Question & Answer - Feeding, Eating, & Drinking
Which gastrointestinal issues interfere with successful feeding? How do you recognize the symptoms?
ANSWER FROM: Krisi Brackett, MS, CCC-SLP, Feeding Specialist in Chapel Hill, North Carolina
There are many reasons why infants and children develop feeding problems. The underlying issues can range from prematurity, neurological dysfunction, respiratory issues, gastrointestinal dysfunction, and learned patterns of behavior to many other issues. Research supports that a significant number of children have feeding difficulties related to gastrointestinal (GI) dysfunction (Field, Garland, & Williams, 2003; Fishbein, Branham, Fraker, Walbert, Cox, & Scarborough, 1993; Hyman, 1994; Rommel, DeMeyer, Feenstra, Veereman-Wauters, 2003).
Working closely with a child's medical team or referring physician can improve his or her “gut comfort” which will improve his or her response to feeding therapy. A child's response to therapy techniques will be better if the child feels better. Improvement in therapy can be seen in the following ways:
So, what types of GI disorders contribute to feeding problems, and how do they present?
Definition: “Delay or difficulty in defecation, present for 2 or more weeks, is a common pediatric problem encountered by both primary and specialized medical providers (NASPGHAN, 2006).”
Presentation: Constipation can slow motility, cause pain or discomfort, and increase gastroesophageal reflux. Children may present with gas, bloating, crying during/after eating, complaints of stomach pain, poor appetite, volume-limiting, grazing, picky eating, food refusal, and aversive feeding behaviors.
Therapist questions to ask: Ask caregivers about stooling including how often the child goes, ease of going (e.g., straining or not), size of stool, and consistency of stool (e.g., hard or soft, formed or unformed).
Intervention: The goal is to achieve daily stooling to keep the digestive system moving. There are different strategies that may be used by the physician or nurse practitioner that can include a “clean out” if necessary to eliminate stool that is backed up, as well as stool hydration, fiber intake, stool softeners, laxatives, and dietary changes.
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
Definition: Gastroesophageal reflux (GER) “is the passage of gastric contents into the esophagus with or without regurgitation and vomiting. GER is a normal physiologic process occurring several times per day in healthy infants, children, and adults. Most episodes of GER in healthy individuals last < 3minutes, occur in the postprandial period, and cause few or no symptoms. In contrast, GERD is present when the reflux of gastric contents causes troublesome symptoms and/or complications. Every effort was made to use these 2 terms strictly as defined” (NASPGHAN & ESPGHAN, 2009).
Presentation: GERD can cause eating to be painful and contribute to learned association between eating and discomfort. Children may present with a variety of symptoms:
Therapist questions to ask: Ask caregivers about hard and soft signs of reflux (mentioned above). Use case history to identify GER issues versus other symptoms reflecting constipation, Eosinophilic Esophagitis (EoE), and allergy/intolerance.
Intervention: Reflux management can include:
EOSINOPHILIC ESOPHAGITIS (EOE)
Definition: EoE is an allergic/immune condition that involves inflammation or swelling of the esophagus. In EoE, large numbers of white blood cells called eosinophils are found in the tissue of the esophagus (AAAAI, n.d.; Eosinophilic Esophagitis Home, n.d.).
Presentation: EoE may include poor weight gain (failure to thrive); refusal to eat; vomiting often occurring with meals; heartburn; difficulty swallowing (dysphagia); pain or discomfort with swallowing (odynophagia); food becoming lodged within the esophagus (food impaction); coughing; or chest, throat, or abdominal pain.
The symptoms of EoE vary with age as noted below:
Therapist questions to ask: Ask caregivers questions to “tease out” reflux issues vs. EoE. Ask about history of allergies including eczema, hives, and rashes. Ask about parents’ and siblings’ histories with eating. Poor improvement during reflux management may be an indication that EoE needs to be evaluated (Note: adequate GER management may involve trials on different medications).
Intervention: Diagnosis involves endoscopy and biopsy. Some centers will initially treat for GERD. If the child does not show improvement, they will then scope (esophagogastroduodenoscopy - EGD) to assess for esophagitis (including a biopsy to identify EoE). Treatment may vary across institutions but often includes swallowed steroids to reduce inflammation, allergy testing, dietary changes to eliminate food triggers, and periodic endoscopy to assess improvement.
Definition: A condition where the stomach contracts less often and less powerfully, causing food and liquids to stay in the stomach for a long time. Gastroparesis can be caused by viral infections, scar tissue, previous stomach surgery, some medications, neurologic problems, and endocrine problems including diabetes, adrenal problems, and thyroid disease. However, in as many as 60% of children with gastroparesis, the cause is not known (Nationwide Children’s, n.d.).
Therapist questions to ask: Ask about the child’s feeding schedule and patterns. Children with slow emptying often graze, volume limit, or have a poor appetite.
Intervention: May involve testing (upper GI x-ray, gastric emptying scan, endoscopy), medication (for reflux or motility, pain, nausea, constipation management), nutritional changes (predigested formulas, smaller meals more often throughout the day, changes in rate and volume if tube fed).
The GI issues presented here (i.e., constipation, GERD, EoE, and gastroparesis) are fairly common among children with feeding problems. Of course, there are many other medical concerns that interfere with a child's comfort and desire to eat.
If you are a feeding therapist, it is important to educate yourself regarding the many issues that interfere with feeding progress, so you can advocate for your patients to receive proper treatment which will improve your therapy outcomes. If you are a parent, it is also important to be educated about these problems, so you can work effectively with your child’s feeding therapist and other members of the feeding team for his or her best health and well-being.
The American Academy of Allergy, Asthma, & Immunology (AAAAI). (n.d.). Eosinophilic Esophagitis (EoE). Retrieved from http://www.aaaai.org/conditions-and-treatments/related-conditions/eosinophilic-esophagitis.aspx
Eosinophilic Esophagitis Home. (n.d.). What is Eosinophilic Esophagitis (EoE)? Retrieved from http://www.eosinophilicesophagitishome.org/
Field, D., Garland, M., & Williams, K. (2003, May-Jun.). Correlates of specific childhood feeding problems. Journal of Paediatric Child Health, 39(4), 299-304.
Fishbein, M., Branham, C., Fraker, C., Walbert, L., Cox, S., & Scarborough, D. (1993, Sept.). The incidence of oropharyngeal dysphagia in infants with GERD-like symptoms. Journal of Parenteral and Enteral Nutrition, 37(5), 667-673. doi: 10.1177/0148607112460683 (Epub, 2012, Sep 18)
Hyman, P.E. (1994, Dec.). Gastroesophageal reflux: One reason why baby won't eat. Journal of Pediatrics, 125(6, Pt 2), S103-109.
Nationwide Children's. (n.d.). Gastroparesis. Retrieved from http://www.nationwidechildrens.org/gastroparesis
North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN). (2006, Sept.). Evaluation and treatment of constipation in infants and children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Journal of Pediatric Gastroenterology and Nutrition, 43(3), e1-13.
North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), & European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). (2009, Oct.). Pediatric gastroesophageal reflux clinical practice guidelines: Joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). Journal of Pediatric Gastroenterology and Nutrition, 49(4), 498-547.
Rommel, N., De Meyer, A.M., Feenstra, L., & Veereman-Wauters, G. (2003, Jul.). The complexity of feeding problems in 700 infants and young children presenting to a tertiary care institution. Journal of Pediatric Gastroenterology and Nutrition, 37(1), 75-84.
ABOUT THE AUTHOR
Krisi Brackett, MS, CCC-SLP is a feeding specialist with over 20 years of experience working with children who have feeding and swallowing difficulties. She is co-director of the Pediatric Feeding Team at the North Carolina Children's Hospital, University of North Carolina (UNC) Healthcare in Chapel Hill, North Carolina. Follow her at http://www.pediatricfeedingnews.com/ to read her blogs, dedicated to providing up-to-date pediatric feeding information. Krisi teaches a 2-day workshop on using a medical/motor/behavior approach to feeding, is an adjunct instructor teaching a pediatric dysphagia seminar at UNC-Chapel Hill, and has co-authored a chapter in Pediatric Feeding Disorders: Evaluation and Treatment (Therapro, 2013).
This article was originally published on Krisi Brackett's website in May of 2014. She has given her permission for the reprinting of this article on the Ages and Stages® website. Here is the original link to the article: http://pediatricfeedingnews.com/gi-issues-that-interfere-with-successful-feeding-how-to-recognize-the-symptoms/