GI/Nutrition assessment of child who may require tube feeding

1. GI/Nutrition assessment of child who may require tube feeding David Wilson Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh; Child Life and Health, University of Edinburgh

2. Malnutrition in childhood • Undernutrition – traditionally the most important nutritional problem • Overnutrition (obesity) – rapidly increasing in prevalence; now the most common disorder of childhood

3. 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

4. ICP Model of Growth

5. Normal growth in infancy • 28 weeks gestation – 1.5% weight/d • Growth at term – 1.0% weight/d • Mean term weight3500 g • Regain birthweight7 - 10 days • Double weight4-5 months • Treble weight12 months

6. Energy and fluid intakes • Term: volume150 - 170 ml/kg/d • Term: energy110 kcal/kg/d • MBM and formula0.67 kcal/ml • Adult2000-3000 kcal/d

7. Energy balance • Energy in = Energy out (zero balance) • (Energy intake) - (sum of energy outputs) • POSITIVE balance, energy is stored • NEGATIVE balance, energy is lost

8. 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)

9. Growth 2% Thermogenesis 8% Physical 25% activity Basal 65% metabolism Total Energy Expenditure (division of energy needs) between infancy and puberty

10. 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

11. 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

12. 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

13. Undernutritionin 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

14. 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)

15. 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

18. HETF: before and after

19. 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

20. Professional discussions • Multidisciplinary team (NST especially nutrition support nurse) • Vital role of paediatric dietitian • Paediatric surgeon/SALT/Radiologist • ‘Own team’ – local professionals

21. GI Investigations • History and physical examination • Barium swallow • pH metry • Upper GI endoscopy and biopsy • Other investigations

23. Barium studies • Detects anatomic abnormalities well • HH, stricture, malrotation, pyloric stenosis, other anatomical issues especially if marked scoliosis • Aspiration • Poor for detection of reflux

25. 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

28. 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

31. GORD Complications • Worsened GI dysmotility • Undernutrition • Peptic stricture • Barrett’s oesophagus • Respiratory consequences eg aspiration

32. 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

33. 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)

34. 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)

35. Nutritional transition – from this…

36. …..to this