CBL: Growth and Feeding Flashcards
What further questions to ask in Hx of problems related to poor feeding
- , feeding regime what and how often
- any other symptoms associated with feeding/after feed
- general medical condition of a child
- recent infections
- how are feeds tolerated?
- Maternal post-natal mental and physical condition
- child’s development)
- consider partent-child interaction
- feeding environment
- suckling reflex of a child, child’s interest in eating
What on the growth chart defines a ‘failure to thrive’?
Failure to thrive: fall in 2 centiles
Potential differentials for ‘feeding difficulties’
Potential differentials:
- change in feed (e.g. change from breast to bottle) -> cow’s milk protein intolerance (comes with diarrhoea of increased frequency)
- Cow’s milk protein intolerance – diarrhoea increased in frequency, loose stool (no blood in it), often when switched from a breast to bottle; it is chronic inflammation, no IgE - mediated
- Reflux – e.g. when a baby cries after having a feed (relationship with feed)
Cow’s milk protein allergy
- management
- prognosis
- Try different formula (e.g. partially hydrolysed formula) -> and see if better; if massively better then do not re-challenge with normal milk; if not massively better -> re-challenge with normal milk (as we do not want to keep them on formula unnecessary as it’s expensive and on prescription)
Prognosis: most will grow up of it below 2 y old, some after up to 5y old) -> gradually introduce dairy products (iMAP Milk ladder) -> to gradually build up the tolerance
Sometimes, mum will breastfeed and ingest dairy, and it affects hypersensitive baby – mum will need to stop dairy for the period of breastfeeding
General approach to the management of feeding difficulties without any obvious cause
- Ask a carer/parent to _keep a diary r_ecording food intake (amount and type) and mealtime situation (e.g. setting, behaviours)
- Encourage lifestyle changes: enjoyable mealtime environment, eating together, allowing a child to be ‘messy’ with their food etc.
- Formula supplementary feeding (but any available breast milk should be encouraged to use for feeding before use of formula)
- Short-term use of energy-dense food
- Referral to a paediatric dietician
- Oral liquid nutritional supplements -> for infants with faltering growth despite other interventions
- Monitor
- Other investigations: UTI, celiac etc
Pathological vs non-pathological causes of ‘feeding problems’
Try to distinguish between pathological and non-pathological causes:
- Non-pathological: overfeeding (help from dietician, health visitor) -> if growth parameters are all big and baby is big
- Pathological: genetic syndromes, endocrine problems -> if growth parameters are different (e.g. big head, low weight)
What does usually happen to the weight of a baby shortly after birth?
Baby will drop on weight at the beginning due to loss of connection with the placenta, fluid, meconium etc. therefore wight can drop slightly (up to 10%) after birth
Hx of an ‘unsettled baby’; what further questions to ask?
Unsettled baby:
- What exactly does a mum mean by ‘unsettled’?
- Time of being ‘unsettled’
- When does he start getting ‘unsettled’?
- What would stop him?
- What would trigger?
What volume of feeds is considered as normal?
120-150ml/kg/day (24 hours)
(1 ounce = 30mls)
Approach and management to a reflux in baby
Reflux treatment:
- Feed in small amounts/volumes -> more often
- Position during feeding
- antireflux milk – but not the most effective
- Drugs: PPIs (Omeprazole), Ranitidine, Gaviscon
Drug treatment: usually at presentation, a thickener was already tried -> acid suppression needed BUT…
…Try to avoid drugs at first -> may suggest weaning -> even below 6 months -> if 3-4 months try to feed with solids
If below 3-4 months -> acid suppression
(for exam purposes: try solids only when child is 6 months, before acid suppression)
What may be a cause of a weight drop and persistent diarrhoea in a baby after having gastroenteritis?
Management
- damage to baby’s intestine mucosa -> enterotoxins destroyed villi à secondary lactose intolerance (baby not able to digest a lactose)
Management: consider lactose-free milk
A lethargic but normal weight 16 months old vegetarian girl
Differentials
- Anaemia -> e.g. due to iron deficiency
Ask about: diet, supplements, milk
*a girl in this history drinks A LOT of milk (and she is a vegetarian, not much iron rich foods) -> milk is OK for calories but does not have iron
- leukaemia -> need to think of it due to iron deficiency, ask for bruising
What do we see ‘blood wise’ in leukaemia?
Leukaemia picture:
- anaemia
- thrombocytopenia
- blasts and abnormality (low or high WBCs)
Are the bloods helpful in the diagnosis of lymphoma?
Lymphoma: bloods are not that helpful -> look at lethargy, night sweats, lymphadenopathy
Growth Chart
What do we do in terms of a pre-term infant (<37 weeks)?
- Plot measurements using gestation-adjusted age
For preterm infants of less than 32 weeks gestation there is a specialist “low birth weight” chart which should also be used for other infants requiring special care in the early weeks
Look how a 33 week old newborn’s weight is plotted on the chart
Look at the picture: how to plot on a growth chart for a pre-term baby
