Gastrointestinal Issues during Infancy€¦ · •Fourth week development –Esophagus, stomach,...

Confidential

Feeding and ExcretingGastrointestinal Issues during Infancy

Cheryl Cairns, DNP CPNPCommunity Pediatrics

Pediatric Institute

© Cleveland Clinic 2017

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• Participants will be able to discuss infant feeding of both

formula and breastfed infants

• Participants will be able to discuss common infancy

gastrointestinal issues

• Participants will be able to discuss red flags that need

further evaluation

Objectives

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• Fourth week development

– Esophagus, stomach, liver and pancreas

– followed by both small and large intestine

• Absorption and digestive functions present at term

• Motor function

– Provided by the enteric nervous system

– 24 weeks but may

– Not be fully functional until approximately 40 weeks

• Hormonal regulation including

– Peptides are present by the end of the first trimester but may not may not be fully distributed until reaching term gestation

• Immune defenses

– Throughout gestation and continue after birth

Gastrointestinal Development

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Gastrointestinal Tract

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• Ingestion

– Consumption of food and other substances through the mouth

• Digestion

– Metabolism in which substances are mechanically and chemically

converted for use

– 1. Cephalic Phase (nervous system is stimulated )

– 2. Gastric Phase (release of gastric juices and pH balancing)

– 3. Intestinal (excitatory and inhibitory reflexes control passage)

• Absorption

– Movement of nutrients and water into circulatory and lymphatic

system

• Excretion

– Elimination of undigested material

•

Gastrointestinal Tract

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• Exclusive breastfeeding is recommended for the first 6

month

– Including premature and sick newborns

– Except when precluded by medical contraindications

• Partial breastfeeding refers to the infant receiving breast

milk for some feedings and liquid supplements such as

formula at other times

• Formula feeding refers to use of breast milk substitutes to

provide infant nutrition

Feeding

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• Exclusive breastfeeding for the first 6 months could

– Save 1.3 million lives each year

– Particularly in underdeveloped countries

• Human milk contains just the right amount of fatty acids, lactose, water and amino acids

– Brain development and growth

– Contains most of the nutrients required to sustain the healthy infant for the first 6 months of life

• Breast milk is easy to digest

• Contains antibodies

– Custom-designed to provide the term, preterm and vulnerable infant protection from contagious diseases

– Protects the infant against many noncontagious diseases that develop later in life

Breastfeeding

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• History

– Milk supply nipple / areola assessment

– Colostrum

– Pain / soreness

– Engorgement

– Low milk supply /over-abundant milk supply

– Blistered / cracked/bleeding

– Softer after feeding

– Inverted / flat

– Mastitis / inflammation

– Fever / flu symptoms

– Hydration

– Plugged duct

• Assessment Infant

Assessment of mother

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• History

– Awake, alert, very active, fussy, very passive, sleepy, lethargic

– Feeding behavior, position and latch (visual or verbal)

– Chin indents breast

– Audible swallowing circular movement of jaw

– Nipple confusion

– Cries at the breast

– Falls off breast: during feed, end of feed

– Stays attached and sleeps, no sucking

– Feeds on nipple, not areola

– Lips not flanged

– Cheeks rounded

– Frenulum

Assessment of infant

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• Kangaroo care

– South America

– Premature infants

– Benefits for all infants

• Benefits

– Warmth

– Stability of heartbeat and breathing

– Increased time spent in the deep sleep and quiet alert states

– Decreased crying

– Increased weight gain

– Increased breastfeeding

– Improves milk production by the mother

– Parent satisfaction

Skin to Skin

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• 20 cal/oz

• Human milk fat

• Lactose

• 70% whey, 30% casein, 9 g/L

• Iron 0.3 mg/L

• Vitamin D 21 IU/L

• 260 mOsm/kg H20

• Contains DHA and AA

Breast Milk

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Standard formula

• 20 cal/oz

• Soy, coconut, sunflower, palm

• Lactose

• 60:40, casein whey 18:82 >15 g/L

• Iron 12mg/L

• Vitamin D 405 IU/L

• 265-300 mOsm/kg H20

• DHA and AA added

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• Standard– Similac, Enfamil, Carnation, Store brands

• Soy– Isomil, Prosobee, Alsoy,

• Protein hydrolysates– Pregestimil, Nutramigen, Alimentum

• Elemental– Neocate, Elecare

• Premature– Enfacare, NeoSure

• “Next Step”—older infants and toddler

Formula: Types and Brands

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Formula

https://www.aptaclub.co.uk/fckassets/aptaclub/howmuchtofeed_chart.g

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• Breastmilk with milk supplement– 26 kcal/oz

– 25cc breast milk + 25cc of 32 kcal/oz Similac Natural Care

– 28 kcal/oz– 25cc breast milk + 25cc of 36 kcal/oz Similac Natural Care

– 30 kcal/oz– 25cc breast milk + 25cc of 40 kcal/oz Similac Natural Care

• Breastmilk with powder– 22 kcal/oz

– 3 oz breast milk = ¾ tsp Enfacar

– 24 kcal/oz– 3 oz breast milk + 1 ¼ tsp Enfacare P

– 26 kcal/oz– 3 oz breast milk + 1¾ tsp Enfacare P

– 28 kcal/oz– 3 oz breast milk + 2 ¼tsp Enfacare P

– 30 kcal/oz– 3 oz breast milk + 2 ¾ tsp Enfacare

Recipes for Increasing Caloric Intake

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• Definition: Gastroesophageal Reflux Disease

– GER

–Normal physiological process of frequent regurgitation in absence of

pathology

– GERD

–Reflux that causes pathological consequences

• Gastroesophageal reflux (GER)

– Common in healthy infants, in whom gastric fluids may reflux into

the esophagus 30 or more times day

GERD / GER

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• Overfeeding

• Weak abdominal muscles

• Immature or weak lower esophageal sphincter

• Slow digestive system

• Allergies

• Lactose Intolerance

• Nicotine lowers the lower esophageal sphincter pressure

GERD Etiology

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• Fussiness

• Cough

• Gagging

• Crying during or after a feeding

• Difficulty lying in supine position (sleeping)

• Arching

GERD Symptoms

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• Poor weight gain

• Vomiting consistently

• Wheezing

• Stridor

• Persistent cough

• Apnea

• Irritability

• Hematemesis

• Abdominal tenderness, distension

GERD Red Flags

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• Positioning

• Infants younger than 12 months of age should be placed

in the supine position for sleep, even if they have reflux

• Smaller feedings often reduces the frequency or quantity

of reflux

• Keep infant upright for 20 to 30 minutes after feeding

• Trial of cow’s milk free diet if breast fed

• Formula change to non-cow milk formula

GERD Treatment

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• Medical Management - PPIs

• Pediatric Dosing for Lansoprazole

– Prevacid®

– < 3 months 1.5 to 1.75 mg/kg three times per day

– 3 - 6 months 1.25 to 1.5 mg/kg three times per day

– 7 months to 2 years 1 to 1.25 mg/kg three times per day

• Pediatric Dosing for Omeprazole

– Prilosec ®, and generic form

– < 3 months 1.5 mg/kg three times per day

– 3 - 6 months 1.25 mg/kg three times per day

– 7 months to 2 years 1 mg/kg three times per day

GERD Treatment

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Prevacid® (lansoprazole) prescribing information.

http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/020406s075,021428s022lbl.pdf

Prilosec® (omeprazole) prescribing information.

http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/022056s007,019810s091lbl.pdf

• 4 month old female with history of “ fussiness and

spitting”

• Exclusively breastfed until 2 months

• Now supplemented with one bottle of Similac Sensitive

• Breast feeding every 2-3 hours during the day and up

more frequently at night

• Infant was 7 lbs 2 oz at birth now at 9 lbs

• Mom states “ I just don’t know what to do anymore”

• What is your assessment and plan?

Case Study # 1

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• Definition

– Infrequent bowel movements are passed

– Painful defecation

– Passes large caliber and hard stools that

– Excessive straining

• Etiology

– Inadequate hydration

– Low-fiber diet

– Slow intestinal transit

– Minimal activity level or inactivity

– Behavioral

Constipation

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• Straining

• Stool

– Formed and hard like small pebbles

– Soft and mushy

– May even be wide and large

– Liquid stool (like diarrhea) may pass out around hard stool

• Infrequent stools that are difficult to pass

• Abdominal distention

• Fussiness

Constipation Symtoms

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Stool Consistency

http://www.chikd.org/upload/thumbnails/ckd-19-1-1f2.gif

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• Delayed passage of meconium

• Loss of weight or failure to gain weight

• Bloody stools

• Severe abdominal distention

• Perianal fistula

• Absent anal wink

• Sacral dimple

Constipation red flags

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Dietary changes

• Fruits and vegetables

• Increase fiber

• 1-2 oz fruit juices (prune, pear)

– Juice is not recommended routinely

• Oatmeal or barley cereal

– Rice cereal can cause constipation in some children

• Education

• Behavioral management for children

Constipation Management

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• Mediation

– Miralax - polyethylene glycol is an osmotic laxative

– Polyethylene glycol works by retaining water in the stool, resulting

in softer stools and more frequent bowel movements

– Polyethylene glycol does not affect glucose or electrolytes in the

body

• Clean out

– High dose oral laxatives

– PEG 1-1.5 g/kg/day x 3-6 consecutive days

• Maintenance therapy

– Lower dose PEG 1 g/kg/day

– 1-2 months

– d/c when no more hard stools or withholding behavior

Constipation Treatment

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• Four week old male 32 week premie

• Breastfed exclusively

• Was stooling every 2 hours yellow seedy

• Now stooling every 5 days

• Mom has noticed straining over the past week and today

noticed blood in the stool

• What is your assessment and plan?

Case Study #2

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• http://pediatrics.aappublications.org/content/136/3/596

• http://pediatrics.aappublications.org/content/early/2013/04

/24/peds.2013-0421

• http://www.naspghan.org/files/documents/pdfs/cme/jpgn/

Evaluation_and_Treatment_of_Functional.24.pdf

References

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