KRISTEN WESTBROOKJESSICA SMITH

6/26 /2012

Medical and Nutritional Management of Feeding

Disorders

Medical Management

Digestion Overview:

Gastrointestinal System: Serves to break down food and attain its nutrients for energy.

Starts in the mouth, where chewing and the addition of saliva breaks down food and turns it into a bolus

The bolus is then swallowed, moving through the pharynx and into the esophagus. The esophagus pushes the food through the LES and into the stomach

Digestion Overview:

The stomach releases acid and enzymes and churns the food to break it down. It then contracts to push the food through the pyloric sphincter and into the small intestine

Moves through the small intestine and is stored in the large intestine until it is expelled from the body

Medical Issues with Feeding

Gastroesophageal RefluxMotilityTreatmentsStool patternsAllergies

Gastroesophageal Reflux: GER

Retrograde movement of the contents of the stomach into the esophagus and above Can manifest as violent vomiting or a “wet” burp

GER: Incidence and Prevalence

Reflux episodes are very common in infants, many infants “spit up” in the first few weeks/months of life

Parents are concerned with approximately 20% of infants

However, only 1-8% of children have GERD80% of babies outgrow reflux in the first year

of life.

Causes of GER

Reflux develops because of the failure of one or more of the usual protective mechanisms of the digestive system or

The failure of the clearance mechanism that should handle the reflux

Common Causes of GER:

Allergies to dietHistal hernia/impaired esophageal clearanceLow muscle toneCNS diseaseTransient lower esophageal sphincter

relaxations

What is harmful about GER? Where does reflux go?

The most harmful part of reflux is gastric hydrochloric acid (HCl)

This HCl can go to the: esophagus Lower and upper airway External environment

Infant GER

Most common reasons for Infant GER include: Immaturity of the GE and respiratory anatomy Underdeveloped postural tone

Immature muscle tone of the torso Often in slumped positions causing abdominal pressure,

hypotonia is also common in preemies Dietary factors

Majority liquid Large amount of intake in comparison to volume of

stomach Allergies to protein’s in their diet

Pediatric GER: Common Signs and Symptoms

Crying and Irritability While this may occur in children who do not have

GER, it is one of the common signs that a child may have refulx

Arching Again, may occur in children who do not have GER,

however is a common occurrence in those who doRegurgitation

The most prominent symptom of reflux in pediatricsRefusal feedings

Occurs in ~50% of those with esophagitis

Pediatric GER: Common Signs and Symptoms

Sandifer’s Syndrome An exaggerated form of “arching”, often involves neck

hyperextensionGagging and Choking

A classic symptom of GER, as liquid nears the airway

Clinical Signs of GER

Oral-Nasal Cavity: Bad breath: acid/formula breath Gagging, oral defensiveness, sensory issures Runny nose, chronic nasal blockage, sinus infection Dental problems, tooth enamel erosion Ear pain/ear infections Increased drooling/salivation snoring

Clinical Signs of GER

Larynx/Pharynx Dysphagia, “lump in throat”, choking Subglottic stenosis, apnea, bronchospasms,

laryngospasms Throat clearing, hoarse voice, laryngitis Hiccups, audible swallow

Clinical Signs of GER

Lungs Pulmonary compromise Chronic cough, wheezing, stridor Pneumonia, asthma, congestion, bronchitis Recurrent croup

Stomach: Recurrent vomiting during and after meals, spitting

up Hemetemesis Esophagitis, esophageal stricture, ulcers, bleeding,

webs

Clinical Signs of GER

Weight Issues Failure to thrive, malnutrition

Eating Stress signals Behavioral issues

Pain Excessive crying/irritability during and after meals Pain, heartburn, chest pain, stomach pain

How often do GER symptoms arise?

Can be everyday, or rareTend to be more prevalent during times of

illness and stressPoor diet can exacerbate symptoms

Motility Disorders

Motility is the movement of the digestive system and by this process the movement of food through the digestive system

When one part of the digestive system is not functioning properly for whatever reason, a motility disorder can occur

Motility Disorders

Generally a physiological problem, or an issue in the way the body (in this case digestive system) works, as opposed to a specific structure or cause

Occurs when the stomach does not contract as often and does so with less power, causing food to stay in the stomach longer

Evaluation of GER

May subjectively assess feeding disorders/GER with: Medical history Posturing, other signs of disress Ear infections Frequent swallows after feeding Diet diary Caregiver behavior during/about meals Nutrition/development Feeding schedules Food aversions Sleep patterns

Evaluation of GER

Objective Assessments Barium Swallow/upper GI MBSS if backflow enters larynx and above pH probe Endoscopy Scintigraphy manometry

Treatment of GER

Goal of treatment is to eliminate pain and reduce acid

Treatment can be divided into three categories: 1. Conservative Measures 2. Pharmacotherapy 3. Surgical therapy

Conservative Measures

Postural ApproachesDietary ApproachesSoothing TechniquesAvoiding exposure to smoke

Pharmacotherapy

Types of medications given: Antacids Histamine H2 receptor blockers Prokinetics Proton pump inhibitors Appetite stimulants Pain management Constipation management

Surgical Intervention

Most popular procedure is a Nissen fundoplication Many side affects Re-occurence rat: 3-40% after 4-9 years Most drastic for of intervention, only recommended for cases in which other treatment options are unsuccessful. Often used for patients with:

issues relating to GER affecting breathing (aspiration and apnea)

Erosive esophagitis High risk groups including cystic fibrosis and children with

neurologic impairments

Up and coming treatments for GER:

EsophyXMelatoninGastric pacingBaclofenAcupunctureNew MedicationsDurasphere

Nutritional Management

What is nutrition?

Nutrition: The science or study that deals with food and nourishment in the body

Calories: unit of measurement of energy with which you eat

Nutrients:  a chemical that an organism needs to live and grow 6 types:

Carbohydrates, fats, minerals, proteins, vitamins, and water

Normal Feeding Development

Milk/formula: birth to 4 months Sucking/suckling

Purees - 4-6 months Midline tongue patterns

Mashed foods: 6-10 months

Chopped foods: 12 months Vertical chewing and rotary

Regular rotary chewing: 2-3 years

Nutrition ScreeningsIdentifies children who

are at risk for nutritional problems

Weight, height, head circumference, and weight-height ratio is measured

Helps determine acute and chronic nutritional status

Gives a “standard” to go by

Screening Measurements

Head circumference is especially important during the first 2-3 years when rapid brain growth occurs; usually only effected in chronic severe undernutrition

Height for children under 2 to 3 years are measured in supine position

Weight-height percentage is more meaningful than weight at this age.

Weight of premature babies should be taken daily to keep track of fluid balance

Nutritional Needs

Breast milk is the optimal source of nutrition for healthy infants for first 6 months

Helps with immunity

Protein requirements are high at birth because of rapid rate of growth, decrease with time over first year

Recommended Daily Allowances (RDA) and Reference Dietary I (RDI) can be used to look at nutritional needs of healthy people

Usual intake of food for infants is 150 to 200 ml/kg/dayEnergy requirements are determined by size, age,

gender, physical activity, and rate of growthFor premature infants, the amount of calories, protein,

and fluids is highly variable and depends on the specific case

Types of Infant Formulas

Breast milkMilk based formulasLactose free formulasMilk based which thickens in the stomachSoy based formulaSynthetic proteinHydrolyzed whey- fast absorbingHydrolyzed casein protein- absorbed directly

into the intestine

Nutritional Assessment

Looks at anthropometic measurements, dietary history, clinical findings, biochemical profile, feeding skills development, and observations of behavior with caregiver

History: 3 day diary of all food and liquid consumed

Time and duration of feedings Problems with eating and feeding Physical activity recorded for caloric intake and energy

expenditure can be calculated

Malnutrition

Defined: loss of body composition, particularly fat and proteins, which can be prevented or reversed by nutritional repletion primary type: inadequacies and imbalances in the

quantity or quality of foods consumed Secondary type: produced by disease and disability

Failure to Thrive (FTT)- infants and children who fail to grow as expected based on normal growth patterns (not an accepted medical term)

Feeding problems may come from:

Uncoordination of suck/swallow/breathe sequencing

Developmental delayAnatomic abnormalitiesHealth issuesMisconceptions of appropriate feeding

Alternative Routes to Feeding

Enteral feedings- utilize the GI tract Preferred over parenteral feeds

Parenteral feedings- provide nutrients directly into the bloodstream and bypass the GI tract

Alternative Routes to Feeding

Orogastric (OG) tube- small flexible tube inserted through the mouth into the stomach; used for premature infants

Nasogastric (NG) tube- small, flexible tube inserted through the nose into the stomach

Jejunostomy (JT)- Surgical creation of an opening to the middle portion of the small intestine (jejunum), through the abdominal wall

Gastrostomy tube (GT)-  a surgeon makes an opening through the skin, abdominal wall and stomach wall, then puts into the opening a tube, or a small porthole-like device that has an opening at skin level 

Parenteral- way of delivering nutrition through peripheral veins when the gastrointestinal tract is nonfunctional and must be bypassed for a variety of reasons

OG Tube Pros and Cons

Pros: No surgery needed Usually for short period of time Low risks

•Cons:-Irritation or discomfort in esophagus-partial blockage of airway -decreased suck/swallow mechanism-Potential perforation of the esophagus or the stomach

NG Tube may be used for many reasons:

administering nutrients or medicationremoving liquids or air from the stomachadding contrast to the stomach for x-raysprotecting the bowel after surgery or

during bowel rest

Why Jejunal Tube?

used for children who cannot use their upper GI tract because of: congenital anomalies GI surgery immature or inadequate gastric motility severe gastric reflux a high risk of aspiration

Cons to Jejunal Tubes

difficult to position and may dislodge or relocate

require continuous drip feeding which results in limited patient mobility and decreased ability to lead a "normal" life

carry a greater risk of formula intolerance, which may lead to nausea, diarrhea, and cramps

What are the advantages of a G Tube?

The ability to provide additional food and calories.No nasogastric tubes are needed-no more tape

issuesLess time spent giving feedingsFeedings can be done at night when child is

asleepDoes not interfere with daily activitiesLess chance of child spitting upLess chance of tube coming outTube is easy to replace.

What are the disadvantages of a G Tube?

Become infectedLeakIrritatedMalfunctionDependentOral problems, lack of stimulation to oral

cavityVomitingDiarrhea

Types of Feeds with G Tube

Continuous: Over an extended time period feedings are given by a pump at a slow rate. An example would be 30cc per hour for 24 hours.

Bolus: A larger amount of feeding is given 3-6 times per day. Sometimes given by a pump over a certain amount of time (one hour) or simply allowed to run into the stomach by gravity using a roller clamp to slow down flow as necessary.

Direct: Direct feeds are given with the feeding set hooked directly into the gastrostomy tube.

Chimney: given by dripping the feeding into a vent that is attached to the gastrostomy tube.

Things to think about when tube feeding

an important consideration in tube feeding is the family's ability and willingness to carry out the tube feeding program

Concerns include: the availability and cost of equipment and formula home sanitation and family hygiene family support systems other psychosocial factors

Transitioning to Oral Feeds

When tube is present, work on oral stimulation. Child needs to learn to associate feelings in mouth with feeling full in the stomach

Questions to ask yourself: Is the child safe to feed? How are their oral skills? Has the medical condition for which the child had tube

placed been corrected? Are the parent and child ready to transition? Do they have time to devote to transitioning?

Promote hunger, follow a schedule of normalizationDecrease calorie intake by tubeTake small steps

Oral Stimulation Importance

Nonnutritive sucking should be encouraged for those unable to eat orally

Many children in these situations lose interest and skill for oral feeds, could cause feeding problems later in life

For most infants, sucking is comforting. Babies on tube feedings benefit from use of a pacifier during feedings to stimulate the lips, gums and tongue. As the child grows, the child should have other opportunities to chew or suck. Oral stimulation will promote normal growth and development.

References

Arvedson, J. C., & Brodsky, L. (2002). Pediatric wallowing and feeding: Assessment and management. (2 ed., pp. 187-276). Clifton Park, NY: Delmar Cengage Learning.

Gastrostomy tube placement. (2011, May 18). Retrieved from http://surgery.med.umich.edu/pediatric/clinical/physician_content/procedures/gastrostomy_tube.shtml

Hao, G. (2012). Nutritional Management. Retrieved from North Carolina Central University Blackboad.

Technical aspects of enteral feeding. (2007, March 20). Retrieved from http://depts.washington.edu/growing/Nourish/Tubetech.htm

Tube feeding for children. (2008). Retrieved from http://www.pedisurg.com/pteduc/tube_feeding.htm