limits
    2. Ensure patency of Replogle tube prior to commencing sham feed. Gently aspirate the suction lumen of the Replogle tube, then flush with 3ml sodium chloride 0.9% and gently aspirate the 3ml sodium chloride 0.9% back from the pouch.

    Ongoing Assessment

    Ongoing assessment of cardio-respiratory status during and post sham feed with observation for respiratory compromise including:

    • Respiratory distress
    • Apnoea
    • Desaturation with oxygen saturation below 90%
    • Bradycardia
    • Stridor
    • Use of accessory respiratory muscles

    Assessment of feeding including:

    • coordination of sucking, swallowing and breathing
    • management of feed volume with no coughing, choking or aspiration episodes


    If the infant has any signs of respiratory distress/compromise or difficulty with the sham feed, or coughing or choking episodes, the sham feed should be ceased immediately. The infant should be reassessed by the Oesophageal Atresia Nurse for safety regarding sham feeding before another sham feed is attempted by bedside nursing staff.

    If there is any pink or blood stained aspirate, cease the sham feed immediately and check the suction pressure is not higher than -50mmHg. Contact the neonatal and surgical teams (and the Oesophageal Atresia Nurse if available), and withhold sham feeds until consent is given by the surgical team to continue with sham feeds. Document any problems with sham feeding in the EMR (Progress Notes).

    Equipment

    • New specimen trap (40ml) for each sham feed
    • 20 ml oral syringe
    • 10 ml syringe
    • 10 ml ampoules of sodium chloride 0.9%

    Technique

    1. The Oesophageal Atresia Nurse should be present for the first sham feed.
    2. Sham feeding may be by breast or bottle. Review orders for sham feeding prior to commencing or administering a sham feed (EMR: NICU Feeding Regime: Sham Feeding).
    3. Ensure oxygen saturation probe and cardio-respiratory monitor on with limits set (HR 100-200 and oxygen saturation 90-100%).
    4. Disconnect Replogle tube from Atrium UWSD Unit. Ensure Replogle tube is in correct position and patent.  Gently aspirate the suction lumen of the Replogle tube with a 10ml syringe, then flush with 3ml sodium chloride 0.9% and gently aspirate the 3ml sodium chloride 0.9% back from the pouch. Record all flushes and Replogle tube drainage in LDA for Replogle tube.
    5. Attach new specimen trap to Replogle tube and suction tubing. This is to collect the milk feeds.
    6. When ready to commence feed, ensure wall suction set to -50mmHg to -60mmHg. Ensure suction does not go higher than -60mmHg during a sham. Observe frequently during feed for fluctuations in the wall suction, and alter the dial to maintain -50mmHg to -60mmHg.

    Breastfeed:  

    • Oesophageal Atresia Nurse to be present for first sham feed.
    • Oesophageal Atresia Nurse, NICU AUM, Bedside Sham Feeding Nurse, NICU Educator or Clinical Support Nurse to be present for initial breastfeeding attempts in the first 1-2 weeks of sham feeding.
    • Breastfeeding may start when suck/swallow/breathe is well coordinated.
    • During breastfeeding infant should be positioned head up with infant’s trunk at least 45 degrees upright.
    • Mother to offer breastfeed. Initial breastfeeds to be offered after mother has expressed. 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 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 breastmilk taken by sham into the infant’s gastrostomy (empty the specimen trap of breastmilk into an appropriately sized oral syringe attached to gastrostomy tube; this prevents waste of enzymes). This breastmilk needs to be re-fed at the same time as the feed; it cannot be kept for a later feed.
    • Give gastrostomy feed at the same time as the sham feed; this gives the infant the sensation of the stomach filling with feed whilst orally feeding.
    • Burp infant, as this gets the infant used to burping (which will be necessary post repair of oesophageal atresia).
    • Following completion of the sham feed and re-feeding via gastrostomy tube, disconnect and discard the specimen trap.  Then flush with 3ml sodium chloride 0.9% and gently aspirate the 3ml sodium chloride 0.9% back from the pouch to clear the Replogle tube, and reconnect to Atrium UWSD Unit (suction set between -15 to -35cmH2O, as set prior to sham feed). Ensure wall suction is -80 mmHg.
    • Record sham feed in EMR Flow Sheets as a comment in Enteral Feeding section (enter breastfeed and volume taken by sham) to provide a reference for how sham is progressing.
    • Once tolerating sham feeds well, aim to grade infant up over a number of weeks to 4 sham feeds per day.

    Bottle feed:

    • Oesophageal Atresia Nurse to be present for first sham feed.
    • Oesophageal Atresia Nurse, NICU AUM, Bedside Sham Feeding Nurse, NICU Educator or Clinical Support Nurse to be present for initial bottle feeding attempts in the first 1-2 weeks of sham feeding.
    • Offer bottle feed only if mother planning to bottle feed with EBM/ formula and does not wish to breastfeed. 
    • Initial bottle feed should be 10 ml volume or less.
    • Warm entire volume of feed to be given, pouring amount for sham feed into the bottle (ideally Medela Haberman Special Needs Feeder) and offer sham feed on slow flow setting with teat for first 2 days.
    • Increase bottle feed by 5 ml 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.
    • When an appropriate volume is taken or the infant is no longer interested in feeding or the specimen trap is nearly full, re-feed the EBM/formula taken by sham into the infant’s gastrostomy (empty the specimen trap of EBM/formula into an appropriately sized oral syringe attached to gastrostomy tube; this prevents waste of enzymes). This EBM/formula needs to be re-fed at the same time as the feed; it cannot be kept for a later feed
    • Give gastrostomy feed at the same time as the sham feed; this gives the infant the sensation of the stomach filling with feed whilst orally feeding.
    • Burp infant, as this gets the infant used to burping (which will be necessary post repair of oesophageal atresia).
    • Following completion of the sham feed and re-feeding via gastrostomy tube, disconnect and discard the specimen trap. Then flush with 3ml sodium chloride 0.9% and gently aspirate the 3ml sodium chloride 0.9% back from the pouch to clear the Replogle tube. Reconnect to Atrium UWSD Unit (suction set between -15 to -35cmH2O, as set prior to sham feed). Ensure wall suction is -80 mmHg.
    • Record sham feed in EMR Flow Sheets as a comment in Enteral Feeding section (enter bottle feed and volume taken by sham) to provide a reference for how sham is progressing.
    • Once tolerating sham feeds well, aim to grade infant up over a number of weeks to 4 sham feeds per day.
    • Liaise with OA Nurse regarding when to progress to extra slow flow teat from Medela Haberman Special Needs Feeder.


    Family Centred Care

    It is the responsibility of the clinician caring for the infant receiving sham feeding to ensure that the parents understand the rationale for the intervention, as well as potential complications.


    Companion Documents

    • Sham feeding in oesophageal atresia at Victoria General Hospital, Vancouver– DVD
    • Replogle tube management guideline


    Links


    References

    • 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.
    • Bass J. 2002. “A technique to facilitate nursing care in patients with long-gap esophageal atresia.’ Pediatric Surgery International. 18: 749-750.
    • 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
    • Cavallaro S, Pineschi A, Freni G et al. 1992. ‘Feeding troubles following delayed primary repair of esophageal atresia.’ European Journal Pediatric Surgery. 2: 73-77.
    • Foker, J. E.; Kendall Krosch, T.C.; Catton, K., Munro, F.; Khan, K.M. (2009). Long-gap esophageal atresia treated by growth induction: the biological potential and early follow-up results. Seminars in Pediatric Surgery, 18(1): 23-29.
    • 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.
    • Hawley, A.  2001.  Long-gap Oesophageal Atresia – A Nursing Perspective.  Journal of Child Health Care.  5 (1). Pp.19-25.
    • Hawley, AD & Harrison D. ‘Suctioning Practices for the upper oesophageal pouch in infants with unrepaired oesophageal atresia in Australia and New Zealand.’ P105. Perinatal Society of Australia and New Zealand Annual Congress March 2003, Hobart, Australia
    • Hawley, A, McLeod, EJ & Hunt, RW. 2011. Tube feeding dependence in infants with repaired oesophageal atresia and distal trachea-oesophageal fistula. Journal of Paediatrics and Child Health. 47 (S1), April, pp. 86.
    • 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 May 5, 2016 from www.we-are-eat.org/wp-content/uploads/2014/10/181.pdf
    • Puntis, JW, Ritson DG, Holden CE, Buick RG. 1990. ‘Growth and feeding problems after repair of oesophageal atresia.’ Archives Disease in Childhood. 65:84-88.
    • Sri Paran T, Decaluwe D,Corbally M, Puri P. 2007. ‘Long-term results of delayed primary anastomosis for pure OA: a 27 –year follow-up.’ 23 (7): 647-651.
    • Vancouver Island Health Authority – Special Care Nursery Unit Manual. 2010. ‘Guidelines for sham feeding infants with esophageal atresia.’

    Evidence Table

    Sham feeding for infants with unrepaired long-gap oesophageal atresia Evidence Table

    Please remember to read the disclaimer


    The development of this nursing guideline was coordinated by Alisa Hawley, RN, Butterfly Ward and Sharlene Pattie,Clinical Nurse Educator, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated July 2016.