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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 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
    • 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 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 (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 oesophagus

    Traction 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). 

    Indications for sham feeding

    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).

    Infant 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:

    1. Replogle tube management
    2. Sham feeding 

    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
    • Replogle tube Fg10 ideally positioned in oesophageal pouch via nare
    • 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 and for all sham feeds in the first 5 days after commencement

    Special Circumstances

    • Occasionally the infant’s surgeon may request for an infant with traction (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.

    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
      1. Perform hand hygiene and ensure appropriate personal protective equipment (PPE)
      2. Ensure correct position of the Replogle tube in the oesophageal pouch by ensuring it is secured/taped at the correct length.
          • Ensure patency of the Replogle tube prior to commencing a sham feed
          • Gently aspirate the suction lumen of the Replogle tube, then flush with 2mL sodium chloride 0.9%
          • Gently aspirate the 2mL sodium chloride 0.9% back from the oesophageal pouch

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

        2. 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. 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.

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

        Technique

        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 syringe
        b) then flush with 2mL sodium chloride 0.9% and gently aspirate the 2mL sodium chloride 0.9% back from the oesophageal pouch
        c) 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.

        Breastfeed:  

        • Oesophageal Atresia Nurse to be present for first sham feed and all sham feed attempts in the first 5 days after commencement.
        • Oesophageal Atresia Nurse, Clinical Nurse Educator or Clinical Support Nurse to be present for initial breast feeding attempts in the first 1-2 weeks of sham feeding
        • Breastfeeding may start when suck/swallow/breathing 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 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.
        • empty the specimen trap of breast milk into an appropriately sized enteral feeding syringe attached to gastrostomy tube
        • and administer the feed via gravity
          • this prevents waste of salivary enzymes
          • This is the preferred method of re-feeding the sham feed.  The breast milk can also be re-fed via the feeding pump into the gastrostomy only if necessary (with the pump programmed to deliver the feed over approximately 30 minutes)
        • If re-feeding feed via feeding pump, discard enteral feeding set after each sham feed

        Please note:This breast milk needs to be re-fed at the same time as the feed; it cannot be kept for a later feed.

        • Give the gastrostomy feed at the same time as the sham feed; this gives the infant the sensation of satiety while the stomach is filling with feed during sham 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: 
          • Aspirate the suction lumen of the Replogle tube,
          • then flush the Replogle tube with 2mL sodium chloride 0.9% slowly,
          • and gently aspirate the 2mL sodium chloride 0.9% back from the oesophageal pouch to clear the Replogle tube
          • Repeat flushes (as above) until return is clear
          • Disconnect and discard the specimen trap  
          • Reconnect Replogle tube to the Atrium UWSD Unit (suction set between -20 to -35cmH2O, as set prior to sham feed) to the Replogle tube
          • Ensure wall suction is reset at -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 feeding is progressing
        • Once tolerating sham feeds well, aim to grade infant up over a number of weeks to 3-4 sham feeds per day

        Breastfeeding Sham


        Bottle feed:

        • Oesophageal Atresia Nurse to be present for all sham feeds in the first 5 days
        • Oesophageal Atresia Nurse, Clinical Nurse 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 is planning to bottle feed with expressed breast milk (EBM) and/or formula and 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 to be ordered Oesophageal Atresia Nurse and will be documented in 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
        • 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 feeding into the infant’s gastrostomy via slow gravity feeding:

          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.

          • Empty the specimen trap of EBM/formula into an appropriately sized enteral syringe attached to gastrostomy tube (this prevents waste of salivary enzymes)
          • This is the preferred method of re-feeding the sham feed
          • The EBM/formula can also be re-fed via the feeding pump into the gastrostomy, if necessary, (with the pump programmed to deliver the feed over approximately 30 minutes).
          • If re-feeding feed via feeding pump, discard enteral feeding set after each sham feed
        • Give the gastrostomy feed at the same time as the sham feed; this gives the infant the sensation of the stomach filling with feed whilst orally sham 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 the Replogle tube suction lumen with 2mL sodium chloride 0.9%
          • and gently aspirate the 2mL sodium chloride 0.9% back from the pouch to clear the Replogle tube
          • Repeat flushes (as above) until return is clear
          • Reconnect the Replogle tube to Atrium UWSD Unit (suction set between -20 to -35cmH2O, as set prior to sham feed)
          • Ensure wall suction is on -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 feeding is progressing
        • Once tolerating sham feeds well, aim to grade infant up over a number of weeks to 3-4 sham feeds per day
        • Liaise with Oesophageal Atresia Nurse regarding suitable teat for bottle sham feeds
        • 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

        Bottle sham

        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

        • Aseptic technique
        • Emergency Procedures
        • Replogle tube management
        • Intermittent oesophageal pouch suction guideline
        • Sham feeding in oesophageal atresia at Victoria General Hospital, Vancouver– DVD

        Links

        http://oara.org.au/

        http://www.tofs.org.uk/home.aspx

        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.

        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

        Desrosiers, 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): 22
        Retrieved November, 11, 2019 from https://academic.oup.com/dote/article/32/Supplement_1/doz047.64/5518460

        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

        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

        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.’ 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 from
        https://clinicaltrials.gov/ct2/show/NCT03350022

        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, Lactation Consultant (IBCLC) / Oesophageal Atresia Nurse, Koala Ward and approved by the Nursing Clinical Effectiveness Committee. Updated November 2020.