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:
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 mealtime, 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 dietician, an occupational, speech, physical and mental health therapist, a nurse, a family resource coordinator, an early intervention teacher, 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 nutritional/dietary 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.
Your feeding team has received a referral from a local pediatrician to assess Jasmine, a former 30 week premie 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 kcals/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 kcals/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).
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: Jasmine’s formula was recently increased to a 22 kcal/oz. preparation based on her physician’s recommendation due to poor weight gain. Shari, with the encouragement of her mother-in-law, has tried unsuccessfully to introduce rice cereal by spoon in hopes that it might help Jasmine gain weight.
Diet records indicate the following "typical" feeding routine:
9:00 am |
Rice cereal, a couple bites attempted, crying and spitting
out food 4oz. Formula |
1:00 pm |
4 oz formula |
5:00 pm |
Rice cereal, a few bites attempted, crying and spitting out
food 4 oz formula |
9:00 pm |
4 oz formula |
12:30 am |
4 oz formula |
Although difficult to estimate, Shari thinks that Jasmine is probably spitting up about 1Ž2 oz to 1-1/2 oz per day.
Anthropometrics: Wt: 3775 grams Length: 55.2 cm OFC: 37.8 cm.
Feeding Environment: Jasmine is usually fed on the family room couch, held by her mother. Kyle is also in the room watching TV or singing along with music videos so that Shari can watch both kids at the same time. Usually the overhead lights are on to help "brighten" Shari’s mood. Jasmine is usually put in her crib to finish sleeping after the feeding.
Feeding Observation: Jasmine is observed to get noticeably irritable as she sees the bottle pulled out for her feeding. Jasmine looks away and fusses as Shari brings the bottle to her lips. The bottle has a Nuk nipple, which is broad and flat. Jasmine’s neck, arms, legs and trunk become hyperextended and she starts arching to the side during the feeding. Some coughing is observed during sucking pauses. Jasmine soon tires from the feeding and begins to nod off. Shari is upset, but persistent in her repeated attempts to get in more formula. She says this is typical, but at home it goes on for a longer period of time. When Jasmine sucked on the gloved finger of the feeding therapist, tongue protrusion was noted, which contributed to an inefficient suck. With the feeding, Jasmine had increases in respiratory rate from 55 breaths per minute (bpm) to 80 bpm and heart rate increases from 140 beats per minute to 195 bpm. Signs of labored breathing, sternal contractions and fatigue were observed with the feeding, however no obvious cyanotic related color changes were noted.
Assessment: Formula intake (including estimated caloric losses from spitting up) provides energy intake within the standard range (110 kcal/kg). However, this does not meet Jasmine’s current energy needs because she has inadequate growth. Energy needs are estimated to be in the range of 130-140 kcals/kg/day. Fluid goals are met (150 cc/kg). Jasmine’s respiratory status was significantly stressed during feeding; she could benefit from the addition of supplemental oxygen during feedings. Jasmine is not developmentally ready for solids by mouth. She appears to suffer from possible reflux and should also be considered as a candidate for possible aspiration from reflux. She has behaviors and a medical history consistent with oral aversions. Jasime would benefit from evaluation for reflux and aspiration. Based on results of the evaluation, Jasmine might require treatment for reflux or aspiration or perhaps feeding therapy/ encouraging facial and oral play.
Recommendations:
Jasmine is currently 6-1/2 months, with a corrected age of 4 months of age. 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 and Reglan 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 added rice cereal to some but not all feedings, but has made recommended positional changes during Jasmines 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:
Anthropometrics: Wt: 6.25 kg, L: 62.0 cm, OFC: 41.1 cm
Feeding Observation: Shari wrapped Jasmine snugly in a blanket and demonstrated nice hip flexion positioning for the feeding. When the bottle was presented, Jasmine became fussy, while Shari forced the nipple into Jasmine’s mouth. Jasmine’s neck was in an extended position and tongue protrusion was noted, however she did much better when her neck was repositioned with slight flexion. Although Jasmine’s endurance was much improved, she did show signs of tiring after 15 minutes and presented clear signs that she was finished. Shari did not pick up on these cues and continued to feed; she was visibly tense during the entire feeding observation. Respiratory rate and heart rate remained WNL during the feeding; no coughing was observed.
Assessment: Caloric intake of 885 kcals/day (~140 kcal/kg/d) is suporting adequate growth at this time. Fluid intake (~160 cc/kg) is adequate. The family appears to have been overwhelmed by the number of previous recommendations. There has been no noticeable improvement in terms of Jasmine’s oral aversion.
Recommendations:
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, height: 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:
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: Wt: 8.70 kg, Length: 68.2 cm, OFC: 44.2 cm
Assessment: Caloric intake is 1250 kcals/day. Solids contribute 15-20% of total calories. Fluid intake is adequate. Continue formula preparation at 24 kcals/oz and plan to gradually introduce milk from a cup in the next month. Shari agreed that she is ready for this change now that she is more confident that Jasmine’s growth has improved. Diet records indicate a developmentally appropriate feeding schedule of meals and snacks, including independent feeding with teething foods, such as crackers and biscuits. Strategies to gradually improve tolerance to soft, small lumps should be introduced.
Recommendations:
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 wks CA 2975 g just < 50th% 48.2 cm just < 50th% 33.5 cm 50th% 2 mo’s CA 3775 g < 10th% 55.2 cm just < 50th% 37.8 cm just < 50th% 4 mo’s CA 6.25 kg 50th % 62.0 cm 50th% 41.1 cm 50th% 6 mo’s CA 7.75 kg just > 50th% 64.8 cm 50th% 42.9 cm 50th% 8 mo’s 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:
The optimal 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 in only 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 chart, which was close to the 50th% for weight and height and has fallen significantly to below the 10th% for weight. 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, they should not be dropping major growth channels.
- Increased caloric needs due respiratory distress/desaturation, BPD
- Fatigue/poor endurance: limit 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, poor 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
At 4-1/2 months, Jasmine’s corrected age (CA) is 2 months. She was born at 30 weeks gestation or 10 weeks (2-1/2 months) prematurely. Using CA one can more appropriately adjust expectations for growth and developmental milestones. Thinking in terms of corrected age can help decrease family disappointment regarding their babies progress vs. focusing on chronological age. Depending on the severity of prematurity and medical complications, the VLBW may face delays even when using CA.
As far as introduction of solids, a starting point would be to look at CA. In this case, 2 months is inappropriately early for introduction of solids. Solids, in the form of infant rice cereal, is generally recommended between 4-6 months CA. In addition, the following developmental milestones indicate readiness for solids:
- Infant can sit with support and has neuromuscular control of the head and neck.
- Infant can take food without choking or gagging.
- Infant can indicate desire for food by opening the mouth and leaning forward.
- Infant can indicate satiety by leaning back and turning away.
- Strong extrusion reflex has faded, and infant demonstrates ability to swallow non-liquid foods, to transfer food from the front of the tongue to the back, and to draw in the lower lip as the spoon is removed.
- Infant exhibits beginning of up and down chewing movements as opposed to sucking movements with mou
Instructions for mixing formula to 26 kcal/oz should likely follow these recommendations: It is safe to concentrate formulas to 24 kcal/oz and then to add modular carbohydrate and/or fat products to increase the concentration above 24 kcal/oz up to 30 kcal/oz. Increasing the formula alone above 24 kcal/oz may pose a risk to an infant with immature kidneys and/or tenuous fluid balance due to the increased renal solute load. Whenever concentrating formula be sure to check percentage of total calories for macronutrients for adequacy and assure proper fluid intake for hydration.
Recipe listed in website for 26 kcal/oz is:
13 oz (390 ml) of liquid concentrate, 1 Tbsp. + 2 tsp. of Polycose, and add water to get final volume of 645 ml
Liquid concentrate would be preferred due to the ease of precise measurements, especially when concentrating formula. Powdered formula scoops have been shown to have variable sizes and do not always equal 1 Tbsp. as previously assumed, in addition precise measurements using scoops can be more difficult. Liquid concentrate, however, is more expensive than powdered formula and may be cost prohibitive for some families. In that case, a careful demonstration of formula concentrating instructions would be recommended.
The feeding environment can either help optimize the feeding experience or represent a significant source of stress, which can contribute to feeding problems. The feeding environment is an important component to successful feeding and should always be evaluated whenever an infant has growth or nutrition issues. Potential sources of stress within the feeding environment can include: bright lights, noise, TV, variations in ambient temperature and distracting movements of siblings or others. Feeding guidelines should be provided to help decrease exposure to a stressful feeding environment and eliminate counterproductive distractions.
- Coughing observed during sucking pauses at initial feeding assessment may indicate formula ascending into pharynx from gastroesophageal reflux (GER)
- Medical history of two upper respiratory infections (URI) and resulting hospitalizations within the 11 weeks since the initial hospital discharge
- Avoidance of bottle upon presentation may be related to discomfort of reflux and aspiration.
- Delayed oral/motor skills can increase risk of aspiration cue to poor control and coordination
- Infants with increased respiratory rate may be at higher risk of aspiratio
Increases in heart rate >10 beats/min and respiratory rates of 80 breaths/min, as measured during pauses in sucking, may indicate that the feeding is placing excessive demands on the infant. In this is the case, the infant may be working too hard to feed efficiently. Additional support to the cardiorespiratory system, such as supplemental oxygen or medications and/or nutritional support by way of non-oral supplements may be needed.
Evidence that difficulties exist in the feeding relationship between Shari and Jasmine include:
- Feeding is described as dreaded and stressful, often ends with mother crying, infant sleeping.
- Feedings are prolonged, around an hour
- Oral aversions make feeding unpleasant for Jasmine, difficult for Shari to provide nutrition
- Reflux/aspiration/impaired respiratory status causes discomfort, negative reinforcement of feedings
- Poor reading of feeding cues such as satiety signals
- Force feeding-- Shari feels pressure to provide high amounts of calories with each feeding
- Fearful outlook of future feeding
- Oral/facial aversions due to experience with prolonged airway intubation or tube feeding, which can result in lack of infant interest/enjoyment
- Limited exposure to oral stimulation if fed via nasograstric tube early in life. Lack of early oral sensory input can lead to hypersensitivity and hyperirritability during feeding.
- Prolonged feeding times and/or poor feeding endurance results in stress for infant and feeder.
- Oral motor problems may limit infants self-regulatory abilities (such as sucking to relieve stress and help reach an organized state), decreasing opportunities for parent-infant interaction. Preterms are often found to have higher rates of "difficult" temperament in the first months of life. Infant’s birth weight and temperament at 4 months of age are predictive of mother-infant interaction with preterm infants.
- Bonding issues due to prolonged hospitalization and medical status
- Postnatal complications can increase stress and interfere with feedings
- Lack of parental confidence regarding feeding
- Increased rates of maternal depression and anxiety with VLBW infants
- Infant perceived as fragile, mothers might feel insecure handling infant
- Growth problems can exacerbate maternal pressure at feedings.
Sensitive periods are developmental windows of opportunity when infants are ready to accept advances in taste, texture, and/or feeding methods. If these "sensitive periods" are missed and the corresponding feeding experience is not provided, it may be difficult for the feeding development to progress normally. Often a child who missed feeding exposures during these sensitive periods seems to get stuck at a certain level of feeding progressions and has a difficult time making the next developmental change. This is especially important for babies with prolonged naso-gastric or gastrostomy feedings. Some type of ongoing oral motor program is needed for tubefed children, even if they are not taking foods by mouth at that time.
Finger Foods: Child should already have developmental indicators for pureed solid foods and
- Infant can sit independently and maintain balance while using hands to reach and grasp objects.
- Infant grasps large pieces of food such as thick, dry, infant toast, in a palmar grasp.
Cup Drinking: Child should have demonstrated developmental indicators for pureed solid foods, finger foods and
- Infant exhibits ability to control size of sip and to manipulate liquid bolus to back of mouth and swallow without choking or gagging.
Girls Growth and Development Curve
Prepared by Drs. D. Gairdner and J. Pearson. Published in Archives of Disease
in Childhood 1971.