Feeding Issues

There are several feeding and gastro issues that a child with special needs may have. Some of these issues can be addressed with therapy and sometimes a feeding tube may need to be placed.
 
Dysphagia is a swallowing disorder and is a symptom found in a number of neurological disorders. Difficulties can range from a total inability to swallow, to coughing or choking. Some children may not be able to start the swallowing reflex (a stimulus that allows food and liquids to move safely through the pharynx). Food may get “stuck” in the throat or the child may drool because they cannot swallow their saliva. A weak tongue or cheek muscles may make it hard to move food around in the mouth for chewing or to close the mouth properly to aid in swallowing. Food pieces that are too large for swallowing may enter the throat and block the passage of air. Weak throat muscles can not move all of the food toward the stomach. Food can fall or be pulled into the windpipe and liquids may be inhaled or “penetrate” the trachea causing aspiration, which may result in a lung infection/pneumonia. Dysphagia also often makes it difficult to take in enough calories and fluids.There are different treatments for various types of dysphagia including muscle exercises to strengthen weak facial muscles or to improve coordination, using thickeners, but for some children, oral feeding/drinking may not be possible. They may need to have a feeding tube placed.

 
Gastroesophageal Reflux- Reflux is painful, causing infants to cry constantly, refuse to eat, spit up frequently, and sleep poorly. If GER is left untreated, long-term complications such as feeding disorders, inadequate weight gain, narrowing of the esophagus, and damage to the tissue in the esophagus, called Barrett’s syndrome, can develop. A muscle at the top of the stomach (also called the Lower Esophageal Sphincter or LES) naturally opens and closes to allow swallowing, burping, and vomiting. Refluxing occurs when the stomach acid and partially digested food flow back up through the LES into the esophagus. When the stomach contents flow inappropriately up into the esophagus they bring acid from the stomach. As the acid irritates the tissue inside the esophagus, it becomes inflamed and reddened. This is called esophagitis. If the reflux is severe, the stomach contents may go high enough into the esophagus to be aspirated or spilled into the lungs causing choking, color changes, frequent respiratory infections, apnea and/or bradycardia.

  • spitting up frequently (more than 2 times a day);
  • fussy often throughout the day (specifically before, during or after eating)
  • refusing to eat,
  • fighting eating;
  • taking only small amounts of formula or food, regardless of the amount of time since the last feeding;
  • back arching during feedings;
  • bradycardia;
  • choking or apnea during or after eating;
  • skin color turns pale or grayish during or after eating;
  • poor weight gain; and/or
  • requent respiratory infections.

The first line of treatment is usually a combination of positioning and diet changes. For children that do not respond to these, the next step is using medications. This group of drugs are called prokinetic drugs which increases the tone of the LES as well as increasing the speed at which the stomach empties into the small intestine.  For many children with severe GER, acid-reducing products that protect the lining of the esophagus may be useful at decreasing pain. Antacids such as Maalox may be effective, but large and frequent doses are required. Anti-secretory drugs which reduce the amount of acid produced by the stomach are used, such as Tagamet, Zantac, Prilosec, &Prevacid. Children with severe GER resistant to medications, may need surgery. These are most often needed in children who reflux so much that they have failed to grow sufficiently or there is chronic respiratory problems such as repeated aspiration pneumonia. Another group of children who often need this surgery are those who have gastrostomy tubes, as the presence of gastrostomy tubes greatly increases the incidence of GER. Fundoplication is the most reliable way to surgically prevent reflux, and is successful more than 90% of the time. The top of the stomach (the fundus) is wrapped around the LES; this increases LES pressure and also serves as a valve in preventing GER. 


 
Oral Defensiveness- Some children dislike certain flavors, textures, or temperatures of food. They may avoid putting any objects in their mouth, or may ‘mouth’ things, anything, constantly. Many children have had a variety of feeding problems since infancy. They may gag, overstuff, and choke.

  •  dislikes having teeth brushed and/or face washed
  •  has a limited food repertoire and/or may avoid certain food textures – especially mixed textures
  •  will take their food off the fork or spoon using only their teeth, keeping their lips retracted
  •  will gag easily when eating and may only get food down by taking a drink with it
  •  may exhibit signs of tactile defensiveness such as; disliking being touched, avoiding messy play – glue, play doh, mud, sand, finger paints, etc. – , or, may not pick up eating utensil or food with a grasp that involves the palm of his hand

 
Failure To Thrive– Failure to thrive (FTT) is defined as a child with deficiencies in weight and height as compared to age related normals.  Failure to thrive includes children whose weight and height are less than the 3rd percentile or whose weight or height have decreased more than 2 major percentiles 

 
Feeding Tubes- a medical device used to provide nutrition to patients who cannot obtain nutrition by swallowing. The state of being fed by a feeding tube is called enteral feeding or tube feeding. Placement may be temporary for the treatment of acute conditions or lifelong in the case of chronic disabilities. Tube feedings can be initiated for a wide variety of reasons. A feeding tube can be used for bolus or continual feedings.nasogastric feeding tube, or “NG-tube”, is passed through the nares (nostrils), down the esophagus and into the stomach.

gastric feeding tube (or “G-tube,” or “button”) is a tube inserted through a small incision in the abdomen into the stomach and is used for long-term enteral nutrition. The most common type is the percutaneous endoscopic gastrostomy (PEG) tube. It is placed endoscopically: the patient is sedated, and an endoscope is passed through the mouth and esophagus into the stomach. The position of the endoscope can be visualized on the outside of the patient’s abdomen because it contains a powerful light source. A needle is inserted through the abdomen, visualized within the stomach by the endoscope, and a suture passed through the needle is grasped by the endoscope and pulled up through the esophagus. The suture is then tied to the end of the PEG tube that will be external, and pulled back down through the esophagus, stomach, and out through the abdominal wall. The insertion takes about 20 minutes. The tube is kept within the stomach either by a balloon on its tip (which can be deflated) or by a retention dome which is wider than the tract of the tube. (http://en.wikipedia.org/wiki/Feeding_tube)

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