Author: Krisi Brackett Ms SLP/CCC
A 2 year old boy with a genetic disorder, difficulty gaining weight, a gastrostomy tube, and a constantly runny nose was seen by a feeding specialist at the request of his mother for refusal to eat by mouth.
Initial evaluation: The child?s medical history, physical exam, and observation of movement and function, revealed the following;
Immature Oral-motor Skills: The patient was able to move his lips, tongue, and cheeks normally. When eating, he used a sucking pattern and mashed food using his tongue, which is a pattern that 8 ? 9 month old infants use to eat food.
Gastroesophageal reflux, stomach discomfort, and gagging and retching: The patient had a history of gastroesophageal reflux (spitting food or liquid back up) and poor eating. At 6 months of age, he had surgery for reflux called a nissen fundoplication where they tighten the top of the stomach to stop food or liquid from going back up. He also had a feeding tube (g-tube) put into his stomach because he wasn?t eating enough to gain weight and grow. The patient was fed 8 ounces of Pediasure 4 times each day through the tube and was very uncomfortable during feedings. His mother said that he often gagged, retched, and even vomited during tube feedings and that this had been happening since 6 months of age.
Chronic nasal and upper airway congestion: He had a constantly runny nose, redness around the eyes and sometimes had upper airway congestion.
Refusal to eat: Except for tasting (but not swallowing!) dry salty foods once in awhile, the patient refused to eat.
Intervention:
1. GI Intervention: Several changes were made to make his stomach more comfortable. First, his formula was changed to Peptamum jr., a broken down whey protein formula made by Nestle and secondly, the delivery of his tube feedings were slowed down. His tube feedings were switched to continuous at night over 12 hours. His doctor added zantac to help make the patient?s stomach more comfortable.
Result: These changes immediately stopped his gagging and vomiting. The patient tolerated his feedings better and even became more interested in foods. His runny nose got better as did the redness around his eyes.
2. Behavioral Intervention: The patient began feeding therapy twice a week to improve his ability to accept foods and swallow them. A structured feeding plan was started where they patient would sit in a high chair and whomever was feeding him would give him a bite of food which was followed by a reward (clapping, toys). This was done for a certain number of bites, always with a reward if he took the bite of food.
Result: Because the patient?s stomach felt better, he responded well to the structured feeding technique. In 3 months, he has gone from taking a plain spoon with no food for a prize to taking 4 ounces of pureed food. His parents practice at home 3 times per day.
3. Oral-Motor: Since the patient was using a sucking pattern and had food stick to the top of his mouth or his teeth while eating, during his structured feeding, the bites of food were placed into the sides of his mouth, which made his tongue move from side to side. This helped change his sucking pattern so that he could start to move his tongue around more in his mouth.
Result: He no longer had food stuck to the top of his mouth during meals.
Follow-up: This patient continues to do well in therapy and is able to eat more food each week. Now that he is eating 3 ?4 ounces per feeding session, we are adding variety (2 different foods per meal) and a cup with a taste on it (to start him accepting a cup with a taste to his lips for a reward). The reward is now given after 2 bites.
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