Medical and Nutritional Management of Feeding Disorders

1. Medical and Nutritional
Management of Feeding Disorders
KRISTEN WESTBROOK
JESSICA SMITH
6/26/2012

2. Medical Management

3. 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

4. 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

5. Medical Issues with Feeding
 Gastroesophageal Reflux
 Motility
 Treatments
 Stool patterns
 Allergies

6. 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

7. 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 GERD
 80% of babies outgrow reflux in the first year of life.

8. 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

9. Common Causes of GER:
 Allergies to diet
 Histal hernia/impaired esophageal clearance
 Low muscle tone
 CNS disease
 Transient lower esophageal sphincter relaxations

10. 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

11. 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

12. 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 do
 Regurgitation
 The most prominent symptom of reflux in pediatrics
 Refusal feedings
 Occurs in ~50% of those with esophagitis

13. Pediatric GER: Common Signs and Symptoms
 Sandifer’s Syndrome
 An exaggerated form of “arching”, often involves neck
hyperextension
 Gagging and Choking
 A classic symptom of GER, as liquid nears the airway

14. 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

15. Clinical Signs of GER
 Larynx/Pharynx
 Dysphagia, “lump in throat”, choking
 Subglottic stenosis, apnea, bronchospasms, laryngospasms
 Throat clearing, hoarse voice, laryngitis
 Hiccups, audible swallow

16. 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

17. 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

18. How often do GER symptoms arise?
 Can be everyday, or rare
 Tend to be more prevalent during times of illness
and stress
 Poor diet can exacerbate symptoms

19. 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

20. 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

21. 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

22. Evaluation of GER
 Objective Assessments
 Barium Swallow/upper GI
 MBSS if backflow enters larynx and above
 pH probe
 Endoscopy
 Scintigraphy
 manometry

23. 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

24. Conservative Measures
 Postural Approaches
 Dietary Approaches
 Soothing Techniques
 Avoiding exposure to smoke

25. Pharmacotherapy
 Types of medications given:
 Antacids
 Histamine H2 receptor blockers
 Prokinetics
 Proton pump inhibitors
 Appetite stimulants
 Pain management
 Constipation management

26. Surgical Intervention
 Most popular procedure is a Nissenfundoplication
 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

27. Up and coming treatments for GER:
 EsophyX
 Melatonin
 Gastric pacing
 Baclofen
 Acupuncture
 New Medications
 Durasphere

28. Nutritional Management

29. 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

30. 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

31. Nutrition Screenings
 Identifies 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

32. 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

33. 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/day
 Energy requirements are determined by size, age,
gender, physical activity, and rate of growth
 For premature infants, the amount of calories, protein,
and fluids is highly variable and depends on the
specific case

34. Types of Infant Formulas
 Breast milk
 Milk based formulas
 Lactose free formulas
 Milk based which thickens in the stomach
 Soy based formula
 Synthetic protein
 Hydrolyzed whey- fast absorbing
 Hydrolyzed casein protein- absorbed directly into
the intestine

35. 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

36. 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)

37. Feeding problems may come from:
 Uncoordination of suck/swallow/breathe sequencing
 Developmental delay
 Anatomic abnormalities
 Health issues
 Misconceptions of appropriate feeding

38. 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

39. 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

40. 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

41. NG Tube may be used for many reasons:
 administering nutrients or medication
 removing liquids or air from the stomach
 adding contrast to the stomach for x-rays
 protecting the bowel after surgery or during bowel
rest

42. 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

43. 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

44. What are the advantages of a G Tube?
 The ability to provide additional food and calories.
 No nasogastric tubes are needed-no more tape issues
 Less time spent giving feedings
 Feedings can be done at night when child is asleep
 Does not interfere with daily activities
 Less chance of child spitting up
 Less chance of tube coming out
 Tube is easy to replace.

45. What are the disadvantages of a G Tube?
 Become infected
 Leak
 Irritated
 Malfunction
 Dependent
 Oral problems, lack of stimulation to oral cavity
 Vomiting
 Diarrhea

46. 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.

47. 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

48. 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 normalization
 Decrease calorie intake by tube
 Take small steps

49. 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.

50. 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.
Gastrostomytube 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