NHD clinical - case study
by Kate Harrod-Wild Paediatric Dietitian Wrexham Maelor Hospital
Kate Harrod-Wild is a paediatric dietitian with over 15 years experience of working with children in acute and community settings. Kate has also written and spoken extensively on child nutrition.
Infant feeding problem The following case study proves that sometimes patients get better – perhaps - despite our interventions, rather than
because of them!
David was referred to the dietitian aged five and a half months, having been admitted to the paediatric ward complaining of poor fluid intake. Mum was very stressed and anxious. David had been born at term by emergency caesarean sec- tion and was initially breastfed. However, Mum felt she did not have enough milk and so moved onto formula feeding within days. David developed diarrhoea and his parents took him to A&E, where they were reassured that he wasn’t dehydrated and were advised that he probably had gastroenteritis. When the diarrhoea didn’t improve, the Health Visitor suggested a lactose-free formula and the diarrhoea stopped. A few weeks later, David started to vomit. He saw the GP and then a paediatrician, but he didn’t tolerate Gaviscon or omeprazole, although ranitidine did seem to improve his symp- toms. By the time of admis- sion, feeding had been deteri- orating for some while and he had only been feeding when sleepy, but in the previous few days he wouldn’t even feed in this way and had become de- hydrated. He was reported to refuse a spoon and gagged on finger foods.
On the day of assessment by the dietitian, David had only taken 40mls since wak-
ing in the morning and it was now mid-afternoon. The dieti- tian witnessed a nurse trying to bottle feed him and he became very distressed. As a result of the severe aversive feeding and the very low fluid intake, after discussion with the consultant, a 48-hour trial of exclusively nasogastric feeding commenced. Normal infant formula was used as the family had been using this in the previous couple of weeks in an attempt to improve his intake. The hypothesis was that, if aversive feeding was the main problem, being nil by mouth would settle the symp- toms, but if they continued, possible gastro-oesophageal reflux (GOR) would then have to be explored further. A complicating factor, however, was that he had already been started on dom- peridone.
Mum was initially very grateful for help. David developed di- arrhoea on NG feeds and was windy and restless and so he was changed to an amino acid formula in case of any undi- agnosed food intolerance which may have been causing the diarrhoea and/or contributing to any GOR. This didn’t improve the diarrhoea, but the decision was made to continue with the hypoallergenic formula to avoid constant changes to the man- agement plan. Intermittent efforts to restart oral feeding with bottle were unsuccessful as David was still very averse to the teat. A week into his admission, he was seen by the specialist health visi- tor who works in the psychology department and on the feed- ing team with the dietitian. At this point Mum was much more
NHDmag.com Aug/Sept '10 - issue 57
‘As a result of the severe aversive feeding and the very low fluid intake, after discussion with the consultant, a 48-hour trial of exclusively nasogastric feeding commenced.’
relaxed and the baby himself had changed markedly; he was relaxed and gurgling, rather than being constantly miserable. The specialist health visitor felt strongly that the aversion to the bottle was learned behaviour and that David wouldn’t feed when asleep if he was in severe pain. However, she couldn’t rule out the contributions of previous GOR, maternal anxiety or a combination as precipitating factors. Certainly maternal stress and anxiety were a major continuing factor. The specialist health visitor and dietitian worked out a pat- tern of milk by tube and three solid meals per day – with major emphasis on finger foods, messy play - and tried to discourage attempts to give more than David was prepared to take hap- pily. Mum was very negative and couldn’t see how this would help. The maternal grandmother and the rest of the family were also very negative, wanting immediate results and were not able to accept that he was not likely to go back to taking bottles; especially since he had not ever fed well from a bottle.
The specialist health visitor went to the ward daily, spend- ing up to two hours with the family reiterating advice, but Mum would immediately dis- count the agreed plan which-
ever professional came into the room next. Two part-time dieti- tians were involved and they pulled back, as it was felt that too many professionals were involved and this was leading to the family hearing slightly different messages, although the same advice was being given each time.
David was discharged after two weeks, as Mum was desper-
ate to get home. Mum was anxious as to how long David would need the tube as she was due to return to work as a teacher in six weeks. We said that we couldn’t tell her how long he would need it and tried to reassure her that a lot could happen in six weeks. Less than a week later the health visitor rang as Mum was very distressed and anxious, not following the plan and felt she was not being supported. The specialist health visitor again spent a considerable length of time with Mum and Dad in outpatients; this was the only time that Dad attended, as he apparently worked long hours.
The parents felt that the tube was not improving David’s in- take as he was being sick and it was agreed they could take it out. They were advised to use a cup containing thickened milk in the day and use a bottle at night, as well as giving sol- ids three times a day. Unfortunately, David was readmitted a few days later because of poor fluid intake. At this point the patient was able to self feed solids such as yoghurt and choco- late pudding, using a sponge finger dipped into the foods. The specialist health visitor felt he was managing good quantities when observing feeding, but Mum and Grandma felt that the
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