We (me and a dietician) recently saw a medically complex child with who was refusing her bottle. Her mother expressed extreme frustration with feeding time stating that she had to sing and dance in order for her child to take her bottle. Bottles took 45 minutes to an hour with frequent refusals and pulling off of the nipple. It was so exhausting she had returned to NG feeds for the last feed of the day .
We watched her eat. Mother presented the bottle and she drank 4 ounces beautifully before stopping. Mother said, “she never eats like this.” When probing further, this child had not eaten for 5 hours. Mother had held a feed in anticipation of the feeding team appointment. This often happens, children eat well in the clinic because their feeding time is delayed and they are hungrier or empty and more willing to accept volume of food or liquid.
This child’s typical feeding schedule was 5 feeds of 4 1/2 ounces of formula every 3 hours with purees first at 3 of the meals. Last formula volume was given via NG tube over an hour due to parent exhaustion.
What does this tell us about this child- Perhaps?
- this child needs more time between feeds to empty and develop hunger.
- this child has slow gastric emptying or delayed motility in the digestive tract.
- is being pushed with volume and it is contributing to oral aversion
- is uncomfortable with volume of oral intake.
Further discussion revealed that the child is not stooling every day and appears to be getting constipated which might be contributing to poor interest in feeding and refusal as well as slower motility. A trial off of reflux meds preceded the oral aversion and refusal. His formula is also higher calorie which might be causing difficulty in tolerance or perhaps he calorie limits?
Recommendations are often trial and error. We felt we would rather see 3 good feeds than 4 hard feeds. we recommended a new feeding schedule: 3 oral feeds of 4-5 oz allowing 4 to 4 1/2 hours between feeds, a 4th feed will be given via his NG over 2 hours and will make up the caloric volume needed. This feed will be given at bed time. Child will resume reflux meds and small amount of prune or pear juice will be used to obtain a daily stool. We stopped the puree feeds for 2 3- days to try the new schedule and then recommended adding in 1 puree feed per day until the next clinic visit. If there is no improvement, we will consider reducing the caloric density of the formula, adding in a medicine for motility or appetite, or changing the formula to something more elemental.
Other thoughts on manipulating feeding schedules to encourage intake:
- If children are grazing or frequently snacking throughout the day, trying implementing some structure to meal time by asking parents to not offer food 1 to 1 1/2 hours before a meal.
- A child who is feeding frequently at night at the breast or getting bottles might have poor appetite in the morning. If it is age appropriate and the child typically would not be eating at night, try slowly reducing and eliminating the night time feeding without compromising weight gain.
- Children who drink Pediasure or a high calorie supplements at meals may be filling up or even holding out for the formula which is often very sweet and subsequently not eating food. Try offering smaller amounts of the supplement after food is presented. For example, if a child needs 16 oz of a supplement, try offering it in 4 ounce volumes instead of 8 ounces at meal time which can be filling.
- Supplements: Another consideration is to offer the supplement at the hardest meal. Some of our kids present with total refusal to eat at school or daycare, places where there may be no ability to carry out feeding therapy plans.This might be a good time to offer the supplement, and caregivers can carry out therapeutic feeding goals at meal time.
- For children who are tube fed: we often try to manipulate tube feeds to allow for a significant period of time off of the tube or use small bolus size to allow the child to develop hunger and appetite.