NHD clinical - case study
same amounts were minimal. The specialist health visitor rec- ommended more self feeding and limited feeding with spoon – foods suggested included chips as a possible finger food, which led to a violent outburst from Mum, who felt this was en- tirely inappropriate. The dietitian saw them immediately after- wards and they were unhappy and felt the plan wouldn’t work. Grandma was particularly vehement.
‘The ward asked for a detailed plan as they were not clear as to what was wanted; this was provided and led to a more consistent approach from the nursing staff, which undoubtedly helped to reduce conflict and mixed messages.’
The ward asked for a detailed plan as they were not clear as to what was wanted; this was provided and led to a more consistent approach from the nursing staff, which undoubt- edly helped to reduce conflict and mixed messages. Next day, in discussion with Mum and Granddad, it was revealed that Mum was difficult to feed as a baby, although this was denied by the family the following day. At last, the specialist health visitor had a conversation with Mum where she ap- peared to accept that David was unlikely to feed well again from a bottle. David was once more discharged with a com- promise between the plan and Mum’s previous feeding prac- tices. Unfortunately, he was then admitted four days later with diarrhoea and vomiting and a tube was passed. Unbelievably, as David improved during this admission, he started picking up a bottle of formula and feeding himself
– as long as he was in a highchair and not held! A week after discharge, at nine months old he was eating and drinking well! He will be reviewed at one year to switch back to nor- mal milk from amino acid formula. He almost certainly won’t need this, as he is now on a normal diet. However, since he had such a rocky path, it would seem unwise to change any- thing and risk undoing the excellent progress he has made.
Conclusion
This was an exceptionally difficult case. The intervention only lasted six weeks, but felt much longer due to the inten- sity of contact with the family and led to as much stress in the healthcare team as in the family. Usually, when there is a parent who finds it difficult to think ‘out of the box’, there is another family member who can help them to do so. In the case of this baby, all the immediate family seemed to have very inflexible thinking. They could not envisage anything other than bottles and spoon feed- ing as the majority method of feeding for this baby. Neither could Mum think about factors that might have contributed to his problems other than medical ones, nor did she have the insight to see how a different management plan/style could help to remedy this situation.
The situation was made worse as with every different day and shift, the family sort a different idea/plan from each nurse and doctor on duty. We perhaps should have acted sooner to put a comprehensive plan in place; our usual style is a more relaxed one, giving suggestions and allowing the family some flexibility to interpret these to suit their parenting style. This simply didn’t work with this particular family. As a team, we began to see a very bleak outlook for this little boy and were concerned that with Mum needing to be so in con- trol, he would eventually become aversive to solids as well. This may well have ended with an essentially healthy child having a feeding gastrostomy placed. Instead, thankfully, even at nine months, this little lad took his future into his own hands. We have never been so pleased to be rendered redundant!
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NHDmag.com Aug/Sept '10 - issue 57
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