Rosen & Barkin's 5-Minute Emergency Medicine Consult (266 page)

• A well-hydrated, comfortable child with a normal physical exam and recent history of good weight gain may not need any ED workup beyond assuring good follow-up.
  
• Children who show evidence of distress, dehydration, discomfort, respiratory distress, or poor weight gain require further evaluation.
  

• Initial assessment if child failing to thrive or appears malnourished:
  
  • CBC, urinalysis, electrolytes, BUN, glucose, erythrocyte sedimentation rate (ESR) and/or CRP, thyroid functions, LFTs, total protein, and albumin
    
• Cultures of blood, urine, if concern of infection—CSF analysis and culture if concern for meningitis
  
• Serum NH3, urine for organic acids, and blood for inborn errors or metabolism if concern for metabolic disorders
  

• CXR if suspected cardiopulmonary concerns
  
• EKG if cardiac disease suspected
  
• Referral or admission for ultrasound and other imaging studies as indicated. Fiberoptic or videofluoroscopic evaluation of swallowing may be needed.
  
• MRI if concerns for brainstem, skull base, or spinal problems
  

• May need a multidisciplinary evaluation involving speech pathologist, pediatrician, and potentially an otolaryngologist.
  
• Surgical correction of specific pathology
  

Feeding disorder encompasses symptoms observed as a final pathway for many disorders.

Specific clues to the etiology may include:

• Prolonged feeding, fatigue:
  
  • Consider cardiac disease.
    
• Recurrent pneumonias:
  
  • Consider chronic aspiration.
    
• Stridor with feeds:
  
  • Consider glottic or subglottic anomalies.
    
• Suck–swallow–breathing coordination:
  
  • Consider nasal congestion, choanal atresia.
    
• Vomiting, diarrhea, abdominal pain, colic:
  
  • Consider allergy or GER.
    

TREATMENT

• Assess vital signs and hydration; resuscitate as necessary.
  
• Assess for and treat hypoglycemia.
  

• Cardiovascular/respiratory/fluid resuscitation as needed
  
• Assess for and treat hypoglycemia if suspected.
  

• Treat dehydration if present:
  
  • Oral rehydration if practical
    
  • IV if PO contraindicated, not tolerated, or impractical
    
• Ondansetron for acute vomiting
  
• Treat respiratory distress if present:
  
  • Nasal suction to clear secretions prior to feeding may be very helpful in young infants with URI/bronchiolitis symptoms
    
  • Oxygen and other interventions as needed
    
• Treat infection if suspected.
  

Ondansetron: 0.1 mg/kg IV or PO q8h PRN nausea or vomiting—min. oral dose 2 mg, max. dose 4 mg:

• Monitor if patient at risk of QT prolongation
  
• For short-term use (2–3 doses) in patients >6 mo.
  
• Review FDA black box warning re QT prolongation
  

FOLLOW-UP

• Suspected systemic infection
  
• Inability to maintain hydration
  
• Sustained hypoxia during feeding
  
• Significant failure to thrive:
  
  • Particularly in infants <3 mo
    
• Decompensated cardiopulmonary disease
  
• Symptomatic anemia or endocrine dysfunction
  
• Negligent or overwhelmed caretaker
  

• Demonstrated ability to tolerate oral feedings
  
• Weight gain if failure to thrive
  
• Reliable caretaker and follow-up
  

• Specific referrals based on source of problem
  
• For complex or chronic feeding problems, a multidisciplinary approach is often needed.
  
• Chronic disease process may interfere with feeding AND increase caloric needs:
  
  • Nonoral nutrition such as percutaneous endoscopic gastrostomy (PEG) tubes are often needed to address these issues.
    

• When available, a primary provider is the most important resource for follow-up.
  
• In the case of complex problems, a multidisciplinary approach is often needed—the primary provider is often in the best position to coordinate this.
  

• Successful feeding in infants requires coordinated, effective interaction of complex physiologic, developmental, and environmental factors.
  
• The factors are interdependent—disruption of 1 often leads to disruption of others:
  
  • Premature infant gavage fed for immature suck–swallow coordination, misses critical period for developing this reflex—develops aversion to oral stimulus because of recurrent noxious stimuli.
    
• Feeding problems of recent, acute onset are likely to have a single identifiable cause:
  
  • Gastroenteritis, pyloric stenosis, pharyngitis, sepsis
    
• In an infant with upper respiratory symptoms the answer may be as simple as vigorously suctioning the nose to effectively clear it immediately before feeding
  
• More chronic, long-term problems are more likely to have multifactorial and/or subtle causes:
  
  • Feeding is an essential part of the parent–child interaction:
    
    • Dysfunctional interaction may be the cause of or a response to a feeding problem.
      
• Chronic feeding issues of medical origin may result in continued behavioral feeding difficulties even after the medical problem is corrected.
  
• Swallowing disorders and aspiration are frequently occult.
  

• Arvedson JC. Assessment of pediatric dysphagia and feeding disorders: Clinical and instrumental approaches.
  Dev Disabil Res Rev
  . 2008;14(2):118–127.
  
• Bernard-Bonnin AC. Feeding problems of infants and toddlers.
  Can Fam Physician
  . 2006;52(10):1247–1251.
  
• McDevitt, Barbara E. Vomiting, spitting up, and feeding disorders. In: Baren JM, Rothrock SG, Brennan JA, et al, eds.
  Pediatric Emergency Medicine
  . Philadelphia, PA: Saunders-Elsevier; 2008:319–327.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Failure to Thrive
  
• Feeding Tube Complications
  
• Inborn Errors of Metabolism
  
• Intussusception
  
• Irritable Infant
  
• Malrotation
  
• Pyloric Stenosis
  
• Vomiting, Pediatric
  

CODES

• 779.31 Feeding problems in newborn
  
• 783.0 Anorexia
  
• 783.3 Feeding difficulties and mismanagement
  

BASICS

• Extubation:
  
  • Accidental or intentional
    
  • More common with nasoenteric tubes compared with percutaneous endoscopic gastrostomy (PEG) tubes, gastrostomy tubes (G tubes), or jejunostomy tubes (J tubes)
    
• Occlusion:
  
  • Small diameter:
    
    • Most common with nasoenteric tubes
      
  • Pill fragments
    
  • Inadequate flushing
    
  • Physical incompatibilities between formula and medications:
    
    • Adherence of formula residue to inner wall
      
  • Essential to rule out malposition, fracture, and dislodgment
    
• Peristomal wound infections:
  
  • Risk factors:
    
    • Malnutrition
      
    • Stomal leak
      
    • Local irritation
      
    • Poor wound care
      
    • Immunosuppression
      
    • Diabetes mellitus
      
    • Poor wound healing
      
    • Obesity
      
  • Excessive traction on tube:
    
    • Leads to delayed maturation of gastrocutaneous tract
      
    • Increases stomal leakage
      
• Stoma leak:
  
  • Problematic with distal obstruction (mechanical or dysmotility); more common with high gastric residual
    
  • Excessive tube motion
    
• Aspiration pneumonia:
  
  • At risk:
    
    • Impaired cough/gag reflex
      
    • Delayed gastric emptying from ileus
      
    • Obstruction
      
    • Gastroparesis
      
    • Gastroesophageal reflux (frequent with large nasoenteric tube)
      
• Diarrhea:
  
  • Medication induced:
    
    • Antibiotics
      
    • Promotility agents
      
  • Overgrowth of
    Clostridium difficile
    , other bacteria, or
    Candida
    
  • High osmolar formula
    
• Feeding intolerance:
  
  • High residual suggests GI motility dysfunction
    
  • Delivery is too rapid
    
  • High osmolarity formula
    
  • Lactose or fat intolerance
    
  • Low serum albumin
    
• Uncommon complications:
  
  • Abdominal wall hematoma
    
  • Fistulas:
    
    • Hepatogastric
      
    • Gastrocolic
      
    • Colocutaneous
      
  • Perforation (usually with placement)
    
  • Pressure sores/ulcerations
    
  • GI bleeding
    
    • Esophagitis, gastric pressure ulcers, concomitant PUD
      
  • Gastric outlet obstruction
    
    • Partial or complete obstruction at the pylorus or duodenum by part of tube or Foley catheter balloon used for temporary replacement
      
  • Buried bumper syndrome
    
    • Rare but potentially serious
      
    • Bumper becomes lodged between the gastric wall and skin due to gastric ulceration from excessive tension
      
  • Bowel volvulus around PEG tube