In this section
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 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
Rationale for sham feeding
infants with unrepaired long-gap oesophageal atresia to learn to feed orally.
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:
Infants with long-gap OA are often managed with a delayed oesophageal repair, a growth induction procedure (traction suture techniques) or oesophageal replacement surgery.
Replogle tube: A double lumen tube which
is placed into the oesophageal pouch and connected to continuous low pressure
suction (-20 to -35 cmH20), allowing the pouch to be kept clear of
saliva and secretions which can spill into the lungs.
Tracheo-oesophageal fistula: abnormal connection between the trachea and oesophagusTraction suture techniques: Involves growth induction of the oesophagus to enable delayed primary oesophageal reconstruction in patients with long-gap oesophageal atresia. Sutures are placed internally on the upper oesophageal pouch and lower end of the oesophagus under tension. Sutures may also be placed on the upper and lower ends of the oesophagus and brought out onto the neonate’s lateral chest wall under tension (e.g. as in the Foker process).
Infants with long-gap OA awaiting a delayed primary repair by
oesophageal anastomosis, or oesophageal replacement surgery, or those infants
with traction sutures in-situ that are stable postoperatively (and the infant’s
surgeon has requested commencement of sham feeding).
is stable postoperatively following insertion of a gastrostomy tube and tolerating
more than 100mL/kg/day of bolus enteral feeds via gastrostomy
Important note: The RN prior to caring for a neonate/infant
with unrepaired OA must have successfully completed competencies on:
Assessment of suitability of infant for sham feeding:
1. Ongoing assessment of cardio-respiratory status during and post sham feed
2. Assessment of feeding including:
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. Then the infant should be
reassessed by the Oesophageal Atresia Nurse or Surgical Registrar for safety
regarding sham feeding before another sham feed is attempted by nursing staff.
If the infant shows any signs of oral aversion, or
difficulty coordinating suck, swallow & breathing with sham feeds please
cease the sham feed and contact the Oesophageal Atresia Nurse. Then do not recommence sham feeding until
further assessment by the Oesophageal Atresia Nurse or Surgical Registrar.
If there is any
pink or blood stained aspirate, cease the sham feed immediately and check the
suction pressure is not higher than -60mmHg.
problems with sham feeding in the EMR (Progress Notes).
1. The Oesophageal Atresia Nurse should be present for the first sham feed & all sham feeding attempts in first 5 days after commencement of sham feeding.
2. Sham feeding may be by breast or bottle (maternal preference). Review orders for sham feeding prior to commencing or administering a sham feed (EMR: NICU Feeding Regime: Sham Feeding).
3. Perform hand hygiene and ensure appropriate PPE.
4. Ensure oxygen saturation probe and cardio-respiratory monitor on with limits set (HR 100-200 and oxygen saturation 90-100%).
5. Disconnect Replogle tube from Atrium UWSD Unit. Ensure Replogle tube is in correct position (correct length) in the oesophageal pouch and patent. a) Gently aspirate the suction lumen of the Replogle tube with a 10mL syringeb) then flush with 2mL sodium chloride 0.9% and gently aspirate the 2mL sodium chloride 0.9% back from the oesophageal pouchc) This flush may need to be repeated (as above) to ensure patency of the Replogle tube.
Record all flushes and Replogle tube drainage in LDA for Replogle tube.6. Attach a new specimen trap to the Replogle tube and suction tubing. This is to collect the milk feeds.7. When ready to commence the sham feed, ensure wall suction set to -40 to -60mmHg. Individual recommendation for suction pressure will be ordered by Oesophageal Atresia Nurse. a. Ensure suction does not go higher than -60mmHg during a sham feed. b. Observe frequently during the sham feed for fluctuations in the wall suction, and alter the dial to maintain -40 to -60mmHg.
breast milk needs to be re-fed at the same time as the feed; it cannot be kept
for a later feed.
Please note: this EBM/formula needs to
be re-fed at the same time as the feed; it cannot be kept for a later feed.
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.
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.
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.2015.03.010Desrosiers, C, Thiboutot, L, Faure, C & Aspirot, A. (2016). Sham feeding in children with long gap esophageal atresia: A controlled study. 4th International Conference on Esophageal Atresia, Sydney, September.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, 195: 659-662.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): 22Retrieved November, 11, 2019 from https://academic.oup.com/dote/article/32/Supplement_1/doz047.64/5518460Hawley, 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.pdfLemoine, 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/29.3.294bSri Paran T, Decaluwe D, Corbally M, Puri P. (2007). ‘Long-term results of delayed primary anastomosis for pure OA: a 27 –year follow-up.’ Pediatric Surgery International, 23 (7): 647-651.Vancouver Island Health Authority – Special Care Nursery Unit Manual. (2010). ‘Guidelines for sham feeding infants with esophageal atresia.’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. Retrieved 11th November, 2019 fromhttps://clinicaltrials.gov/ct2/show/NCT03350022
Sham feeding for infants with unrepaired long-gap oesophageal atresia Evidence Table.
Please remember to read the disclaimer
development of this nursing guideline was coordinated by Alisa Hawley, Lactation Consultant (IBCLC) / Oesophageal Atresia Nurse, Koala Ward and approved by the Nursing Clinical Effectiveness Committee. Updated November 2020.