Bly, L., McBeth, M., Olagunju, I., Hirst, H., Block, D., Bird, F., & Luiselli, J. K. (2024). Single-case evaluation of oral feeding intervention and gastrostomy tube fading in adults with intellectual and multiple disabilities. Journal of Intellectual & Developmental Disability, 49(1), 107-114. https://doi.org/10.3109/13668250.2023.2206296

Reviewed by:
Chantal Taluba, BFA, and Robert H. LaRue, PhD, BCBA-D
Graduate School of Applied and Professional Psychology, Rutgers University

Why research this topic?

Individuals with intellectual and multiple disabilities often present with concurrent oral feeding and swallowing disorders, which impact food and liquid consumption (Manduchi et al., 2020). In some cases, gastrostomy tube support is necessary to support nutritional intake and hydration and reduce the risk of aspiration and lower respiratory tract infections (Clarke et al., 2013; Harvey et al., 2019). While gastrostomy tubes have beneficial effects for nutrition and hydration, long-term dependence can have drawbacks, including health complications, an increased risk of death, and limited improvements in quality of life. These concerns highlight the need for additional research. In such cases, weaning from feeding via a gastrostomy tube may be clinically indicated.

As the decision to reduce or eliminate feedings through a gastrostomy tube must be determined on a case-by-case basis with input from a multidisciplinary team, there are notable benefits to oral feeding. The ability to eat with others can have social benefits and potentially improve quality of life. Previous studies on oral feeding interventions and gastrostomy tube fading have been limited to pediatric patients. Since several methods have been used to decrease dependence on gastrostomy tubes in children, the extent to which these same procedures have utility in adult populations remains unclear (e.g., Taylor et al., 2019a). The aim of the current study was to determine whether the interventions utilized with the pediatric population can be effective for fading the use of gastrostomy tubes for adult patients with intellectual and multiple disabilities.

What did the researchers do?

In the current investigation, the researchers conducted two single-case time-series analyses to evaluate whether behavioral supports and appetite-stimulation strategies (e.g., fading gastrostomy tube supplementation) could help reduce dependence on gastrostomy tubes in adults. Two adults (Marjorie, 72, and Michael, 28) with profound/severe intellectual and multiple disabilities were included in the current study. Both were long-term gastrostomy tube users. Both participants underwent a pre-intervention assessment to ensure that swallowing problems and aspiration would not make oral feeding unsafe. The researchers also collected baseline information on how much food or liquid each participant ingested by mouth and how much liquid (e.g., Ensure, Pedialyte) was consumed via gastrostomy tube. Intervention consisted of several components, including introducing and gradually increasing food types and quantities, maintaining consistent food texture (pureed), and systematically fading gastrostomy tube supplementation. Behavioral strategies, such as reinforcement, were used to gradually increase oral feeding. This increase was paired with the systematic reduction of feedings via gastrostomy tube. The care providers responsible for implementing the feeding intervention were trained by a supervising speech-language pathologist (SLP).

What did the researchers find?

The researchers were able to successfully fade gastrostomy tube feedings while increasing oral feeding for both participants. For Marjorie, the percentage of her oral food consumption increased to 95.5% of opportunities (i.e., spoonfuls accepted). Two years after the intervention, Marjorie still consumed an average of 92.4% of her food orally and no longer received supplementation through a gastrostomy tube. Her weight prior to the intervention was 132 pounds and later increased to 136 pounds during the last week of the intervention. At the two-year follow-up, Marjorie’s weight had decreased, but she had experienced no health complications.

For Michael, oral liquid consumption increased from an average of 37.6 oz of liquid each day to 60.3 oz per day because of the intervention. Feedings through the gastrostomy tube were faded entirely during the intervention, and the gastrostomy tube was eventually removed entirely. Michael’s weight remained stable throughout baseline and intervention, and no health complications were noted.

Further, the experimenters noted that the intervention appeared to correlate with a positive impact on both participants’ quality of life. During the intervention and follow-up, neither participant was hospitalized, experienced any serious illnesses/gastrointestinal concerns, or had any interruptions to their medications. Additionally, Marjorie and Michael had the opportunity to eat meals with their peers, which they appeared to enjoy.

What are the strengths and limitations of the study?

The current study has several strengths. Perhaps the greatest contribution is that the current study may be the first to outline effective feeding and gastrostomy tube fading procedures for adults with intellectual/multiple disabilities. In addition, the long-term follow-up is a significant strength of the study. This demonstrates that the transition to oral feeding without gastrostomy tube supplementation was maintained over an extended period for both participants. Additionally, the current protocol incorporated input from a multidisciplinary team (e.g., SLPs, nurses, behavior analysts, dieticians) to ensure both clinical and nutritional factors were addressed and to keep participants safe.

The current study also has some limitations. First, the study only included two participants, which limits the ability to generalize the findings to a broader population. Another notable limitation was the use of an AB design to evaluate the intervention effects. While the intervention outcomes appeared favorable, the quasi-experimental design makes it impossible to determine if other factors not measured in the study may have influenced the results. Additionally, the researchers did not collect inter-observer agreement (IOA) data as a part of the study, meaning there was no confirmation that the staff recording the data did so consistently and reliably. Lastly, the intervention requires significant resources, such as a multidisciplinary team and staff members, to ensure the supervision and training of care providers. Therefore, it may be difficult to replicate the procedure in a setting with fewer supports.

What do the results mean?

Overall, the findings of this study suggest that behaviorally-based intervention and interdisciplinary coordination can be implemented to increase oral feeding and fade gastrostomy tube feeding in adults with intellectual/multiple disabilities. Notably, one participant was 72 years old, demonstrating that successful transition from gastrostomy tube dependence to oral feeding may be achievable even with elderly individuals. The procedures outlined in the current study not only potentially improve health outcomes for this at-risk population but could also allow for additional social inclusion during mealtimes and, consequently, improve quality of life.

References:

Clarke, G., Harrison, K., Holland, A., Kuhn, I., & Barclay, S. (2013). How are treatment decisions made about artificial nutrition for individuals at risk of lacking capacity? A systematic literature review. PLOS One, 8(12), 1-7. https://doi.org/10.1371/journal.pone.0061475

Harvey, P. R., Thomas, T., Chandan, J. S., Bhala, N., Nirantharakumar, K., & Trudgill, N. J. (2019). Outcomes following feeding gastrostomy (FG) insertion in patients with learning disability: A retrospective cohort study using the health improvement network (THIN) database. BMJ Open, 9(6), e026714. https://doi.org/10.1136/bmjopen-2018-026714

Manduchi, B., Fainman, G. M., & Walshe, M. (2020). Interventions for feeding and swallowing disorders in adults with intellectual disability: A systematic review of the evidence. Dysphagia, 35(2), 207-219. https://doi.org/ 10.1007/s00455-019-10038-5

Taylor, S. A., Purdy, S. C., Jackson, B., Phillips, K., & Virues-Ortega, J. (2019a). Evaluation of a home-based behavioral treatment model for children with tube dependency. Journal of Pediatric Psychology, 44(6), 656-668. https://doi.org/10.1093/jpepsy/jsz014

Reference for this article:

Taluba, C., & LaRue, R.H. (2026). Research synopsis: Single-case evaluation of oral feeding intervention and gastrostomy tube fading in adults with intellectual and multiple disabilities. Science in Autism Treatment, 23(7).

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