GI/Nutrition assessment of child who may require tube feeding
David WilsonDepartment of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh; Child Life and Health, University of Edinburgh
Malnutrition in childhood
• Undernutrition – traditionally the most important nutritional problem
• Overnutrition (obesity) – rapidly increasing in prevalence; now the most common disorder of childhood
GI-nutrition principles
• GI-Nutritional assessment
• Facilitate nutritional support (intermittent and chronic), and also fluid and drug administration
• Paediatric fundamental: importance of sustaining growth throughout infancy and childhood, allowing normal pubertal development and growth spurt
ICP Model of Growth
Normal growth in infancy
• 28 weeks gestation – 1.5% weight/d
• Growth at term – 1.0% weight/d
• Mean term weight 3500 g
• Regain birthweight 7 - 10 days
• Double weight 4-5 months
• Treble weight 12 months
• Term: volume 150 - 170 ml/kg/d
• Term: energy 110 kcal/kg/d
• MBM and formula 0.67 kcal/ml
• Adult 2000-3000
kcal/d
Energy and fluid intakes
Energy balance
• Energy in = Energy out (zero balance)
• (Energy intake) - (sum of energy outputs)
• POSITIVE balance, energy is stored
• NEGATIVE balance, energy is lost
Energy assessment: In and out
• In - energy intake (quality/quantity)
• Out - energy losses (stool, urine, vomit)
• Out - energy needs (BMR, activity, catch up
growth, disease specific needs)
• Chronic imbalance gives malnutrition
(undernutrition or obesity)
Physical
25%activity
Thermogenesis
8%
Basal
65%metabolism
Growth
2%
Total Energy Expenditure (division of energy needs) between infancy and puberty
GI-Nutritional Assessment• Current and recent health, past history• Typical dietary intake – food, fluids, supplements• Feeding difficulty–chokes, aversion, time, aspiration• GI dysmotility – reflux, bilious vomiting, distension,
constipation• Maldigestion or malabsorption• Medications; respiratory issues; orthopaedic • Clinical examination including fluid status• Energy assessment – ins and outs• Nutrient assessment – minerals, vitamins, trace
metals• Measurement and plotting • Family issues and concerns
Prevalence of undernutrition in UK
• Quoted as up to 10% in primary care
• Generally old or poorly designed studies
• Armstrong J, Reilly JJ. Scot Med J 2003
• Use of Scottish Child Health Surveillance System
(Preschool) for 1998-2001
• 4.7% <2nd centile; significant link with deprivation
Undernutrition in chronic disease
• Survivors of pre-term birth• Respiratory - BPD, CF• Neurodevelopmental disability• Congenital heart disease• Renal disease• Immunological disease• Haematological/oncological disease• Chronic liver/gastrointestinal disease
Undernutrition in Hospital
• Occurs in children’s hospitals in UK
• Hendrikse et al (Clin Nutr 1997) - Glasgow
• Studied 226 children (wards and clinics)
• 16% underweight, 15% stunted, 8% wasted
• Only 35% recognised as malnourished
• Non-digestive disease - 13% underweight
Consequences of undernutrition
• Immunodeficiency • Impaired gastrointestinal function• Respiratory and myocardial dysfunction• Reduced muscle mass, poor wound healing• Growth failure, pubertal delay• Altered behaviour and psyche• Premature mortality• Neurodevelopment – in all groups• Programming (Barker effect) – long-term
outcomes (cardiovascular health, diabetes etc)
GI Dysmotility
• GORD– abnormal reflux (GOR is physiological)– refluxate passes into oesophagus or oropharynx and
produces pathologic symptoms– increased frequency / duration of GOR episodes
• Duodeno-gastric reflux (biliary reflux)• Abdominal distension (pseudo-
obstruction or mechanical)• Constipation
HETF: before and after
Family/carer discussion
• Results of GI-Nutritional assessment
• Tube? - intermittent or chronic need for nutritional support and/or fluid and/or drug administration
• Alternatives to tube feeding in short term
• How we tube feed and how long for
• Complications of tube feeding
• Importance of oral feeding
Professional discussions
• Multidisciplinary team (NST especially nutrition support nurse)
• Vital role of paediatric dietitian
• Paediatric surgeon/SALT/Radiologist
• ‘Own team’ – local professionals
GI Investigations
• History and physical examination
• Barium swallow• pH metry• Upper GI endoscopy and biopsy• Other investigations
Barium studies
• Detects anatomic abnormalities well• HH, stricture, malrotation, pyloric stenosis,
other anatomical issues especially if marked scoliosis
• Aspiration
• Poor for detection of reflux
Diagnosis: pH metry
• Frequency and duration of acid reflux (pH less than 4)
• Quantifies acid exposure• Assesses temporal association with
symptoms• Is it needed? On or off treatment study • 24 hour study with diary card
GI endoscopy and biopsy
• Visualisation and precise documentation• Presence and severity of oesophagitis• Endoscopic grading• Tissue diagnosis• Excludes other disorders• Therapeutic intervention• Correlation with histology / symptoms
GORD Complications
• Worsened GI dysmotility
• Undernutrition
• Peptic stricture
• Barrett’s oesophagus
• Respiratory consequences eg aspiration
Other investigations
• Manometry /EGG • Scintigraphy (milk scan)
– technetium-labeled formula– assesses reflux / gastric emptying / aspiration– up to 24 hours imaging
• Lipid laden macrophages• Intraluminal oesophageal impedance
Types of nutritional support
• Diet structure (3 meals and snacks)
• Energy boosting – particularly fat
• Oral calorie supplements
• Energy/nutrient dense feeds (FTT)
• Enteral nutrition – enteral tube feeding
• Parenteral nutrition (usually PN+EN)
Types of enteral feeding tube
• Nasogastric tube – usually short term usage
• Gastrostomy tube (PEG tube, primary button gastrostomy, RIG tube, ‘open’ surgically placed gastrostomy)
• Jejunal tube (transpyloric NJ tube, surgically placed jejunostomy, transgastric G-J, or PEG-J)
Nutritional transition – from this…
…..to this