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
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
•
Regain birthweight 7 - 10 days
•
Double weight
4-5 months
•
Treble weight
12 months
3500 g
Energy and fluid intakes
•
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 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)
Total Energy Expenditure (division of energy
needs) between infancy and puberty
Growth
2%
Thermogenesis 8%
Physical
activity
25%
Basal
metabolism
65%
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 (pseudoobstruction 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