The Impact of Gastrointestinal Issues on Oral Feeding

Gastrointestinal (GI) issues significantly impact oral intake by influencing a child’s relationship with food, their willingness to eat and their oral-motor skill development. The GI tract, comprised of a complex and intricate series of organs, is designed to transport food through the digestive system absorb and distribute nutrients necessary for growth and generate waste to be eliminated. Efficient (and painless)digestion allows for a positive mealtime experience which in turn contributes to optimal nutrition and growth. When a child suffers from reflux, vomiting or discomfort during/after meals, he/she may begin to have a negative association with eating. Consequently, the child may resist eating or become a very picky eater in an effort to avoid pain. Because there is a high incidence of gastrointestinal disorders in children with Kabuki Syndrome, it is important for parents and therapists to understand the relationship between GI symptoms and feeding, appetite and growth. This article outlines two major GI issues; gastroesophageal reflux disease and constipation, as well as their impact on feeding in children with Kabuki Syndrome.

GASTROESOPHAGEAL REFLUX (GER) is defined as the effortless movement of gastric contents into the esophagus. The majority of infants and toddlers reflux or “spit up” occasionally and this is a normal phase in the development of the GI system. Infrequent reflux typically has minimal effects on oral feeding and will often be outgrown by 1-2 years of age. In contrast, chronic reflux or gastroesophageal refluxdisease (GERD) produces clinical symptoms that interfere with a child’s health, appetite and growth. GERD is prevalent in children with Kabuki Syndrome as approximately 42% of children have reflux, 23% have regurgitation and 63% gag/vomit while eating.

Causes: Gastroesophageal reflux occurs during transient relaxations of the lower esophageal sphincter (LES) or with inadequate adaptation of the sphincter tone to changes in abdominal pressure. The LES is a band or muscle tissue responsible for closing and opening the lower end of the esophagus. When working properly, this muscle opens to allow food to pass through into the stomach and closes again to keep stomach contents contained. If the LES opens spontaneously (called transient relaxations or TLESRs) the Stomach contents may be transported back into the esophagus, mouth or be expelled from the body.

Symptoms: GERD can present in a variety of ways and a child may exhibit one or multiple symptoms. Common manifestations include vomiting (with poor growth), gagging/choking, respiratory issues (apnea, cyanosis, chronic cough, asthma, gurgly respirations), halitosis (bad breath), frequent swallowing, severe sleep disturbances, frequent hiccups, dental carries, irritability, food refusal, back arching during feeding, chronic ear infections/laryngitis/rhinosinusitis and/or an inability to consume large volumes per feeding. It is important to remember that not all children will vomit with reflux. Children may have more subtle symptoms (known as “silent reflux”) which can result in esophageal inflammation and pain.

gastric 1Assessment: Your child’s Pediatrician or Gastroenterologist may recommend a variety of tests to determine the severity of his/her GER. Upper Gastrointestinal Series (UGI) - Barium (a chalky drink) is swallowed and x-rays show the shape of the esophagus and stomach. This test can find a hiatal hernia, blockage and other problems that might mimic reflux.

Esophagogastroduodenoscopy (EGD) - After the patient is given a sedative medication so they are asleep, a small flexible tube with a very tiny camera is inserted through the mouth and down into the esophagus and stomach. The lining of the esophagus, stomach and small intestine can be examined and biopsies (small pieces of the lining) can be painlessly obtained. The biopsies can later be examined with a microscope, looking for inflammation and other problems.

gastric 2

 

 PH Probe - A thin light wire with an acid sensor at its tip is inserted through the nose into the esophagus. The probe detects and records the amount of stomach acid coming back up into the esophagus when the child has symptoms such as crying, arching or coughing.

Nuclear Milk Scan - A small amount of radio active material is mixed into breast milk/formula and consumed by the child. The scan begins while the child is swallowing and will continue for approximately one hour. The child will lay on their back, on the table with the camera underneath them.

 Treatment: Environmental/Behavioral Treatment Strategies:

Dietary - formula changes in infants (may be changed to soy, hydrolyzed or amino-acid formula), minimize foods high in fat (fat delays gastric emptying), avoid acidic/spicy foods, minimize caffeine, tea, chocolate, spearmint/peppermint (may lower LES pressure).

Position - feed infants in an elevated side-lying position with no compression on the abdomen, staying upright 20 minutes after meals, elevating the head of the bed.

Activity - no bouncing, swinging or compression of the stomach for up to 20 minutes.

Frequency/Quantity of feedings - smaller, more frequent feedings to avoid over distention of the stomach (total volume should remain the same).

Thickening formula with rice cereal - some physicians may recommend adding rice cereal to formula, but thickening is done less frequently (especially by gastroenterologists) as this strategy may worsen GER symptoms if gastric emptying is slow.

Medications:

Antacids - neutralize gastric acid and reduce negative esophageal effects of acid exposure (rarely used in infants/toddlers); examples include Tums, Mylanta, Maalox.

Histamine-2 Receptor Antagonists (H2Ras) - decrease acid production by inhibiting the receptivity of the cells that produce hydrochloric acid in the stomach. Examples include; Ranitidine (Zantac), Cimetidine (Tagamet), Nizatidine (Axid), Famotidine (Pepcid).

Protein Pump Inhibitors (PPIs) - block the production of gastric acid completely by acting as a proton pump inhibitor. Examples nclude; Omeprazole (Prilosec), Lansoprazole (Prevacid), Esomeprazole magnesium (Nexium), Zegerid (contains omeprazole and sodium bicarbonate {antacid}).

Prokinetic Drugs - increase upper GI motility (may improve peristalsis, increase LES resting pressure, reduce gastric emptying time). Examples include; Metoclopramide (Reglan).

Antibiotics - a low dose of Erythromycin is sometimes used to enhance stomach emptying. How effective are GER medications? It depends on the child and the severity of reflux. Be aware that GER medications are meant to decrease acid production and/or increase GI motility (not necessarily eliminate vomiting).

gastric 3Surgery: Nissen Fundoplication surgery is where the gastric fundus (upper part) of the stomach is wrapped 360° around the inferior portion of the esophagus, reinforcing the closing function of the lower esophageal sphincter.

Impact on Feeding: As mentioned previously, children with gastroesophageal reflux often associate pain with eating and in turn alter their eating patterns. Infants may become averse to the bottle or have difficulty transitioning to solid foods. Toddlers often become picky eaters and limit their food repertoire to certain textures, tastes and/or colors. In order to maximize nutrition and weight gain, toddlers need to have at least 30 foods in their diet (10 proteins, 10 starches and 10 fruits/vegetables). If your toddler has a limited food repertoire, a formal feeding evaluation by a licensed Speech-Language Pathologist or Occupational Therapist may be warranted.

CONSTIPATION is present in 47% of children with Kabuki Syndrome. It is a gastrointestinal issue characterized by infrequent bowel movements, hard stools or straining during bowel movements.

Causes: Constipation can be caused by a variety of factors including (but not limited to) inadequate fluid intake, inadequate dietary fiber, cow’s milk protein allergy, abnormal muscle tone and/or malnutrition.

Treatment: Fluids - increase fluid intake. Diet - decrease constipating foods (e.g., milk, cheese, yogurt, bananas, applesauce, etc.); increase fiber intake (high-fiber food lists available online). Medications - common medications for constipation in the pediatric population includes Milk of Magnesia, mineral oil, Lactulose and Miralax.

Impact on Feeding: When children are constipated, they experience a sensation of being bloated and full. Consequently, their appetite is affected and they often reduce their oral intake. It is necessary to maintain a regular and pain-free bowel pattern in order to boost appetite and Nutrition.

In summary, although parents are responsible for feeding their children, they do not have to shoulder the complications of a child’s GI and feeding problems alone. There are numerous feeding clinics across the country and internationally that focus on a multi-disciplinary approach to feeding. By involving several specialists (GI’s, Dieticians, Speech-Pathologists, Occupational Therapists, etc.) in a child’s care, families can formulate a treatment plan that addresses the medical, nutritional and emotional aspects of a feeding disorder.

For more information please contact me at: lori.scott@vanderbilt.edu or (615)322-1973.