Case Study: Baby Jasmine

Learning Objectives

Feeding Team Approach

History

Feeding Team Assessment # 1

Feeding Team Assessment #2

Feeding Team Assessment #3

Feeding Team Assessment #4

Study Questions

Growth Charts

Learning Objectives:

This case study addresses post discharge nutritional care of VLBW infants. The focus is on a multidisciplinary team approach to ongoing and developmentally changing feeding issues. Participants should be able to satisfy the following learning objectives:

1. Calculate and plot an infant’s growth parameters using corrected age. Be able to recognize patterns of growth that indicate growth faltering.
2. Gain an appreciation for the importance of the multidisciplinary team approach in addressing the potentially complex nutritional concerns of post discharge VLBW infants.
3. Recognize the diverse array of potential contributors to poor weight gain that should be addressed in treatment strategies for VLBW infants.
4. Understand developmental milestones as they relate to feeding progressions.
5. Demonstrate an understanding of key concepts that impact feeding outcomes such as the feeding environment, oral aversions, the feeding relationship and sensitive periods.

Feeding Team Approach:

Feeding problems are a daily, stressful routine for many families with a VLBW infant. Feeding issues are usually multi-factorial and complex, involving nutrition, growth, bonding, behavior, developmental readiness, oral aversions, medical complications, financial stress, and time constraints. In order to meet the diverse challenges associated with feeding issues, the most effective approach is the utilization of a feeding team.

A feeding team includes a multidisciplinary group of professionals, each with a specialized area relevant to the feeding experience. Feeding teams may include various combinations of the following: a registered dietitian nutritionist, an occupational, speech, or physical therapist, a mental health specialist, a nurse, a family resource coordinator, an early intervention educator, a social worker, and a physician. The family is also a part of the feeding team. The family helps identify issues that need to be addressed, provides feedback as to the effectiveness of treatment strategies, and operates as a "reality check" regarding the practicality of recommendations within the context of the family.

The specifics of a feeding team consultation may vary, but usually include an assessment of growth, a nutrition evaluation, and a feeding observation that focuses on oral motor skills, positioning and stability, environmental considerations, feeding behaviors, medical status and family dynamics. The appointments conclude with demonstrated treatment strategies that compose the feeding team plan. With each appointment, the team is able to draw upon the expertise of its members to create, modify and refine recommendations to optimize feeding and growth outcomes in a dynamic, integrated, and multidisciplinary manner.

History:

The feeding team has received a referral from a local pediatrician to assess Jasmine, a former 30 week preemie with a diagnosis of moderate BPD (bronchopulmonary dysplasia). Jasmine has a chronological age of 4 1/2 months and presents with inadequate weight gain and "feeding problems."

Medical records indicate that Jasmine had a birth weight of 1450 grams, a birth length of 40.1 cm, and an OFC of 28.2 cm. She required intubation and mechanical ventilation at birth. After three days she was extubated and received O₂ via nasal cannula along with a course of steroids. Although initially parenterally fed, Jasmine was transitioned to gavage feedings within 5 days postnatally using a standard preterm formula mixed to 24 kcal/oz. At 34 weeks gestation, Jasmine received a combination of bottle and gavage. At the time of discharge (37 weeks gestation), Jasmine was exclusively bottle-fed with a standard, iron fortified infant formula (20 kcal/oz). She was discharged with half a standard daily multivitamin supplement and inhaled bronchodilators prn. Her discharge weight was 2975 grams, with a length of 48.2 cm and an OFC of 33.5 cm. Since her initial discharge she has been briefly hospitalized twice with upper respiratory infections (URI’s).

Feeding Team Assessment #1:

Jasmine was brought to the appointment by her mother, Shari. Shari describes herself as Jasmine’s primary caregiver, although her husband Don and her mother-in-law, Colleen, do participate in some of the feedings. Jasmine’s 4-year old brother, Kyle, was at home with his grandmother during this appointment.

Shari describes the following: "Feeding times are very stressful for "Jazzy" and me. She will fuss, pull away from the bottle and spit up all of the time. She tires out before she has had enough formula, and I end up spending an hour trying to get her to take all of her bottle because I know she isn’t growing enough. Most feedings end with Jazzy falling asleep and me crying with a half full bottle left in my hand. I really dread mealtimes, I know she needs the calories but she never seems to enjoy feeding—it was so much easier with Kyle, he loved taking a bottle, it was our quiet time together."

Dietary Intake:

Diet records indicate the following "typical" feeding routine:
 

Although difficult to estimate, Shari thinks that Jasmine is probably spitting up about 1/2 oz to 1-1/2 oz per day.

Anthropometrics:

Feeding Environment:

Feeding Observation:

Assessment:

Recommendations:

1. Increase formula to 26 kcal/oz.
2. Discontinue all solid foods by spoon.
3. Decrease the length of feedings—try shorter, more frequent feedings to optimize efficient time of feeding: 15 minutes maximum. Use a timer.
4. Provide a quiet feeding environment with dim lights. Perhaps this could be a quiet color time for Kyle or a time for him to listen to a book tape with headphones.
5. Provide proper positioning during feeding, including neck and hip flexion along with snugly wrapped arms and legs.
6. Switch from the broad flat nipple to a firm, straight one with a round cross section to supply strong pressure along midline to help encourage more efficient sucking patterns.
7. Implement strategies to decrease reflux including upright positioning during and after feedings. Provide 30 degree prone elevated position in crib by using a foam wedge. Instructions discussed and handouts provided.
8. Refer for evaluation for gastroesophageal reflux and aspiration including VFSS (videofluoroscopic swallow study). Consider medications and other treatment approaches based on results.
9. Obtain physicians order to add supplemental oxygen during feedings.
10. Return to clinic in 4 weeks.

Feeding Team Assessment #2

Jasmine is currently 6 1/2 months, with a corrected age of 4 months. Her family canceled her appointment last month, but rescheduled for today’s clinic. Since last seen, Jasmine’s VFSS showed some microaspiration of refluxed formula, although she appeared safe with thickened liquids. Jasmine is now taking Zantac (ranitidine) and Reglan (metclopramide) for medical reflux management. Supplemental oxygen has been added during feedings.

Shari notes an improvement with reflux, particularly since starting meds. She estimates that Jasmine now spits up only "a very small amount, once every few days—usually in her crib." She has made recommended positional changes during Jasmine's feedings. The family hasn’t elevated the crib mattress to 30 degrees, but is willing to try now that things have calmed down a bit. Feedings have become a little less stressful due to time limitations—but they "still aren’t the highlight of our day." Jasmine does not enjoy being touched around the mouth or face and the family avoids any extra touch as much as possible. Shari reports that she has a difficult time getting the nipple into Jasmine’s mouth to initiate feeds. "With Kyle, some days he would eat a lot and other days not too much. It never bothered me, I knew it would even out in the end. With Jasmine, each feeding seems so important, I feel pressure that she takes in a good amount at each and every feeding."

Diet Records:

34 oz/day of 26 kcal/oz formula

Feeding Time Limit: usually 15-25 minutes per feedings

Anthropometrics:

Feeding Observation:

Assessment:

Recommendations:

1. Thicken all formula feedings with oatmeal to prevent microaspiration.
2. Refer for ongoing therapy to address oral aversions and tactile hypersensitivity. Techniques will also be incorporated into all therapy appointments and at early intervention classes for further reinforcement.
3. Watch Jasmine's signals during feedings and try to respond in kind. Slow down, and even discontinue the feeding as needed based on her cues—do not force her to continue feeding when she tires. At this point, ~15 minutes is what she can comfortably handle.
4. Discontinue multivitamin supplements due to adequate nutritional intake.
5. Return for follow-up next month.

Feeding Team Assessment #3

Jasmine’s chronological age is 8 1/2 months. Shari hasn’t tried introducing any solids and is hesitant to add something new to the feedings. She consistently includes the oral/facial play routine her therapist recommends. Shari describes continued frustration over the feeding and acknowledges it is difficult for her to stop the feeding when Jasmine begins to pull away or nod off. Shari wonders if feedings will ever feel like a normal, happy part of Jasmine’s life. She notes that a friend's baby that is at Jasmine’s corrected age is already eagerly eating solids. During the feeding observation, Jasmine did show resistance during the initiation of feeding, but once it was underway, feeding was strong and efficient. Proper positioning was maintained and no evidence of tongue protrusion was noted. Respiratory and heart rates were WNL. Cues that Jasmine was finished with the bottle-feeding were not picked up on, and Shari forced the bottle back into Jasmines mouth, even after adequate volumes had been consumed. Introduction of solids by the therapists at this appointment met with some resistance, but was tolerated and handled safely.

Assessment:

Diet records indicate formula intake is 44.5 oz/day providing ~150 kcal/kg/day. Current intake is supporting weight gain of 25 grams per day. Jasmine’s weight is 7.75 kg, length: 64.8 cm and OFC: 42.9 cm. Shari is not willing to change feedings at this point, due to ongoing concerns regarding Jasmine’s growth. Jasmine is developmentally at a 5-6 month age level and is ready to begin introduction of solids. Jasmine could benefit from increased oral/facial stimulation. Feeding relationship issues continue to contribute significant stress, strategies to take some of the pressure off Shari should be explored.

Recommendations:

1. Introduce infant cereal 2-3 times daily. Focus on opportunities of exposure, don’t worry about nutritional contribution of solids at this point. Jasmine’s father and grandmother will feed Jasmine daily.
2. Information regarding nutritional and developmental progressions was discussed and handouts provided. The family was encouraged to use these as a guide for introducing new foods and feeding techniques. The importance of capitalizing on "sensitive periods" was discussed.
3. Increase oral/facial play. Additional exercises were demonstrated and handouts provided. Jasmine’s father and grandmother have agreed to participate in exercises on a daily basis.
4. Importance of the feeding relationship and watching for feeding cues was discussed. Ellyn Satter’s concept of the division of responsibility was described. Videotapes of the last two feeding observations were reviewed with Shari. Tapes were provided to take home for additional viewing at Shari’s request. (She was surprised to see the degree of struggle that the video showed.)

Feeding Team Assessment #4

At today’s feeding team clinic, Jasmine’s chronological age is 10 1/2 months. Shari reports a significant decrease in stress now that she is getting more family support with the therapies and feedings. She is quick to mention, however, that even with these improvements it still seems like Jazzy does not enjoy mealtimes, although is admittedly much less resistant. Shari reports that Jasmine will eat a nice variety of foods, similar to the guidelines provided. However Jasmine is challenged by foods with multiple textures, and will often spit out lumps. Shari is blenderizing all foods to make them smoother and increase Jasmine’s acceptance. She worries that they may have hit a plateau in terms of Jasmine’s ability to eat any textures. "Every time there is any feeding problem, a little part of me wonders if this is just an off day, or the beginning of a major backslide."

The feeding observation started with Shari initiating oral stimulation exercises suggested by the feeding therapist. The feeding confirmed an acceptance for smooth foods and single texture foods including crackers and teething biscuits. However, when multiple textures were presented, i.e., smooth foods with very small, soft lumps, the lumps were carefully spit out. When finely ground crackers were added to pureed foods, however, she hesitantly ate all that was presented. When cup drinking was attempted, a large amount of liquid fell from the corners of Jasmine’s mouth. When the juice was thickened with pureed fruit, better control was demonstrated. There was no choking or gagging with any of the thin or thickened liquids tried.

Anthropometrics:

Assessment:

Recommendations:

1. Add finely mashed crackers to smooth foods. As Jasmine’s tolerance improves, gradually increase the size of the cracker crumbs. With time, add more challenging textures, but do so in a very gradual manner. Consistency is key. The concept of sensitive periods was again discussed.
2. Continue formula preparation at 24 kcal/oz and plan to gradually introduce milk from a cup in the next month. Instructions for transition provided.
3. Continue to gradually increase volumes of solid foods. Guidelines provided.
4. For improving cup drinking skills, thicken liquids so that they will move slowly and provide Jasmine an opportunity to learn this new skill. Thickening of liquids can decrease as drinking skills improve. Do not use commercial thickeners.
5. Family encouraged to proceed with feeding changes as Jasmine’s developmental indicators dictate.

Study Questions

1. Plot Jasmine’s anthropometric measurements on a growth chart. Calculate Jasmine’s average weight gain since her initial discharge from the hospital at 37 weeks gestation to her initial feeding team assessment? Is her growth adequate and why?

Gairdner and Pearson curve follow.

Age	Weight	Weight Percentile	Length	Length Percentile	OFC	OFC Percentile
Birth	1450 g	just <50th	40.1 cm	just <50th	28.2 cm	50th
37 weeks CA	2975 g	just <50th	48.2 cm	just <50th	33.5 cm	50th
2 months CA	3775 g	<10th	55.2 cm	just <50th	37.8 cm	just <50th
4 months CA	6.25 kg	50th	62.0 cm	50th	41.1 cm	50th
6 months CA	7.75 kg	just >50th	64.8 cm	50th	42.9 cm	50th
8 months CA	8.70 kg	just >50th	68.2 cm	just >50th	44.2 cm	just <50th

 To calculate average weight gain since initial hospital discharge:

3775 g - 2975 g = 800 g

11 weeks = 7 x 11 = 77 days

800 g divided by 77 days = 10.4 g/day

The optimal rate of weight gain for premature infants has not been defined. It is common practice to aim for intrauterine growth rates (15 g/kg/day) and 0.5-1.0 cm/wk in length, during initial hospitalization. Thereafter, expected rates of growth for term infants, using corrected age, may be used for comparison. (0-4 months 20-25 g/d; 5-12 months 15 g/d)

Jasmine is gaining an average of 10.4 g/d; this is only half of the minimum recommended guidelines. In addition, Jasmine is "falling off" her own growth curve. Weight and length were close to the 50^th percentile at discharge, but weight fell significantly to below the 10^th percentile at 2 months CA. There is also evidence that her rate of growth for length may also be slowing. Although VLBW and ELBW infants may not experience catch-up growth in the first 1-3 years of life, their growth should not slow.

2. Based on the information presented at the initial feeding team assessment, what factors are likely contributing to Jasmine’s poor growth?

• Increased energy needs due to respiratory distress/desaturation, BPD
• Fatigue/poor endurance: limited intake
• Inappropriately early introduction of solids, displacing formula attempts
• Reflux: losses and discomfort leading to decreased intake
• Aspiration: Increased URI, illness and hospitalization, higher need, lower intake
• Oral aversion: likely due to previous medical experiences, nipple choice likely exacerbates problems with tongue protrusion, limiting intake
• Inefficient suck-due to tongue protrusion, limiting intake
• Distracting feeding environment with noise, bright lights, TV, sibling
• Hyperextended positioning-reduces intake
• Long feeding times- reinforce negative feeding experience
• Stressful feeding relationship between mom and baby