Our Studies

NoTube’s philosophy and methods are based on scientific knowledge gained from more than 25 years of clinical work experiences.
Our medical experts have researched for many years in the field of early eating behavior disorders, tube dependency and tube weaning exit strategies. They have published many scientific literature and are stnoopill involved in many research projects.

Here, we provide you with our most important articles and studies around the topic. Please get in touch with us at help@notube.com if you would like to get the full articles.

Publications on the subject of eating disorders

Summary of studies/articles

Intensive multidisciplinary intervention for pediatric feeding disorders. A Systematic Review and Meta-Analysis of Intensive Multidisciplinary Intervention for Pediatric Feeding Disorders: How Standard Is the Standard of Care?
Changes in psychopathology of parents of NOFT (non-organic failure to thrive) infants during treatment This is a case study which shows that parents of children with NOFT show severe psychopathology which reduces during the treatment of the child. After one year, only 12% of the parents still show signs of psychiatric disorders.
Psychiatric diagnosis in infancy – a comparison The study compares the two diagnostic systems DSM IV and Diagnostic Classification: Zero to Three. The data provides support for the idea that the use of ZTT DC 0-3 in early infancy may be helpful by increasing the range of clearly defined diagnostic entities.
DC: 0-3 in pediatric liaison work with early eating behavior disorders This article highlights the use of the DC: 0–3 (Diagnostic Classification, Zero-to-Three, 1994) with respect to the special conditions of a hospital pediatric liaison service. The DC: 0–3 system itself has had a positive influence on the structure and quality of diagnostic assessment and the setup of treatment plans in this setting. Experiences with DC: 0–3 in a special group of referred infants with severe eating behavior problems is described.
Infant mental health and feeding disorders from a pediatric perspective This paper highlights feeding disorders from a pediatric perspective. It describes the role of the pediatrician, the influencing variables time, development and growth, the impact of growth data and nutritional protocols, the essential first steps in the feeding clinic but also the diagnostic classification of early eating behavior disorders.
Frühkindliche Essstörungen (in German) The eating development and its stages are discussed, furthermore, there is a description of the several early eating disorders.
Interaktionsdiagnostik oder die Entmystifizierung der empathisch beobachtenden Interpretation zwischenmenschlichen Verhaltens (in German) This book chapter deals with interaction, communication and attachment, discusses the diagnostic approaches and highlights the interaction in early infancy.
Frühkindliche Ess- und Fütterstörungen (in German) This diploma thesis deals with the role of the speech- and language therapists in the interdisciplinary tube weaning program.
Essstörungen (in German) Early eating behavior, its deviations as well as diagnostics and intervention on early eating behavior disorders are discussed.
Auswirkungen von logopädischen Interventionen auf die orofaziale Situation der Kinder nach Operation der Rachemandel (in German) This masterthesis is a longitudinal study and describes whether and how interventions of speech and language therapy may affect children´s orofacial functions like swallowing, sucking, breathing, chewing, etc.. Data was collected over a period of 19 months.
Einfluss des Resilienzstatus von Eltern auf das Entstehen frühkindlicher Essstörungen im Alter von 0-5Jahren (in German) This Diplomathesis specifies the definition of “resilience” and shows if and how a parents’ resilience state can affect their children´s eating behavior.
Der Zusammenhang zwischen der Ekelempfindlichkeit und der Tendenz zu einer Essverhaltensstörung bei Kindern (in German) This Diplomathesis highlights the questions, if there is a correlation between the disgust sensititvity and picky eating between three and six years of age.

Publications on the subject of Tube Dependency and Weaning Strategies

Summary of studies/articles

Efficacy of a standardized tube weaning program in pediatric patients with feeding difficulties after successful repair of their esophageal atresia/tracheoesophageal fistula Children born with esophageal atresia (EA) might suffer from significant oral feeding problems which could evolve into tube
dependency. The primary aim of the study was to define the outcome of tube weaning in children after successful EA repair and
to compare outcomes in children with short gap/TEF (tracheoesophageal fistula) and long-gap EA.
Gastrostomy Tube Weaning and Treatment of Severe Selective Eating in Childhood: Experience in Israel Using an Intensive Three Week Program Background: Children dependent on gastrostomy tube feeding and those with extremely selective eating comprise the most challenging groups of early childhood eating disorders. We established, for the first time in Israel, a 3 week intensive weaning and treatment program for these patients based on the “Graz model.”
Netcoaching: A new and effective alternative to traditional onsite models for supervised tube weaning in infancy Dissertation submitted by Mag.rer.nat. Sabine Marinschek for the Academic Degree of Doctor of Medical Science (Dr. scient. med.) at the Medical University of Graz Department for General Pediatrics, University Clinic for Children and Adolescents, Graz
Long-term Outcomes of an Interdisciplinary Tube Weaning Program: A Quantitative Study. This study analyzes long-term effects (outcome, growth, and nutrition data) in a large sample of formerly tube-dependent children 1 to 6 years after participation in tube weaning programs, based on the “Graz model of tube weaning.
Tube dependency as a result of prematurity. Tube dependency is an inability to make the transition from tube to oral feeds despite the absence of medical reasons for ENS and might lead to symptoms like oral aversion and food refusal. This study aims to evaluate the prevalence of prematurity in a large cohort of tube dependent children.
A Program for Weaning Children from Enteral Feeding in a General Pediatric Unit: How, for Whom, and with What Results?. Frontiers in Pediatrics. 6. 10.3389/fped.2018.00010. Mirete, Justine & Thouvenin, Beatrice & Malecot, Gaelle & Le-Gouëz, Morgane & Chalouhi, Christel & du Fraysseix, Catherine & Royer, Aurélie & Leon, Anais & Vachey, Clément & Abadie, Veronique. (2018) To describe a series of children who were hospitalized for a tube-weaning program in the general pediatric ward of a pediatric tertiary university hospital: describe our method, to determine the success rate of our inpatient pediatric tube weaning program, and search for relevant factors linked to its success or failure.
The Tube a “necessary Evil” on the Way to Orality This article discusses tube feeding in childhood, including advantages and possible disadvantages from a medical but also psychosocial point of view. Development of tube dependency as a non-intended consequence of temporary tube feeding, as well as the necessity for tube weaning, is highlighted. The role of the pediatrician is also discussed.
Nutritional/Growth Status in a Large Cohort of Medically Fragile Children Receiving Long-Term Enteral Nutrition Support. The aim of the present study was to assess the nutritional status and growth of medically fragile children receiving long-term enteral nutritional support (ENS)
Tube weaning via the Internet – is that even possible? (in german) This article deals with an internet-based program that helps children during the transition from tube feeding to oral nutrition. Advantages and disadvantages, technical implementation and target groups are highlighted, results are reported, he practical application is presented, the text is rounded off with a case study.
Unintended Side-Effects of Enteral Nutrition Support: the Parental Perspective: A Quantitative Analysis. The present study highlights the occurrence of unintended adverse effects of enteral nutrition in infancy and childhood, as viewed and reported from a parental perspective.
From each side of the tube: the Early Autonomy Training (EAT) program for tube dependent infants and parents The paper is about the EAT-program, which is used in Graz and describes tube weaning in infants and children.
Prevention and treatment of tube dependency in infancy an early childhood This is an evaluation of the experience of 20 years in weaning children from their feeding tube. Success rates are shown, but also the fact that the frequency and severity of unintended tube dependency in early childhood has to be minimized.
Retrospective and prospective analysis of ICD-10 and ZTT DC:0-3R diagnoses in a population of tube dependent toddlers and young children This diploma thesis deals with the retrospective and prospective analysis of ZTT DC:0-3R diagnosis and ICD-10-diagnosis in an international sample of tube dependent infants.
Tube dependence: a reactive eating behavior disorder This article focuses on the issue of tube dependence. Stages of tube dependence are described, prevention is discussed.
Weaning in children with congenital heart diseases from nutritional tube is easier than in other children This text shows, that 20 out of 20 children (100%) with congenital heart disease could be weaned successfully during the Graz program.
Tube weaning according to the Graz Model in two children with Alagille Syndrome This case study describes the tube weaning according to the Graz model process of 2 children after liver transplant because of Alagille syndrome.
Inpatient tube weaning in children with long term feeding tube dependency: A retrospective analysis This study analyzes 221 cases of tube dependent children who went through the 3-weeks-inpatient program in Graz. 92% of the patients are completely orally fed after the treatment.
A grain of normality – weaning a child with Marshall-Smith Syndrome from feeding tube: a case report This case report highlights the feeding problems in Marshall-Smith-Syndrome and the weaning from a tube in a 5-year-old patient. After 3 weeks the child was weaned successfully and it was able to sustain his nutritional needs orally.
Developmental impact of a standardized tube weaning program (EAT:Early Autonomy Training; Graz Model for weaning tube dependency in infancy) This PhD thesis highlights the question, if tube weaning has an effect on the development of tube dependent children.

Weaning children off enteral nutrition by netcoaching versus onsite treatment: A comparative study
This retrospective open-label study was published in a high ranged pediatric journal in 2014. It aims to show outcomes of two different tube weaning strategies: Onsite- treatment option versus Netcoaching, both based on the Graz model of tube weaning in a large sample of patients. In Netcoaching 90% and in the Onsite-treatment program 81% of children could be weaned off their feeding tubes completely.
Sondenentwöhnung in der frühen Kindheit (in German) This study describes the interdisciplinary Graz Model of tube weaning. From a total sample of 62 children, 59 were successfully weaned off their feeding tube. Only 3 children were partially tube weaned. Furthermore, 3 weeks after the end of the treatment the children thrived significantly.
Essen oder nicht Essen, das ist hier die Frage (in German) This article deals with eating behavior of children and the Graz model of tube weaning. There is also advice for a healthy eating development.
Infantiler Botulismus (in German) On the basis of a case study,the diagnosis and therapy of infantile botulism is discussed.
Sondenentwöhnung (in German) This article describes the possibilities as well as general information about tube weaning.
Klinisch funktionelle Schluckdiagnostik und Effizienz der Sondenentwöhnung bei pädiatrischen Dysphagiepatienten in einer retro- sowie prospektiven Evaluation (in German) This medical diploma thesis deals with the diagnostics of patients suffering from dysphagia and its impact on tube weaning.
Sondenentwöhnung zerebralparetischer Kinder am Grazer Modell und die Aufgabe der LogopädIn (in German) This diploma thesis discusses the speech and language therapy approach during the Graz tube weaning method in children with cerebral palsy.
Mein Kind isst nicht mehr: Systemische- und Bindungsaspekte bei Ätiologie und Intervention frühkindlicher Ess- und Fütterungsstörungen (in German) This bachelor-thesis deals with early eating behavior disorders and tube dependency. The text shows different diagnostic approaches and interventions. Furthermore, the author describes the importance of the mother-child interaction.
Retrospektive Analyse der Prävalenz von Frühgeburtlichkeit (<30SSW) in einer großen Inanspruchnahmepopulation sondendependenter Kinder (in German) This diplomathesis describes how the gestation age of preterm children (<30GW) is related to tube feeding, other complications and the success rate of tube weaning.


Bibliography of our medical experts

Within their medical career our medical experts have published a lot of scientific articles and chapters in different high ranged journals and books. Main topics are mostly related to eating behavior disorders and some stories are simply autobiographic novels. Download a complete list of their publications:

  • Univ. Prof. Marguerite Dunitz-Scheer, MD – Bibliography
  • Univ. Prof. Peter Scheer, MD – Bibliography
  • Dr. Sabine Marinschek, MSc – Publications
  • Dr. Karoline Pahsini, MSc – Publications
  • Elisabeth Beckenbach, MD – Publications
  • Scientific Literature and Medical Background Information


    At the Medical University of Graz

    The NoTube team has researched in the field of early infant feeding behavior disorders, tube dependency and tube weaning strategies for more than 25 years. All our knowledge and experience results from the clinical work of many years at the University Hospital Graz. Our tube weaning approach is based on the Graz Model of tube weaning. Prof. Marguerite Dunitz-Scheer invented the term tube dependency many years ago and described it in many articles extensively. Tube dependency as an unintended result of long-term tube feeding in infancy and childhood might impact the child’s development destructively. One of the latest scientific article, published in a renowned journal in 2014, deals about the high successrate of our telemedical Netcoaching program.

    Classification of feeding behavior disorders

    DC0-3R is the only diagnostic system which supplies at least six subcategories of early feeding behaviour disorders. The system is compatible with DSM IV-R and offers classification on five independent levels of functioning including medical, developmental, social and relational items. Experts of the NoTube team were part of the Task Force Team of the NCCIP (National Center for Clinical Infant Programs) who published the manual in 1994 and came up with the first revision (DC0-3R) in 2005.

    Tube dependency in itself is not a diagnostic category on its own behalf. It can involve posttraumatic aspects, sensory and perceptions issues, anatomical and functional aspects and a range of dysfunctional parental interactions in the feeding situation itself. All these themes are focused on in the diagnostic assessment.

    Download our DC0-3R summary on early eating behavior disorders.