• To understand how nasogastric tube feeding (NGT) under physical restraint affects the parents of children who undergo the intervention
• To recognise that parents may feel empathy for the staff involved but that the situation can also damage their relationship with staff
• To reflect on the use of a trauma-informed approach to mitigate the traumatic effects on parents and, in turn, on their child
Background Nasogastric tube (NGT) feeding under physical restraint is a clinical intervention that may be required when a child or young person is medically unstable secondary to restrictive eating.
Aim To explore the experiences of parents when their child receives NGT feeding under physical restraint and understand the effects of this on them.
Method This is a secondary analysis of data from two previous studies on NGT feeding under physical restraint – one in mental health wards and one in children’s wards – in which semi-structured interviews had been conducted with patients, staff and parents. For this secondary analysis, the authors thematically analysed 31 transcripts of interviews with parents.
Findings Parents reported a range of emotions which could be conflicting in nature, notably relief and shame. In both studies, parents understood the necessity of NGT feeding under physical restraint but experienced the intervention as traumatic. They expressed empathy for staff facilitating the restraint. In the children’s wards study, some parents described conflict and damaged relationships with staff, and three parents had participated in physically restraining their child for NGT feeding.
Conclusion Nursing staff should be aware that NGT feeding under physical restraint is distressing for parents. Adopting a trauma-informed framework may help to mitigate the traumatic effects on parents and, in turn, on their child.
Nursing Children and Young People. doi: 10.7748/ncyp.2025.e1546
Peer reviewThis article has been subject to open peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Fuller S, Thomson S, Nicholls D et al (2025) Nasogastric tube feeding under physical restraint: understanding the effects on parents and how to support them. Nursing Children and Young People. doi: 10.7748/ncyp.2025.e1546
AcknowledgementsThe authors would like to thank all participants for their time and for making their voices heard. The authors would also like to thank Dr Jessica Conrad-Czaja and Dr Stephanie Baker, clinical psychologists, Northamptonshire Healthcare NHS Foundation Trust, for their time and support
Open accessThis is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence (see https://creativecommons.org/licenses/by-nc/4.0/) which permits others to copy and redistribute in any medium or format, remix, transform and build on this work non-commercially, provided appropriate credit is given and any changes made indicated.
Published online: 20 January 2025
Most eating disorders are associated with the person’s over-evaluation of their weight and shape, leading to disturbed eating patterns such as restricted eating or binge eating. However, they can also result from the avoidance of food because of its sensory characteristics, a lack of appetite or concerns about the consequences of eating, such as nausea or vomiting, as seen in avoidant restrictive food intake disorder (ARFID) (American Psychiatric Association 2013).
Eating disorders can develop at any age, but peak onset is during adolescence and early adulthood (Javaras et al 2015, Silén et al 2020). Over the past decade, the numbers of children and young people who have an eating disorder have increased significantly (Hudson et al 2022). There is particular concern when an eating disorder develops in adolescence since this is a period of rapid growth, so episodes of suboptimal nutrition during that period can have long-term adverse effects on health, especially bone health (Nagata et al 2024).
Treatment for eating disorders is usually based in the community with a multiprofessional approach (National Institute for Health and Care Excellence 2020). However, children and young people with restrictive eating disorders, such as anorexia nervosa and ARFID, may require admission to a children’s ward for medical stabilisation (Royal College of Psychiatrists 2022). Children and young people with restrictive eating disorders who are medically unstable will often require a prescribed meal plan as well as monitoring for refeeding syndrome. In most cases, an oral meal plan is sufficient to achieve a safe discharge home. Some children and young people will need either prescribed supplement drinks or supportive (consenting) nasogastric tube (NGT) feeding in addition to their meal plan (Royal College of Psychiatrists 2022).
In some children and young people, however, cognitions about eating and drinking are so strong that they will not tolerate any of these strategies and NGT feeding under physical restraint will become necessary, either to prevent medical deterioration on a mental health ward and avoid transfer to the acute hospital, or as a last resort to keep them alive (Fuller et al 2024b). NGT feeding under physical restraint is typically used in mental health hospitals (Fuller et al 2023a), but research has shown that 38.5% of children’s wards in acute hospitals in England had used this intervention during a one-year period (Fuller et al 2024a).
NGT feeding under physical restraint can be traumatic not only for patients and their parents, carers or legal guardians (hereafter referred to as ‘parents’) but also for staff (Fuller et al 2024b). The effects on patients are complex; some have reported developing post-traumatic stress disorder after having received NGT feeding under physical restraint (Fuller et al 2024b); others have described their gratitude for having received the intervention because it had facilitated their recovery (Tan et al 2010). Nursing assistants have described providing NGT feeding under physical restraint as ‘an unpleasant practice’ and reported experiencing emotional distress, physical exhaustion, injury and physical aggression (Kodua et al 2020).
There is, however, a research gap about parents’ experiences of their child receiving NGT feeding under physical restraint. In the authors’ clinical experience, parents of a hospitalised child often find themselves in a pseudo healthcare provider role, having to provide comfort and support to their child while simultaneously making difficult decisions about their care that the child may strongly resist, with a risk that this will alienate their child from them. The use of NGT feeding under physical restraint in children and young people carries a risk of harm or trauma and parents’ experiences of it therefore merit a deeper understanding.
To explore the experiences of parents when their child receives NGT feeding under physical restraint and understand the effects of this on them.
• Nurses need to recognise that the use of nasogastric tube (NGT) feeding under physical restraint in a child or young person is likely to be traumatic for the parents
• Nurses working in inpatient settings caring for children and young people with restrictive eating disorders require training on attachment-focused and trauma-informed care
• Nurses can use the 3Rs approach – regulate, relate, reason – to help parents manage their emotions when their child receives NGT feeding under physical restraint
• Future research could explore the effects of NGT feeding under physical restraint on all parents, not just the parents of the child or young person receiving this clinical intervention
The authors compared and contrasted data from two consecutive mixed-method studies about the frequency, nature and experience of NGT feeding under physical restraint, which were conducted by the same research group (Fuller et al 2023a, 2024a). The studies were the first of their kind to involve almost all inpatient units in England that use NGT feeding under physical restraint for legal minors who have an eating disorder. Data were received from 100% of mental health wards (Fuller et al 2023a) and 95% of children’s wards (Fuller et al 2024a).
The first study (Fuller et al 2023a) collected qualitative data from patients, parents and staff about NGT feeding under physical restraint in a variety mental health ward settings, including child and adolescent mental health (CAMH) general adolescent units, specialist child and adolescent eating disorder units (SEDUs) and psychiatric intensive care units. The provision of child and adolescent eating disorder inpatient wards in England is variable; where such wards are not available, the local adolescent mental health units generally have inpatient cohorts that are largely composed of patients with eating disorders and have therefore developed high levels of experience and expertise in managing these conditions.
The second study (Fuller et al 2024a) collected qualitative data from patients, parents, staff and security personnel working on children’s wards where NGT feeding under physical restraint is used. Security personnel were included when it emerged that they were also involved in the process of NGT feeding under physical restraint.
The main findings of the two studies have been reported elsewhere (Fuller et al 2023a, 2023b, 2024a, 2024b, 2024c, 2024d). This article reports the findings about parents’ experiences.
The primary studies were advertised online (on the websites of the British Eating Disorders Society, Beat Eating Disorders and the New Maudsley Carers Group), via the research team’s social media and through word of mouth. Potential participants contacted the research team and were sent a copy of the participant information sheet. Participants could talk to the research team on the phone if they had any questions about the research or participation. They were offered a choice between an individual interview or a group interview.
Semi-structured topic guides were used to interview participants, with introduction questions and optional prompts to aid discussion if needed. The semi-structured topic guides were used for the group and individual interviews. At the start of each interview, participants were asked again whether they had any questions about the research or their participation. Two researchers were present for each interview so that if a participant became distressed, there would be someone available to offer support. The interviews were conducted remotely and recorded using a videoconferencing programme. The transcripts were checked manually for discrepancies.
Both studies were approved by Imperial College London’s Research Ethics Committee (reference 21IC7157 for the mental health ward project, reference 6569874 for the children’s ward study). Since participants were not recruited via the NHS, ethical approval from a research ethics committee was not sought. Potential participants were made aware that they would be able to withdraw from the study at any time. All participants signed and returned an electronic consent form before their interview. All data were kept in Imperial College London’s secure data storage facility.
For the secondary analysis reported in this article, the authors included data from all parents who had participated in the two studies, except:
• Those whose child had received NGT feeding under physical restraint after the age of 18 years.
• Those whose child had received the intervention in countries other than England.
• Those whose child had received the intervention before July 2019, when changes to dietetic practice in NGT feeding under physical restraint were made in the UK and Ireland (Fuller and Philpot 2020).
The authors analysed the data using Braun and Clarke’s (2006) framework.
The authors analysed 31 transcripts of interviews with parent participants (Table 1).
| Mothers (or stepmothers) | Fathers | Total number of participating parents | |
|---|---|---|---|
| Study in mental health wards* (Fuller et al 2023a) | 9 | 2 | 11 |
| Study in children’s wards (Fuller et al 2024a) | 15 | 5 | 20 |
Parents had participated in three group interviews for the mental health wards study and in three group interviews and six individual interviews for the children’s ward study. Three parents had participated in both studies, since their child had received the intervention in both environments.
The age range of children and young people involved was 12-18 years in the mental health wards study and 9-17 years in the children’s wards study. The difference in age range was expected because policy differs between settings; CAMH services routinely see patients aged up to 18 years, whereas children’s services typically see patients only until the age of 16 years, with exceptions.
There was considerable overlap in the themes and subthemes that emerged from the thematic analysis of data (Table 2).
A strong narrative was heard of the many conflicting emotions that parents experienced. Parents described the powerful effects of NGT feeding under physical restraint when it was administered to their child, with two subthemes: their emotions when the decision to use the intervention was made and the traumatic nature of the intervention.
Parents understood the imperative to save their child’s life and therefore supported the use of NGT feeding under physical restraint. At the same time, they also acutely felt the horror, pain and blame of agreeing to, allowing, enabling and ‘colluding with’ such a restrictive practice, which was experienced as harrowing and ran deeply counter to their natural instinct to protect, care for and comfort their child.
In this context, parents felt it was helpful that clinicians made the final decision to use NGT feeding under physical restraint, since this relieved them of the moral responsibility and burden of the decision, or at least helped them to share that responsibility and burden. Parents’ difficulty with the moral responsibility of the decision meant it became emotionally and morally significant whether they were involved in the delivery of the intervention or not.
Talking about what they felt when the decision was made to use NGT feeding under physical restraint, some parents described relief:
‘I wanted my daughter to have nutrition, and I didn’t want to be the person making that decision because… of the impact that might have had on my relationship with her. There’s a sort of a feeling of relief […] about that decision being taken out of my hands as a parent.’ (Mental health wards study participant 4)
‘We have been on the ward for days and days and days. I remember thinking, with those machines beeping constantly, that we might lose her. I just didn’t know how we were ever going to get her to eat. When they [paediatric staff] said they were going to NG her I just thought “Finally, someone with a plan”.’ (Children’s ward study participant 49)
At the same time, parents described a sense of blame, self-blame and blame from their child. Parents were worried that their child would blame them for being part of the decision-making process to use NGT feeding under physical restraint – and sometimes reported that their child still blamed them:
‘Weirdly, I beat myself up about this because I remember thinking at the time “Will she blame us [parents] for this”, ’cause it’s such a big decision. She will say to me sometimes, you know, “You made that decision and then you weren’t even there [when they restrained me]”.’ (Mental health wards study participant 11)
‘Sometimes, still today, when we argue about whatever, she will still say: “You took me to that hospital, I blame you for all of this” and it’s horrendous. I just don’t know what to say to her. As a parent if your child is starving, disappearing in front of you, who wouldn’t […] take her to a hospital, nobody, we all would.’ (Children’s ward study participant 26)
In both environments, parents described traumatic experiences, particularly from hearing their child being restrained. Some parents consequently needed therapy:
‘So, we would be downstairs in the waiting area [after being asked to wait outside for their own sake] and we could hear our own kid being restrained. You know your own child’s scream. That was so, so unbelievably traumatising.’ (Mental health wards study participant 2)
‘It was horrible at the time, I remember sitting on the bed and she looked at me and said “Daddy, please help me”, but now it’s even worse, because we can see the layers of trauma in terms of historical abuse that had happened before, that had been added on top of her restraint.’ (Children’s ward study participant 8)
‘I have therapy, every week. Not just about what happened to her, but what happened to me and the impact on the rest of the family was quite horrendous as well.’ (Mental health wards study participant 3)
Three parents described traumatic experiences of having been involved in facilitating the physical restraint of their child; this was only reported by parents in the children’s wards study:
‘Our whole existence became about doing these daily, extremely traumatic feeds. We had to alternate between me and my husband. It was awful, I was having to sit on her legs, hold her arms and get my head in between her head and keep her stable enough to be fed. I don’t think I will ever forget that.’ (Children’s ward study participant 24)
The second overarching theme was the effects of NGT feeding under physical restraint on parents’ relationships with the staff caring for their child, with two subthemes: feeling empathy for staff facilitating the restraint (expressed by parents in both environments) and conflict leading to damaged relationships with staff (expressed only by parents in the children’s ward study).
In both environments, parents expressed feelings of empathy for staff who were facilitating the restraint:
‘You could see there were days when the staff were just worn down after doing one feed after another. I have seen staff with tears in their eyes after difficult restraints.’ (Mental health wards study participant 7)
‘At the point of admission we, me and my husband, were both terrified, they [nursing staff] had such a difficult time doing the restraint, she was fighting them so much, everything was going wrong… They couldn’t pass the tube, the aspirate was wrong […], they had to do an X-ray… It was awful for everyone.’ (Children’s ward study participant 44)
Parents in the children’s ward study described conflict with staff when they advocated for what they thought was the right treatment for their child. This led to a loss of confidence and damaged long-term relationships with staff:
‘When I brought up the [enteral feeding under restraint] guidelines to the matron in charge of the ward, I was told these were just guidelines and they didn’t have to follow them, and that they didn’t set the policy […] So she refused to do anything differently, despite it being in the interest of my daughter and her staff. How can you call yourself a leader? A carer? I struggled every time I saw her after that.’ (Children’s ward study participant 9)
‘When the restraints got bad, they tried to discharge her and I said: “Over my dead body, she’s really ill” and they just said she was “too loud, too shouty”. There was no humanity. How can you trust these people who don’t even want her there?’ (Children’s ward study participant 49)
The findings raised three crucial points: parents whose child received NGT feeding under physical restraint experienced strong conflicting emotions; in some cases, parents were directly involved in the physical restraint of their child – a finding unique to the children’s wards study; and regardless of the setting, this clinical intervention was traumatic for parents.
This study identified feelings of relief and blame among parents. The authors know from clinical experience that parents may also feel helpless or disempowered and therefore express anger or frustration. It is important that nurses understand and empathically address the conflicting emotions experienced by parents when it is decided to use NGT feeding under physical restraint and when their child receives the intervention. Giving parents a safe space where they can share their emotions, and acknowledging that this is a distressing and difficult situation they probably never expected to find themselves in, could help parents manage their emotions. It is important to offer parents this safe space before and after their child receives the intervention, mirroring how staff can be supported with a pre-brief and debrief (Thomas-Unsworth et al 2022).
In children’s wards, there is a positive culture of involving parents in care delivery. Parents are encouraged to support their child to minimise the negative effects of social isolation and of the new medical environment, which can be disorienting and frightening. It is common for parents to stay with and even sleep alongside their child, help feed them and deliver normal parental care working alongside nursing staff. Physical restraint or ‘clinical holds’ often occur, but usually only for infants and very young children who are unable to understand or cooperate with brief minor procedures, such as drawing blood, conducting a spinal tap or having an injection (Page and McDonnell 2015).
NGT feeding under physical restraint is different from the brief restraint, for minor procedures, of very young children, who are relatively easily restrained and then comforted (Preisz and Preisz 2019). The intervention is, by its nature, a process that requires subduing a resisting patient. It involves several adults physically restraining the child or young person and inserting an NGT against their will to deliver nutrition, which may need to be done repeatedly for several days. This level of restrictive practice and the discomfort and aversiveness of inserting a tube through the nasopharynx – which can be painful and cause reflexive gagging and retching – are well beyond the normal parental experience. It is highly distressing to the child or young person, the parent(s) and the staff (Fuller et al 2024b).
Parents being directly involved in the physical restraint of their child for NGT feeding was a finding unique to the children’s wards study. There were no accounts of parents helping to restrain their child in the mental health wards study.
The nature of severe mental illness means that CAMH inpatient settings do not let parents stay alongside their child. Parental support while the child is an inpatient in such settings is typically restricted to neutral or pleasant activities, such as visits, walks around the grounds, home leave and similar planned activities, which are unrelated to nursing care. Therefore, parents are less involved in everyday care delivery and less available to be recruited to assist in NGT feeding under physical restraint.
Furthermore, compared with children’s wards, mental health wards are more likely to have nursing staff who are familiar with compulsory treatment, restrictive practices and how to care safely for uncooperative or resisting patients. Mental health wards are also more likely to have staff trained in safe restraint, have protocols governing restraint and be able to mobilise appropriate staffing resources when restraint is required (Neilson et al 2021). While it is not certain why three of the 20 parents in the children’s wards study were asked to help restrain their child, the authors speculate that this may reflect the culture of parental co-nursing in that setting and a pragmatic response to the lack of available trained staff.
In the authors’ view, the role of the parent is to support and care for their child and that role should be protected. If a parent is asked to help restrain their child, they will no longer be perceived as a carer but as someone to be feared. Research has suggested that when the parenting approach is inconsistent – for example, if a parent is simultaneously caring and threatening – this is damaging for the child (Hughes 2011). An inconsistent parenting approach can contribute to attachment insecurity and lead to the child being unable to regulate their emotions and being more vulnerable to mental health issues or trauma responses (Hughes 2011).
Even when parents are not asked to help restrain their child, the findings suggest that their experience of having their child receive NGT feeding under physical restraint is traumatic, with some subsequently needing therapy. Some parents reported that even hearing their child being restrained for NGT feeding was traumatic. This mirrors research findings showing traumatic experiences of the intervention among staff and patients (Kodua et al 2020, Fuller et al 2024b).
Any approach to make the intervention less traumatic for all involved should be attempted. For parents, there are practical strategies that can mitigate the effects of hearing their child being restrained, such as soundproofing treatment rooms or offering ear defenders (Fuller et al 2024b). More broadly, adopting an attachment-focused and trauma-informed approach is likely to be beneficial. The academic literature does not offer a single approach but multiple perspectives, with the overarching principles of trauma-informed practice (Office for Health Improvement and Disparities 2022) available to be tailored to individual settings. Anyone involved in caring for a child or young person, be it staff or parent, can adopt a trauma-informed approach to care.
Nurses caring for children and young people who receive NGT feeding under physical restraint can use the ‘3 Rs’ (regulate, relate, reason) approach advocated by Perry and Dobson (2013) to support parents:
• Regulate – the nurse provides time and space for the parent to express their feelings, which can help them recover from a fight/flight/freeze response, then process, regulate and control their emotions.
• Relate – the nurse uses their relationship with the parent to express empathy and help them acknowledge their feelings, thereby validating those feelings. The nurse might say ‘I can see you are really worried, this is very hard’, or ask ‘Every parent in this situation feels a range of feelings, what do you feel?’.
• Reason – the nurse helps the parent understand that their emotions are a normal response to a traumatic situation and ensures that their understanding of the situation is not ‘you are doing this to my child’, but ‘my child is really ill, this is difficult but a necessary part of treatment’.
Once nurses have modelled the 3Rs approach with parents, parents can, in turn, use the same approach with their child who is likely to be even more distressed than they are. Parents can support their child in developing a shared narrative of the situation (Hagelquist 2017) – for example, explaining to their child ‘although you don’t feel poorly, the doctors and nurses are very worried how ill you are, and they feel that this is necessary to save your life’.
This is the first article to compare and contrast data on parents’ experiences from two qualitative studies on NGT feeding under physical restraint. Data from interviews with 31 parents were used, so data saturation and meaning should have been achieved (Hennink et al 2017).
Views were only sought from parents in England, so the findings may not represent parents’ experiences in other countries, where clinical practice about NGT feeding under physical restraint may be different. Likewise, the findings may not be applicable to adult settings.
NGT feeding under physical restraint of a child or young person can be traumatic for all involved, but there is a research gap about parents’ experiences. Secondary analysis of data collected in two previous studies on NGT feeding under physical restraint in mental health wards and in children’s wards show that parents experienced conflicting emotions, notably relief and blame. They were extremely distressed knowing or hearing that the intervention was being administered to their child. Nurses can support parents by acknowledging their distress about this intervention and giving them time and space to process their emotions. Adopting an attachment-focused and trauma-informed approach may help mitigate the traumatic effects of this intervention on parents and, in turn, on their child.
09 January 2025 / Vol 37 issue 1
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