Case Study #2:

Feeding Difficulties 2/2 GER, Delayed Gastric Emptying with G-Tube

Displacement

By: Lauren Zendarski

Introduction

Feeding is an important part of the everyday life of infants and young children,

and much parent-child interaction occurs at feeding times. Acid reflux, also called

gastroesophageal reflux (GER), is one of the most common infant feeding problems.

Around 25 percent of all babies experience some degree of it (1). GER can cause a range

of conditions, from the mild (frequent, painless spitting up) to the severe (colic,

abdominal pain, and frequent night waking). In fact, GER is one of the most common

causes of so-called colic. In infants gastro-esophageal reflex is abbreviated as GER

because it is not considered a disease in childhood (1). Most infants will have some type

of reflux or emesis, but they will grow out of it by 6 to 8 months. For some children

gastro-esophageal reflux may lead to many feeding aversions that require alternative

means of nutrition. To better appreciate GER feeding strategies, it helps to know the

mechanics of the condition. Normally, a circular band of muscle, called the lower

esophageal sphincter (LES), separates the stomach from the esophagus. After food enters

the stomach, the LES contracts, acting like a one-way valve that closes and prevents the

stomach contents and acids from regurgitating, or refluxing, back up into the esophagus.

In some babies, the LES is temporarily immature, so it allows partially digested stomach

contents and acids to be refluxed (2). This irritates the lining of the esophagus and causes

the pain that adult’s term heartburn.

In the case of a six month old male who was presented to the hospital with

gagging, vomiting, and emesis for 4 to 5 days, was found to have an extensive history of

GER. Along with these conditions the child had many aversions to food by mouth (PO

intake) with gastroparesis, that lead to failure to thrive (FTT), and alternative means of

nutrition. When he came to the emergency room he had a distended abdomen and was in

shock due to pain. The child was initially diagnosed with bile in feeding. Through an

exploratory lab the child was found to have gastrostomy tube displacement by the

medical Doctor (MD). The Mother of child (MOC) and Father of Child (FOC) were

presented with the child. The parents noted that the child has had a long history of poor

PO intake that has lead to developmental delay. MOC stated that the child had a nissen

fundoplication and gastrostomy tube (G-tube) placement back in December 23 of 2011.

The diet the child was on at home was Elecare 24 calories per ounce (oz) with 4 oz every

4 hours; he would take ½- ¾ PO then rest was bolus via G-Tube. The registered nurse

(RN) reported the child to be 6.5 kg (50th %tile weight/height) and (weight/age: 25th %),

height: 65 cm (10-25% for age), head circumference: 41 cm (10th %tile for age).

Disease Background’s, Diagnosis, and Treaments

As noted earlier GER is what adult’s also call reflux which is a painful medical

condition in which the acid-containing stomach contents regurgitate back into the

esophagus. Normally during swallowing, the food travels down the long, muscular tube

called the esophagus. The muscles in the wall of the esophagus contract from top to

bottom pushing the food down into the stomach. Once swallowing is over and all the

food has entered the stomach, a circular band of muscle called the lower esophageal

sphincter (LES), where the esophagus joins the stomach, contracts and acts like a door

that closes to keep stomach contents and stomach acids from regurgitating, or refluxing,

back into the esophagus. If, instead of closing, the LES remains open, stomach acids

reflux back into the esophagus and irritate, or "burn," the sensitive lining of the

esophagus causing pain (1). The degree of pain the infant has depends upon the severity

of the reflux. If the stomach contents reflux just partway up the esophagus, the baby may

hurt, but not spit-up or vomit. If reflux is severe, the baby may spit-up a little, or a lot.

Sometimes the refluxed gastric contents can enter the back of the throat, causing a sore

throat, choking, gagging, coughing, and erosion of dental enamel. The contents can even

be aspirated into the lungs, causing respiratory infections, wheezing, and asthma-like

symptoms (1). Many children will have emesis or regurgitation at some point in their first

few months of life. Usually infants associate feeding with comfort, yet the baby with

GER may associate feeding with pain and refuse to feed which can cause poor weight

gain. Symptoms to look out for are frequent or recurrent vomiting, failure to thrive,

refusal to feed or difficulty feeding, irritability or fussiness with/after feeding,

regurgitation or bloody vomit, frequent or persistent cough, difficulty swallowing, and

recurrent pneumonia. (1,2).

Diagnosing GER in infants is pretty straight forward. Usually, parents provide enough

details for the doctor to make a diagnosis. Sometimes, however, further tests are

recommended. They include the barium swallow or upper gastrointestinal (GI) series, pH

probe, upper GI endoscopy, and gastric emptying study. The barium swallow study is a

special X-ray test that uses barium to highlight the esophagus, stomach and upper part of

the small intestine (3). This test may identify certain problems such as any obstructions or

narrowing in these areas. The alternative test called the pH probe is currently considered

the best test to diagnose reflux, but it does not always manage to detect the disease. In

this test, a thin tube with a probe at the tip is placed through the nose into the esophagus.

The tip, usually positioned at the lower part of the esophagus, measures levels of stomach

acids. The frequency of reflux is monitored over a prolonged period of time, usually 24

hours. The other test called the Upper GI endoscopy uses an endoscope (a thin, flexible

lighted tube) to look directly inside the esophagus, stomach and upper part of the small

intestine. Pinch biopsies of the esophagus are obtained at the time of endoscopy which

may determine the presence of reflux. Furthermore, the last test is called the gastric

emptying study. This entails the child or infant to drink milk or eat food mixed with a

safe radioactive chemical. This chemical is followed through the gastrointestinal tract

using a camera in order to measure the rate and time at which the stomach contracts and

digestive the material (3).

There are many different recommended treatments for GER in infants; some lifestyle

changes, while some are medical changes. Some lifestyle changes include holding the

child upright when feeding and 30 minutes after feeding. This will help prevent the child

from regurgitating the ingested fluid/food back into the esophagus. It also allows more

time for digestion, and keeps the head elevated to prevent contents from coming back up.

It is also important for parents to check the car seat in order to make sure that the infant is

not slouched down and that the head is at a 45% angle (3). This prevents pressure on the

stomach and esophageal sphincter. Parents should try to feed the child smaller and more

frequent meals. Feeding should occur every 2-3 hours. This will help prevent

overfeeding, which can lead to more pressure in the stomach and more risk the

infant/child to regurgitate. Also, overfeeding and more gastric pressure can produce

more gastric acid. It is important for parents to burp the infant/child several times during

the feeding. Too much air in the stomach will create an unpleasant feeling and

discomfort. Medical Doctors (MD’s) will recommend parents to try using rice cereal.

Rice cereal will help thicken the formula/breast milk, making the child less likely to

regurgitate the fluid. It is harder for a thickened formula/breast milk to pass through the

lower esophageal sphincter than it would if it was a thin liquid (3).

If lifestyle changes do not help the child, parents may need to take on more medical

interventions. Some medications can help the infant or child, such as, Mylanta and

Maalox which are anti-acids parents can obtain over the counter that reduce the gastric

acid produced in the stomach. Acid blockers such as Pepcid, Tagamet or Zantac will

sometimes be prescribed by the MD. These medications also reduce the amount of acid in

the stomach. Other options are proton-pump inhibitors (PPIs) such as Axid, Nexium,

Prevacid and Prilosec are products that reduce the production of acid by blocking the

enzyme in the wall of the stomach that produces acid (4). These medicines that decrease

intestinal gas or neutralize stomach acid (antacids) are also considered safe for

children/infants. However, at high doses, antacids can cause some side effects, such as

diarrhea or constipation. Chronic use of very high doses of antacids also may be

associated with an increased risk of rickets (thinning of the bones) (4).

Other medications used to treat GERD are those that attempt to improve coordination

of the gastrointestinal tract. These include Reglan and Erythromycin. Reglan reduces

symptoms of GERD by speeding up the digestion process and preventing gastric contents

from remaining in the stomach for too long. However, it is associated with many side

effects, some of which can be serious (4). Journal of Pediatric Gastroenterology and

Nutrition, warn that Reglan commonly produces adverse side effects in infants and

children, particularly lethargy, irritability, gynecomastia, galacctorhea, and

extrapyramidal reactions and has caused permanent tardive dyskinesia. (Reglan also can

be associated with a number of drug interactions (5). Taking it with other medications is

also known to increase the effects of several other prescription drugs, including:

acetaminophen (tylenol and other non-aspirin analgesics), antispasmodics (belladonna

alkaloids such as atropine, hyocyamine and scopolamine), cimetidine, cyclosporine and

digoxin (anti-rejection drugs for transplant patients), MAOI medications, antidepressants,

levodopa (treatment for parkinson's disease), narcotic analgesics (opiate painkillers such

as vicodin), tetracycline, any kind of tranquilizer (including sleep medications) (4). With

infants these interactions are usually not a concern because most infants are not on the

extensive list of medications especially the ones noted above. The other medication

option for GI motility is Erythromycin which is an antibiotic that is usually used to treat

bacterial infections. It causes strong stomach contractions which eases reflux; however,

this effect is not lasting. Some common food-medication interactions are grapefruit,

Lipitor, Plavix, and Xanax. (4). Again these interactions do not pose a concern for infants

because they are most likely not on many of these medications. Side effects of

Erythromycin may include, stomach pain, diarrhea, loss of appetite, nausea, vomiting,

bloody stools, hearing changes, irregular heartbeat, red, swollen, or blistered skin, and

yellowing of skin or eyes. Although serious side effects are rare, it is important to discuss

with the child's doctor the pros and cons of taking a prescription medication. (4).

Some infants may require a surgical intervention, known as the nissen fundoplication.

The nissen fundoplication operation is carried out using keyhole surgery (laparoscopy).

The surgeon uses a telescope, with a miniature video camera mounted on it, inserted

through a small incision to see inside the abdomen. (5). Carbon dioxide gas is used to

inflate the abdomen to create space in which the surgeon can operate using specialized

instruments that are also passed through other smaller incisions in the abdomen. The

surgeon moves the top of the stomach upwards and wraps it around the bottom of the

food pipe over the sphincter, securing it with stitches. This strengthens the sphincter, so

that when the stomach is full of food, the top part wrapped around the sphincter

automatically tightens to prevent reflux. It also stops the sphincter relaxing when it

should be squeezed shut. (6).

Sometimes with the fundoplication a child gets a G-tube placed, if they have a history

of poor PO intake. This fundoplication is not a cure for GER, it is only a treatment, so

some parents or MD’s may feel the need to place the feeding tube at the same time (6). A

G-tube is inserted through the abdomen that delivers nutrition directly to the stomach for

children with feeding aversions. Like all invasive procedures, inserting a gastrostomy

tube can lead to significant morbidity or even mortality. Complications from the

operative technique are unusual but include hemorrhage, bowel perforation, peritonitis,

wound separation, infection, and adhesive bowel obstruction. About 2.5% to more than

40% of infants with gastrostomy tubes will have site leakage from accidental device

removal, superficial skin infection, formation of granulation tissue, discomfort, or

internal tube migration causing erosions or obstructions. As many as 10% to 20% of

infants who are tube-fed may still experience vomiting, diarrhea, gastroesophageal reflux,

aspiration, or even oral aversion. (5).

Another disease state that is common in infants with GER, is gastroparesis. These two

conditions can go hand in hand, but the treaments for each can become opposing leading

to more concerns for child’s PO intake and growth. (3). Gastroparesis is a condition

where the stomach contracts less often and less powerfully, causing food and liquids to

stay in the stomach for a long time. This may be caused by the brain's inability to

communicate with nerves in the gastrointestinal tract, which can lead to slower

contractions of the muscles in the intestines. The slower contractions cause food to more

along slower, which causes food to remain the stomach for longer. This can pose many

concerns especially for infants with GER. Gastroparesis may also result from viral

infections, systemic diseases, diabetes or autoimmune problems. Some symptoms to look

out for are frequent abdominal distention, premature abdominal fullness after meals,

heartburn/reflux, weight loss, nausea, vomiting, and little PO intake. (3).

After taking a careful history and doing a physical examination, a number of

different tests may be done when a child/infant has any of the symptoms listed above.

These can include an upper gastrointestinal series in which the child drinks barium that

outlines the esophagus, stomach, and first part of the small intestine on an x-ray. An

upper endoscopy may be done. In this test, a flexible tube called an endoscope allows the

doctor to look at the lining of the esophagus, stomach, and duodenum. Often the most

helpful test is a gastric emptying study which is a nuclear medicine x-ray test. The child

eats/drinks food mixed with a small, very safe amount of a radioactive substance. This

allows the radiologist to figure out how quickly or slowly food leaves the stomach. (3).

Some treatments for gastroparesis are the same as GER, but some contradict the

treatment, which can pose many issues for parents and MD’s. For gastroparesis it is

recommended for the child to be put on a prokintetic, such as, reglan or erythomycin as

noted for GER. Also it is always important to choose breast milk over formula,

especially for the condition of gastroparesis. With breast milk it is natural and made for

the child. It has been shown to decrease sickness, strengthen immune system and allow

better tolerance for the child. In some cases breast milk is not a choice, so it would be

better to choose the hypoallergenic formulas that are partially digested making transit

time faster. (7). A concern with gastroparesis is that infants get fuller quicker, making

them eat less causing issues with developmental growth. A contradicted treatment in

GER for gastroparesis would be rice cereal and G-tube placement. Rice cereal is thicker

and will take longer to digest, causing more of a delay (7). For infants with severe

gastroparesis and little PO intake, a G-tube would not be the choice for tube feeding. The

choice would be a feeding that passes the stomach and goes into the intestines like a

jejunostomy tube (J-tube). (8)

Studies

There are many different studies and reviews of literature for the treatment for GER

and gastroparesis in infants. A study titled Effects of Probiotic and Prebiotic on

Gastrointestinal Motility in Newborns, by: Ingrio, F., G Riezzo, et al. studied the effects

of adding probiotics and prebiotics to formula in order to mimic the natural effects of

breast milk. Human breast milk is always seen as the preferred choice for infant nutrition

because it contains many components that have important bioactive roles. In breast milk

several glycoprotein and soluble oligosaccharides were found to be selectively

stimulatory for bifidobacteria. Some of the oligosaccharides act as receptors for different

pathogens at the mucosal level, which leads to a higher immunological resistance in

breast fed infants. Sometimes breast milk can not be used or obtained, so during the last

few years there have been studies on role of microbial species and strains added into

formula feeds. Bidifobacteria and lactobacilli are the most popular microorganisms for

probiotic applications, and have been found to be the most effective for human use. The

aim of this study was to evaluate the effects of the added prebiotic and probiotic to

standard formula, and measure the effects on gastrointestinal motility in retrospect to a

placebo group and a breast fed group. (10)

Cutaneous electrogastrography (EGG) and ultrasound gastric emptying (GE) were

performed in 49 preterm newborns. Seventeen were exclusively breast fed, 20 were

randomly assigned to probiotic or prebiotic formula, and 12 were chosen for the placebo

formula. The doses were given over 30 days. The prebiotic formula consisted of 0.8

g/dL- Short-chain galacto-oligosaccharides (scGOS), long-chain fructo-oligosaccarides

(lcFOS) (9:1 ratio). The probiotic formula consisted of Lactobacillus Reuteri (L reuteri)

1x10^8 of colony forming units in oil formation. The study is a double-blind placebo

controlled that included healthy preterm, appropriate for gestational age with Normal

Apagar score. They were all enrolled within first week of life. They excluded infants with

respiratory distress, congenital malformation, inborn errors of metabolism, and proven

sepsis or infection. Anthropometrics at baseline of the study were averaged, which is

shown in table 1. (10) Table 1:

Gastric electrical activity was recorded at baseline (first week of study) and about 30

days after the start of the study. All the infants had an overnight fast in order to measure

baseline. The electrogastrography (EGG) was the recorded 30 minutes before and after

the meal. Five-silver chloride electrodes were placed on the infant’s abdomen in order to

measure the electrical signals that traveled through the stomach muscles and the signals

that controlled the muscles' contractions. This can help determine the rate of gastric

motility. Results can be seen in Table 2, which shows that probiotic formula, prebiotic

formula and breast milk have higher rate of muscle contraction and motility than the

placebo formula. (10)

Table 2: p<0.05

The next measure of assessment the study used was rate of gastric emptying. It was

recorded at baseline (first week of study) and 30 days after the start. Ingrio, F., G Riezzo,

et al used ultrasound gastric emptying examinations that had a linear probe which was

positioned at the level of transpyloric plane for visualization of the stomach area. This

was recorded at the start of feedings and every 30 minutes after until 120 minutes.

Results can be seen in table 3, which showed that the prebiotic formula, probiotic

formula, and breast milk allowed for short emptying time compared to the placebo

formula. (10).

Table 3:

Overall the study showed an average body weight increase in the infants by 35

grams per day. Probiotic and Prebiotic added to formula showed to induce GI motility

pattern similar to breast milk. There was an underlying significant difference in placebo

group. This formula mixture could be a future solution for formula fed babies with

delayed gastric emptying. (10).

A second study preformed by Dr. Scott Pentiuk, MD, Therese O’Flaherty, RD, et

al, titled Pureed by Gastrostomy Tube Diet Improves Gagging and Retching in Children

with Fundoplication, focused on different feeding problems in children post-

fundoplication surgery. In children with feeding disorders or certain medical conditions

that prevent PO intake, a gastrostomy tube is sometimes unavoidable. Many children with

feeding difficulties related to GER undergo a nissen fundoplication to prevent further

manifestation of GER or aspiration of food/formula. The complications of

fundoplications have been noted as worsening feeding problems, dumping syndrome,

gas-bloating syndrome, loss of gastric accommodation, and abnormal gastric motility. In

the past it was found that children who underwent a fundoplication and G-tube placement

at the same time were found to have gagging and retching after feedings. The aim of this

study is to test a “pureed by gastrostomy tube” (PBGT) diet in order to see if it decreases

symptoms of gagging and retching. The patients on the PBGT diet received between 2 to

6 bolus per day in varying volumes based on weight and age. (11). A sample diet can be

seen in table 1:

There were a total of 33 patients in the study; all who were followed by the

interdisciplinary feeding team at Cincinnati Children’s Hospital Medical Center. The

patients were put on the diet over a three year span. Some patients continued on the diet

even after the trail. Table 2 shows the age in months of the children as well as the weight

that was recorded at each follow up. Children were scheduled to follow up every 2-3

months. They also preformed telephone surveys in order to have parents rate the

improvement and percent of reduction in the child’s gagging and retching symptoms.

Families were also asked to rate whether their child’s oral intake had increased. (11)

Table 2:

No patients were started on any motility agents during this trial. Weights from 31

children can be noted in table 2. The two other patients did not take part in the follow

ups, but did participate in the telephone interviews. After the initiation of the diet,

children gained an average of 6.2 grams per day. Four children lost weight during the

trial period, but three of them had regained it by the end of the study. Results showed the

52% of the children had a 76-100% decrease in gagging and retching. The rest reported

either a 50% decrease or 25% decrease in symptoms, which can be seen in figure 1. No

patients’ symptoms got worse during the trial. In terms of improvements in oral feeding,

57% of the children were reported to have increase PO intake. The remaining 14 patients

were still eating the same amount or ate nothing by mouth (NPO). These results can be

seen in figure 2. Dr. Scott Pentiuk, MD, and Therese O’Flaherty, RD, et al, found that

PBGT diet is an effective means of providing nutrition to children with feeding disorders,

especially in those with gagging and retching. (11)

Figure 1: p< 0.001

Figure 2: p<0.005

Prognosis/Care

The main concerns for a child/infant with GER and gastroparesis are that they

will associate times of feeding with pain. Adults understand the cause of GERD, unlike

children who do not understand where the pain is coming from, or why it is happening.

All the child/infant knows is when they eat or drink it is associated with discomfort. This

can pose many problems with PO intake, leading to food aversions or bottle aversions.

Also with GER there is a concern for aspiration of food/formula contents which can lead

to pneumonia, reactive airway disease, and esophagitis. These conditions remain sources

of significant morbidity. (12). Children with poor feeding practices, failure to thrive and

PO aversions are recommended to get a tube feed placed, like a G-tube. The G-tube

creates more concerns for the child, such as, displacement, infection, or the children

becoming tube feed dependent. When a child relies on a tube feed for an extended period

of time, it makes it harder for the parents to initiate PO feedings again. (13).

There are some solutions for parents trying to initiate oral feedings again. The

first solution is avoiding “force feeding” the infant/child. This is already a scary time for

the child because it is associated with unpleasant thoughts. It is important to make

feeding time a fun time. Also if the child is already old enough to eat from a spoon, do

not fill the spoon too full. This can cause choking or gagging. Also, when trying to

transition from tube feeding to PO feeding, parents should try to PO feed before tube

feeding. This allows for the child to learn hungry cues, and it is more successful to try

and feed the child when they are hungry rather than when they are satisfied after the tube

feeding. A mistake many parents make, is trying to wean the child from the tube feeding

alone. There are many trained professionals that are willing to help parents wean their

child from the tube feed. (13).

Application to the Patient

This patient is a 6 month old white male child who was admitted to the hospital

with symptoms of gagging and vomiting. The child has been followed by various medical

doctors (MDs) because of feeding difficulties associated with GER and failure to thrive

(FTT). History has revealed that the child was born at 37 weeks gestation, weighing 5

pounds and 3.8 ounces. He was healthy and, discharged home on breast feeding. The

patient also has a history of spitting up and emesis at frequent intervals and at large

amounts. On September 25th 2011, the child had an upper GI series done that

demonstrated delayed gastric emptying as well as GER. The child continued to have

significant failure to thrive, reflux, and vomiting, so he was started on Prevacid and

Reglan. With no improvement in the condition the child underwent a nissen

fundoplication and G-tube placement on December 23, 2011. The patient was doing

well, and tolerating up to 6 to 8 ounces of elecare 24 cal/oz. He had began gaining weight

and tolerating some PO intake.

The few weeks prior to admission the child began having abdominal distention

with gagging and emesis. The MD ordered a cat scan of the abdomen, which showed an

extensive amount of ascities (fluid in the stomach), with uncertain placement of the G-

tube. A paracentesis was performed in order to clear the ascities for diagnosing purposes.

The paracentesis revealed blood tinged fluid, so the child was sent to the operating room.

The MD found the G-tube had been displaced and perforated the duodenum. There the

child had an exploratory laparotomy with omental patch placement. An omentum (a fat

layer in your abdomen) is pulled through the perforation and fixed to the bowel to seal

the "hole" created by the tube feed. At the same time the MD preformed a revision of the

G-tube. The child was then resuscitated with crystalloids, which contain sodium chloride

(NaCl). Sodium chloride solution, is often used because it is isotonic, and therefore will

not cause potentially dangerous fluid shift. (9).

Nutrition Care Process: Diet

This child was admitted on 2/21/12, and was started on pedialyte 4 ounces every 4

hours. He was also started on IVF @ 648 ml per day. At this time the MD was unsure of

the child’s diagnosis, but knew the child was having gagging and vomiting. On 2/24/12

the child was NPO (no food by mouth) because he was intubated status post omental

patch placement for perforated duodenum. The child was started on total parental

nutrition (TPN) with 20 grams of amino acids (AA), 5.25 grams of intra lipids(INL), 45

grams of Dextrose (D). On 2/29 the child remained intubated. The child was receiving

elecare 24 kcal/oz (calories per ounce) @ 30ml/hr (milliliters per hour), but he was not

tolerating his feeds, so the regimen was stopped earlier that day. TPN was started again,

this time, 20 grams AA, 22.2 grams INL, 115 grams D. At this time the registered

dietitian (RD) recommend to continue current TPN regimen and transition to enteral

feeds as medically appropriate per MD and ultrasound results. On 3/5/12 the child was no

longer intubated. He was receiving elecare 20 kcal/oz @ 20 ml/hr and tolerating feeds

well. He was also receiving TPN: 15 grams AA, 14g INL, 75g D. Occupational therapy

(OT) and speech therapy (SLP) were working with the child at this time in order to start

some PO feeds. The child was refusing the bottle. The RD recommend to increase feeds

as tolerated to 35 ml/hr of elecare 20 kcal/oz. If family desired home concentration the

RD recommended gradually increasing feeds to elecare 24 kcal/oz @ 30ml/hr. The very

next day on 3/6/12 the MD request high calorie (kcal) feeds, because TPN was

discontinued (d/c). The RD recommended elecare 24 kcal/oz @ 35ml/hr.

Two days later on the 8th the child began not tolerating his goal feedings again, so

TPN was restarted. Elecare 24 kcal/oz was running @ 15 ml/hr and TPN with 16.5 grams

AA, 10 grams INL, 120 g D. The RD recommended to continue to adjust TPN rate

proportionally with tube feed rate, with goal of tapering TPN when pt is meeting 60% of

estimated needs through tube feeding. If feeding difficulties persisted the RD also noted

the child may return to elecare 20 kcal/oz. On the 13th the child was finally tolerating the

feeds. He was only on elecare 22 kcal/oz @ 25 ml/hr, but was making progress since

TPN was d/c. The RD recommended to continue to increase feeds until they reached the

goal rate of elecare 24 kcal/oz @ 35ml/hr. Later that day Elecare 24 kcal/oz was started

and by the 13th the child was tolerating the goal rate with little to no residuals. The child

tolerated this rate for the rest of his admission 3/14-3/23. During this time OT and SLP

worked with the child in order to initiate PO feeds. The child had a very slow start, with

little to no PO by the time he was d/c. It was recommended that we continue to meet and

work with a SLP until he had transitioned to full PO intake.

Nutrition Care Process: Anthropometrics

The child was admitted with a weight of 6.8 kilograms (kg). He was at the 25th

percentile for weight for age, and 50th for weight for height. This child’s weight was

pretty steady the whole time throughout his stay. The lowest his weight went was 6.4kg

and the highest weight was 7 kg. When he was discharged he was back at his admission

weight of 6.8 kg. The fluctuation in his weight can be noted by his volume overload and

ascities. The child’s head circumference (FOC) was 41 centimeters (cm) on admit and the

day of discharge. This FOC was at the 10th percentile for the child’s age. Also the child

was 65 cm long on admit and discharge, falling into the 10-25th percentile. Overall the

child was average for gestational age, with his ideal body weight (IBW) for length being

7.2 kg. He was close to his ideal; 90% IBW.

Nutrition Care Process: Labs

Overall, the young boy’s labs were not horrible. He does have some noted fluid

issues that can be seen in the fluctuation of sodium and blood urea nitrogen (BUN).

When the child was admitted it looked as though he had normal albumin levels, but over

time the levels began to decrease. This is why albumin is not the best indicator of

nutrition status because it can be affected by the kidneys, liver, and hydration status. In

this case the albumin most likely dropped due to inflammation, shock, and malnutrition.

Sometimes albumin is affected by hydration status, but in this case the child was fluid

overload, so it would have made the albumin seem lower, not higher. Potassium did fall

during one follow up. This can also be affected by many things, but is also very

important. It is part of the electrolytes, which can be affected by hydration or

dehydration. Potassium can also be affected by some antibiotics such as Gentamicin. The

glucose labs were high throughout the child’s stay, which could have been affected by

stress, infection, and his perforated duodenum. Amylase was also high on the 29th of

February. Amylase is usually used for pancreatitis, but in the child’s case it was high due

to obstructed intestine (perforated duodenum) or decreased blood flow to the intestines

(his delayed gastric emptying). Lastly, the liver enzymes are high, which normally are

indicative of liver damage. In the childs case liver enzymes could be high due to some

medications, such as, erythromycin or that the child is currently growing. The alkaline

phosphatase test can sometimes be elevated in children that are growing, because it can

be affected by bone growth. (14). The labs can be seen in the chart below:

101H19ALT

3.1L N/A3.0L3.43.24.2Albumin

22LAmylase

85H27AST

168H156HAlk Phos

103113H114H112H111H120HGlucose

128L1320275LBUN

4.43.74.14.53.1L4.4K

135L138137136142135LNa

3/123/93/32/292/242/21Labs

101H19ALT

3.1L N/A3.0L3.43.24.2Albumin

22LAmylase

85H27AST

168H156HAlk Phos

103113H114H112H111H120HGlucose

128L1320275LBUN

4.43.74.14.53.1L4.4K

135L138137136142135LNa

3/123/93/32/292/242/21Labs

Diet History/Estimated needs

After birth the child was discharged on breast milk, but once the child began having

GER and feeding difficulties the mother stopped breast feeding. At home this child was

receiving elecare 24 calories per ounce, with 4 ounce every 4 hours. The MOC noted the

child took in 1/2-3/4 of the formula by mouth and then the rest was taken via G-tube. The

formula Elecare can be used for intact protein intolerance, malabsorption, severe food

allergies or GI tract impairment. Due to the child’s past medical history this is an

appropriate formula for him. The child was receiving 576 calories and 22 grams of

protein from this diet regimen.

The child’s estimated needs are 535-635 kcal (DRI-RDA x 6.5kg), Protein: 10g-

11g (DRI-RDA x 6.5kg), and Fluid: 650ml (holliday-Segar). DRI stands for the Dietary

Reference Intakes which are developed by the Institute of Medicine’s Food and Nutrition

Board. Recommendations for feeding infants, from infant formula to complementary

foods, are based primarily on the DRIs. RDA is the average dietary intake level sufficient

to meet the nutrient requirement of nearly all (97–98 percent) healthy individuals. Fluid

requirements in children are based on body weight according to the Holliday-Segar

method. Fluid requirements are better estimated by weight than age because a child can

be overweight or underweight for their age. Holliday Segar takes into account this

possibility into account. (5).

The child was on a mix of total parental nutrition and G-tube feedings throughout

his stay because of intolerance to formula feeds related to his delayed gastric emptying.

When the child was admitted he was started on pedialyte and intravenous fluid therapy

(IVF) until MD could make a further diagnostic. The child also had been vomiting so the

MD wanted to make sure he was hydrated. After the patient had the surgical omentum

patch in place they began TPN. The first day the child was only getting 235 calories, and

5.25 grams of protein. By the next day the TPN was increased to meet 100% of patients

needs: calories were 665, and protein was 21 grams. According to A.S.P.E.N. this amount

of protein is sufficient to meet the child’s needs. (5). As noted in the chart below the MD

and RD had a hard time transitioning the child to full enteral feeds. It took almost three

weeks until the child was at the goal rate of feeds and tolerating them. The goal rate was

elecare 24 calories per ounce @ 35ml/hr. This provided the child with 672 calories, 25

grams of fat. This is meeting 100% of patients estimated needs and he was discharged on

these feedings.

Nutrition Problem and Care Plan

The main issues the child faced throughout his stay was altered GI function

related to perforated duodenum, gastroparesis, and post-op ileus as evidence by

intolerance to feeds. This young boy had a lot going on when he entered the hospital, and

the fact that he had a history of failure to thrive made him more at risk for developing

malnutrition. The RD played a key role in his progress of care. The interventions that the

RD chose for the child were initiating and advancing the formula as medically

appropriate. Also, once the child was tolerating the feeds and meeting at least 60% of

estimated needs, the RN could begin tapering the TPN. The RD also noted for the child to

continue on continuous feeds at home rather than the bolus feeds he was on before. The

continuous feeds are not too much volume at once, which is something that should be

avoided with gastroparesis. The RD also wanted the child to remain on Erythromycin and

Florastor to help restore normal GI function. Lastly, the RD wanted the child to continue

to work with occupational therapy and speech language pathologist in order to increase

PO intake. The RD monitored the patient’s weight, labs, bowel movements and tolerance

to the diet. The goal was that the child would increase PO intake to at least 50% of

energy intake. Tolerate enteral nutrition to meet at least 75% of needs, and promote a

positive growth velocity.

Personal Impressions

I feel that with time the child will begin to take in more PO. The parents really

wanted to have their child get better and were there with many questions every step of the

way. With the parents’ dedication and help of the speech langue therapist and

occupational therapist, I feel the child will begin taking all PO. This was an unfortunate

case of events that occurred with the child, especially at his young age. His GER and

gastroparesis are currently under control with medications and hopefully he will grow out

of these conditions. The interesting thing about working with a child is they still have

their whole future ahead of them; this is the time for change, and this time the time for

adaptation. Child and parent’s of child are much more receptive than older adults who

have given up. I foresee the best for this child and his family.

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