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