Finalpresentation
- 1. Medical and Nutritional Management of Feeding Disorders KRISTEN WESTBROOK JESSICA SMITH 6/26/2012
- 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
- 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
Editor's Notes
- #12: Diets-soy or cow’s milk allergies
- #13: Regurgitation—most common in pediatrics, while heartburn is most common in adults
- #15: Increased drooling/salivation—”waterbrash”
- #18: Behavioral issues: averse feeding patterns, refusal, picky eating, avoiding foods/food groups, fear of eating, textures and volume limitationsOther issues: anemia, sweating/dizzyness, headaches, bradycardia
- #21: Causes: diabetes, scar tissue, viral infections, some meds, GERD, smooth muscle disorders, nervous system disease, metabolic disordersSymptoms: heartburn, pain in the upper abdomen, nausea, vomiting of undigested food (often hours after a meal), feeling of fullness after only a few bites of food, weight loss due to poor caloric intake, abdominal bloating, poor appetite, stomach spasms
- #25: Postural approaches: avoiding seated position, infant should be vertical or prone, 30 degree bed elevation, left side down Dietary-smaller, more frequent meals, thickening formula, type of formula Tube feedings: slows rate of feeding, continuous feedings, g-tube bypasses esophagus if this is where the problem liesSoothing techniques: swaddling, movement, distraction, loose clothing, white noise