Nasogastric (NG) feeding is a method of enteral nutrition where a narrow feeding tube is placed through the nose down into the stomach. NG feeding is often used in inpatient settings when a patient with an eating disorder has restricted their food intake to such an extent that their physical health is at risk. The tube delivers fluids, nutrients or medications directly into the stomach, increasing caloric intake. However, it is generally used as a last resort, particularly when done under restraint (NCCMH, 2004).
The primary objective of NG feeding is to stabilise the individual’s physical health, it does not provide a lasting cure. Eating disorders are caused by a combination of biological, psychological, genetic and sociocultural factors that differ between individuals, and successful treatments must address each of these factors and the underlying issues contributing to the refusal to eat (Giombini & Nesbitt, 2023).
In this CYPMHS EveryExpert article, we speak with members of the multidisciplinary team (MDT) at Bere Clinic, a CYPMHS Tier 4 eating disorder service, to discuss their compassionate approach to care and reducing NG feeds to a last resort measure. The team explain how they have been successful in reducing NG feeds at Bere Clinic by prioritising the young person’s perspective and experience in care, ensuring that the young person understands why they need treatment and that they feel empowered in their path to recovery.
Compassionate care
Bere Clinic provides a CYPMHS Tier 4 eating disorder service for young people aged 12-18 years with a primary diagnosis of an eating disorder. The service can also support young people with an eating difficulty with a co-morbid presentation, for example, mental health or psychological issues, such as depression, OCD, anxiety or self-harm.
The specialist MDT at Bere Clinic works closely with young people and their families to understand the goals that are personal to them and help them make progress towards recovery from their eating disorder. Lee Cottrell, Hospital Director, explains the compassionate approach to care that sets the service apart and has helped in reducing NG feeds at Bere Clinic.
Lee says: “Our approach is person-centred and compassionate. We’re willing to consider many different options to help the young person eat. NG feeding is the last resort for us – it’s not an option we want to use, and we try to avoid doing so.
“Eating disorders are complex, and often the young people we support have a co-morbid presentation, so we have to be flexible in our approach. For example, the young people who require the intervention are quite up and down in their presentations, so sometimes they can eat, and sometimes they can’t. We need to tailor their care to how they are presenting and always consider their individual needs, rather than a blanket one-size-fits-all approach.
“We work alongside the young person, giving them more time to understand why nutrition is so important and why they need to have it. We never put the young person physically at risk, but we carry more positive risk than other services might do.”
Understanding pace and attachment
Young people with eating disorders can sometimes become ‘stuck’ on NG feeds, using them for extended periods. Bere Clinic has become known for its effectiveness in supporting young people to reduce their reliance on NG feeds. Claire Weston, Interim Deputy Hospital Director, explains how agreeing on the most appropriate pace for reduction and understanding attachment to NG feeds is a vital part of the process.
Claire says: “For the young people who have been on an NG feed for a long time, the first thing we establish is what their pace might be for coming off the NG feed. This is really important because everyone has a different pace, and it’s about trying to ascertain what pace the young person is most comfortable with. It’s essential we adapt any treatment programmes to this pace – some may want to come off quite slowly, so their care plan is adjusted accordingly. Alternatively, others may want to go at a faster pace, so their plan will reflect this wish.
“To facilitate these personalised plans, at varied paces, and the transition off NG feeds, we must understand the individual’s attachment to the NGs, and why it’s important to them. We can then replace this with something positive. However, the young person might not always feel that there’s anything positive in their life, and this is where we utilise the different skills across our specialist MDT, for example, our psychology team or our dietitians, to work through this.
“Through a collaborative approach between the young person, their family and the MDT, we gradually unpack the different reasons for attachment. Sometimes, the young person may feel that if they come off the NG feeds, then they will no longer be considered ‘sick’ and they won’t receive support. This can cause them to feel afraid because even if they can come off NG, they will continue to have the thoughts and feelings that come with the eating disorder. So it’s our role to reassure them that we still recognise that they are unwell and that we know it is a longer process to get better.”
Mealtime support
Due to these thoughts and feelings, it can feel worse for some young people to be sat in the dining room physically eating rather than having an NG feed. Kirsty Chewter, Dietitian, describes how Bere Clinic offers mealtime support, before and after meals, to assist the young people and ensure the dining room becomes a therapeutic intervention, rather than a traumatic experience.
Kirsty explains: “As soon as a young person is admitted, we work together with them to create their ‘Do’s and Don’ts’ for mealtimes – a list of what they find helpful to talk or not talk about during meals. Each person is different. Some will feel uncomfortable if they are praised for eating, and they won’t want to talk throughout dinner, but others will like the distraction of supportive conversation.
“We record their preferences in their care plans, and this is shared with anybody who works with them. We also offer meal support training here once a week so that team members feel empowered to manage mealtimes, understanding what individuals consider helpful and what they feel is unhelpful.
“We view the dining room as a therapeutic intervention. The young people are in there six times a day, so we try to make it a therapeutic space, not a dreaded space. We received feedback from the young people at our service about how the dining room could be improved, so we’re in the process of redecorating it. We used to have lots of motivational quotes on the wall, but the feedback said it was quite a busy space, so we’ve stripped it back to something calmer. It’s about to be painted and we’ll put their own artwork on the wall as well – we have some talented artists in our current cohort.”
Positive risk-taking
Positive risk-taking is a process that involves taking calculated risks to achieve positive outcomes. Kirsty explains how the team incorporate elements of positive risk-taking in the care they provide.
Kirsty says: “Positive risk-taking is about looking at the situation holistically and taking into account the young person’s mental health and physical well-being. When they’re not eating, their body becomes starved of the food and nutrients it needs. As well as being detrimental to physical health, being starved of nutrients also impacts their mental health, ability to make decisions and day-to-day general well-being. So, it becomes a very complex presentation, and to be of most help, we need to consider this complexity holistically and look at all the factors.
“But when we are confident that they have achieved a safe level of weight restoration, then positive risk-taking can play an important role in reducing NG feeds, particularly when young people are stuck. Sometimes we won’t give them their NG feed if we feel that is the right thing to do for that person; it is a very individualised approach. Each young person needs to be monitored closely to ensure they move forward, rather than backwards.
“A lot of trial and error is involved until we get to the most appropriate way of doing it for that person. Sometimes, they will tell us, “Actually, it’s too fast for me.” So we adjust the approach accordingly – it all comes back to the pace and awareness of what is beneficial for each person.
“It’s also about trying to unpick the beliefs associated with NG feeds that the young person has developed. We spend a lot of time with them talking about the pros and cons of the NG feed, what life can look like without an NG feed, and also giving them the space to be able to share their feelings, and what they think are the pros of having the NG feed.”
Weekly NG review meetings
The specialist MDT at Bere Clinic regularly evaluate their work and the decisions they make to ensure positive outcomes for the young people in their care, especially if those outcomes are around reducing NG feeds. Claire Weston explains how the MDT meet weekly to review the success of their approach and the impact on each individual.
Claire shares: “We have a weekly NG review meeting as an MDT, along with their primary nurse as well. If a young person is having NG feeds, we plan how we’re going to move forward to get them supported off NG and back to oral feeding. Often this is a gradual, step-by-step process, and we review what interventions we have put in place to see what has worked and what hasn’t, plus what we can do next time to move forward. It is really helpful to get all members of the team together – it gives you the best perspective. For example, the nursing team are responsible for delivering the NGs, so they can share feedback on the individual’s moods, on meal support and information that the rest of the MDT might not be able to see.
“We also get psychology input and family therapy input so that we have a holistic picture of the young person and their progress. Regular review meetings mean that we are always fine-tuning what we do, adapting our support to individual needs. This has proven to be really beneficial for getting those that have been stuck on NG feeds off them.”
Nourish to flourish – food education
Food education also plays an important part in reducing NG feeds at Bere Clinic, and Kirsty Chewter shares how the team combine education with therapeutic discussion.
Kirsty says: “We also run a class every two weeks called Nourish to Flourish, and we have educational sessions on nutrition and food choices. We talk through the food groups and discuss what health means to them. Sometimes, a young person might have what we call fear foods, foods that they might have been restricting before their admission. It might be that they’ve decided to cut out all carbohydrates, so in the sessions, we talk about the importance of carbohydrates, what happens if we don’t have carbohydrates, the effects on your body and similar.
“The sessions are educational but also therapeutic, and we talk about their connections to those foods. We discuss their eating disorders, how you get an eating disorder and any influencing factors, for example, social media, or perhaps traumas that they have experienced. We cover how to reframe your thoughts, like what to do when you’ve got unhelpful thoughts, and other support strategies. By spending time with each young person and understanding how they think, we can then personalise their treatment, helping them to achieve their treatment goals.”
Collaborative care plans
Collaborative care planning can improve the care experience and ensure that goals are personalised and meaningful for the individual receiving care. Kerryann Smith, Interim Ward Manager, describes how care plans are formulated at Bere Clinic.
Kerryann says, “All care and treatment that young people receive at Bere Clinic is individualised to them – we go at their pace and we regularly review everything we do. Whenever a young person joins us, we work together to produce their care plan. We always look at what motivates them and what their goals are.
“Goals are personal and different for everyone. Some people’s goal may be as simple as being able to go for a walk or to see their dog again. Others may have bigger goals, such as having more leave in the community with their family, or to see their friends.
“Co-production in care plans is essential for individuals with eating disorders, otherwise, there is no motivation to move forward. If clinicians are always giving instructions and deadlines, then the young person can feel very disempowered. Sometimes, they can’t do what is being asked, and the care team needs to work through that with them. It has to be a collaborative effort.
“The whole MDT inputs into the care plans, in partnership with the young person, and we make a collaborative decision. For example, if we are working on reducing NG feeds at Bere Clinic, we’ll collaboratively agree on the steps we have to take, and these steps are different for every person, depending on how they present. Without the young person being involved in decision making, the care plan would not work because they have to engage in it, and they have to want to work towards recovery.”
Working together with families
Parents and families remain a key support system for young people who stay at Bere Clinic. Lee Cottrell, Hospital Director, explains the importance of family participation throughout the entire treatment and recovery process.
Lee says: “It’s vital to involve parents throughout the whole process – from pre-admission to discharge. Having family members on board is key to achieving positive outcomes for the young person in our care. Pre-admission involvement sets the expectations, so to speak. We outline our approach, our processes and what we expect from them in terms of engagement, for example, how they should work with our dietitians, or with the family therapists. Everyone is clear on their responsibilities and how best to support the young person.
“Eating disorders can take over a family by the very nature of what they are, and the control issues related to that. So, by the time the child is admitted to our service, all family members, especially the parents, have been under a lot of pressure for some time. We’re here to relieve that pressure, but also to help them understand how best they can support their child. For example, when the young person is eating oral food, how can the family provide meal support when they are on leave and things like that.
“It’s so important to work together with the family. Throughout the young person’s stay with us, the family is updated daily by the nursing team, and they are invited to a family group that happens every two weeks, facilitated by the psychology team. The group gives families a chance to speak in a supportive but private space. Families are also invited to ward rounds, which happen weekly, and to Care Programme Approach meetings (CPAs), which happen every six weeks. This is a framework to support the young person’s recovery and their needs by understanding their strengths, goals, support needs, and difficulties. When families stay engaged and we work together, we see better outcomes for the young person.”
References
National Collaborating Centre for Mental Health. Core interventions in the treatment and management of Anorexia Nervosa, Bulimia Nervosa and related eating disorders. London: National Institute for a Clinical Excellence, 2004.
Giombini, L., & Nesbitt, S. (2023). What Does Eating Disorder Recovery Look Like?. Jessica Kingsley Publishers.