Use of Behavioural Technique to Increase Oral Intake, such as Hunger Provocation

• Enterally fed children may not understand what hunger is, feels like, or what it requires from them. Children need to learn how to address hunger and make a connection between hunger and food. Some experts propose that if food is not accepted, the link between eating orally and satisfying hunger is not made, and thus stimulating appetite by reducing tube feeds will not in itself lead to oral intake (Mason, Harris, & Blissett, 2005).
• Hunger provocation may be implemented short term or over many years as skills, volume, and variety of foods are improved. Some children may experience improvements in oral intake immediately, while others may experience weight loss and dehydration. Consider the individual needs of the child and family.
• Support tube weaning with an adjustment in enteral regimen. Bolus feeding may mimic hunger and satiety sensations, while continuous overnight feeding may allow oral experiences during the day (Toomy & Ross, 2011); (Dunitz-Scheer, et al., 2009). However, continuous tube feedings may not allow for development of normal biological rhythms (Senez, et al., 1996).
• When oral intake provides 60 percent of nutrition needs, consider adjusting the enteral feeding regimen to provide supplemental tube feeds during or after meals, or as cycled feeds overnight (Mason, Harris, & Blissett, 2005) (Boullata, et al., 2017).
• When a patient is consuming 75 percent or more of nutrition requirements by mouth for 3 days, consider discontinuing enteral feeding (Boullata, et al., 2017).
• There is limited evidence to support appetite stimulation with medication, e.g. cyproheptadine, amitriptyline, (Krom, de Winter, & Kindermann, 2017); (Davis, et al., 2016). It may be considered for those already engaging in oral intake.