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Confidential
Feeding and ExcretingGastrointestinal Issues during Infancy
Cheryl Cairns, DNP CPNPCommunity Pediatrics
Pediatric Institute
© Cleveland Clinic 2017
DOS Course 20171
• Participants will be able to discuss infant feeding of both
formula and breastfed infants
• Participants will be able to discuss common infancy
gastrointestinal issues
• Participants will be able to discuss red flags that need
further evaluation
Objectives
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• Fourth week development
– Esophagus, stomach, liver and pancreas
– followed by both small and large intestine
• Absorption and digestive functions present at term
• Motor function
– Provided by the enteric nervous system
– 24 weeks but may
– Not be fully functional until approximately 40 weeks
• Hormonal regulation including
– Peptides are present by the end of the first trimester but may not may not be fully distributed until reaching term gestation
• Immune defenses
– Throughout gestation and continue after birth
Gastrointestinal Development
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Gastrointestinal Tract
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• Ingestion
– Consumption of food and other substances through the mouth
• Digestion
– Metabolism in which substances are mechanically and chemically
converted for use
– 1. Cephalic Phase (nervous system is stimulated )
– 2. Gastric Phase (release of gastric juices and pH balancing)
– 3. Intestinal (excitatory and inhibitory reflexes control passage)
• Absorption
– Movement of nutrients and water into circulatory and lymphatic
system
• Excretion
– Elimination of undigested material
•
Gastrointestinal Tract
DOS Course 20175
• Exclusive breastfeeding is recommended for the first 6
month
– Including premature and sick newborns
– Except when precluded by medical contraindications
• Partial breastfeeding refers to the infant receiving breast
milk for some feedings and liquid supplements such as
formula at other times
• Formula feeding refers to use of breast milk substitutes to
provide infant nutrition
Feeding
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• Exclusive breastfeeding for the first 6 months could
– Save 1.3 million lives each year
– Particularly in underdeveloped countries
• Human milk contains just the right amount of fatty acids, lactose, water and amino acids
– Brain development and growth
– Contains most of the nutrients required to sustain the healthy infant for the first 6 months of life
• Breast milk is easy to digest
• Contains antibodies
– Custom-designed to provide the term, preterm and vulnerable infant protection from contagious diseases
– Protects the infant against many noncontagious diseases that develop later in life
Breastfeeding
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• History
– Milk supply nipple / areola assessment
– Colostrum
– Pain / soreness
– Engorgement
– Low milk supply /over-abundant milk supply
– Blistered / cracked/bleeding
– Softer after feeding
– Inverted / flat
– Mastitis / inflammation
– Fever / flu symptoms
– Hydration
– Plugged duct
• Assessment Infant
Assessment of mother
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• History
– Awake, alert, very active, fussy, very passive, sleepy, lethargic
– Feeding behavior, position and latch (visual or verbal)
– Chin indents breast
– Audible swallowing circular movement of jaw
– Nipple confusion
– Cries at the breast
– Falls off breast: during feed, end of feed
– Stays attached and sleeps, no sucking
– Feeds on nipple, not areola
– Lips not flanged
– Cheeks rounded
– Frenulum
Assessment of infant
DOS Course 20179
• Kangaroo care
– South America
– Premature infants
– Benefits for all infants
• Benefits
– Warmth
– Stability of heartbeat and breathing
– Increased time spent in the deep sleep and quiet alert states
– Decreased crying
– Increased weight gain
– Increased breastfeeding
– Improves milk production by the mother
– Parent satisfaction
Skin to Skin
DOS Course 201710
• 20 cal/oz
• Human milk fat
• Lactose
• 70% whey, 30% casein, 9 g/L
• Iron 0.3 mg/L
• Vitamin D 21 IU/L
• 260 mOsm/kg H20
• Contains DHA and AA
Breast Milk
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Standard formula
• 20 cal/oz
• Soy, coconut, sunflower, palm
• Lactose
• 60:40, casein whey 18:82 >15 g/L
• Iron 12mg/L
• Vitamin D 405 IU/L
• 265-300 mOsm/kg H20
• DHA and AA added
DOS Course 201712
• Standard– Similac, Enfamil, Carnation, Store brands
• Soy– Isomil, Prosobee, Alsoy,
• Protein hydrolysates– Pregestimil, Nutramigen, Alimentum
• Elemental– Neocate, Elecare
• Premature– Enfacare, NeoSure
• “Next Step”—older infants and toddler
Formula: Types and Brands
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Formula
https://www.aptaclub.co.uk/fckassets/aptaclub/howmuchtofeed_chart.g
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• Breastmilk with milk supplement– 26 kcal/oz
– 25cc breast milk + 25cc of 32 kcal/oz Similac Natural Care
– 28 kcal/oz– 25cc breast milk + 25cc of 36 kcal/oz Similac Natural Care
– 30 kcal/oz– 25cc breast milk + 25cc of 40 kcal/oz Similac Natural Care
• Breastmilk with powder– 22 kcal/oz
– 3 oz breast milk = ¾ tsp Enfacar
– 24 kcal/oz– 3 oz breast milk + 1 ¼ tsp Enfacare P
– 26 kcal/oz– 3 oz breast milk + 1¾ tsp Enfacare P
– 28 kcal/oz– 3 oz breast milk + 2 ¼tsp Enfacare P
– 30 kcal/oz– 3 oz breast milk + 2 ¾ tsp Enfacare
Recipes for Increasing Caloric Intake
DOS Course 201715
• Definition: Gastroesophageal Reflux Disease
– GER
–Normal physiological process of frequent regurgitation in absence of
pathology
– GERD
–Reflux that causes pathological consequences
• Gastroesophageal reflux (GER)
– Common in healthy infants, in whom gastric fluids may reflux into
the esophagus 30 or more times day
GERD / GER
DOS Course 201716
• Overfeeding
• Weak abdominal muscles
• Immature or weak lower esophageal sphincter
• Slow digestive system
• Allergies
• Lactose Intolerance
• Nicotine lowers the lower esophageal sphincter pressure
GERD Etiology
DOS Course 201717
• Fussiness
• Cough
• Gagging
• Crying during or after a feeding
• Difficulty lying in supine position (sleeping)
• Arching
GERD Symptoms
DOS Course 201718
• Poor weight gain
• Vomiting consistently
• Wheezing
• Stridor
• Persistent cough
• Apnea
• Irritability
• Hematemesis
• Abdominal tenderness, distension
GERD Red Flags
DOS Course 201719
• Positioning
• Infants younger than 12 months of age should be placed
in the supine position for sleep, even if they have reflux
• Smaller feedings often reduces the frequency or quantity
of reflux
• Keep infant upright for 20 to 30 minutes after feeding
• Trial of cow’s milk free diet if breast fed
• Formula change to non-cow milk formula
GERD Treatment
DOS Course 201720
• Medical Management - PPIs
• Pediatric Dosing for Lansoprazole
– Prevacid®
– < 3 months 1.5 to 1.75 mg/kg three times per day
– 3 - 6 months 1.25 to 1.5 mg/kg three times per day
– 7 months to 2 years 1 to 1.25 mg/kg three times per day
• Pediatric Dosing for Omeprazole
– Prilosec ®, and generic form
– < 3 months 1.5 mg/kg three times per day
– 3 - 6 months 1.25 mg/kg three times per day
– 7 months to 2 years 1 mg/kg three times per day
GERD Treatment
DOS Course 201721
Prevacid® (lansoprazole) prescribing information.
http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/020406s075,021428s022lbl.pdf
Prilosec® (omeprazole) prescribing information.
http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/022056s007,019810s091lbl.pdf
• 4 month old female with history of “ fussiness and
spitting”
• Exclusively breastfed until 2 months
• Now supplemented with one bottle of Similac Sensitive
• Breast feeding every 2-3 hours during the day and up
more frequently at night
• Infant was 7 lbs 2 oz at birth now at 9 lbs
• Mom states “ I just don’t know what to do anymore”
• What is your assessment and plan?
Case Study # 1
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• Definition
– Infrequent bowel movements are passed
– Painful defecation
– Passes large caliber and hard stools that
– Excessive straining
• Etiology
– Inadequate hydration
– Low-fiber diet
– Slow intestinal transit
– Minimal activity level or inactivity
– Behavioral
Constipation
DOS Course 201723
• Straining
• Stool
– Formed and hard like small pebbles
– Soft and mushy
– May even be wide and large
– Liquid stool (like diarrhea) may pass out around hard stool
• Infrequent stools that are difficult to pass
• Abdominal distention
• Fussiness
Constipation Symtoms
DOS Course 201724
Stool Consistency
http://www.chikd.org/upload/thumbnails/ckd-19-1-1f2.gif
DOS Course 201725
• Delayed passage of meconium
• Loss of weight or failure to gain weight
• Bloody stools
• Severe abdominal distention
• Perianal fistula
• Absent anal wink
• Sacral dimple
Constipation red flags
DOS Course 201726
Dietary changes
• Fruits and vegetables
• Increase fiber
• 1-2 oz fruit juices (prune, pear)
– Juice is not recommended routinely
• Oatmeal or barley cereal
– Rice cereal can cause constipation in some children
• Education
• Behavioral management for children
Constipation Management
DOS Course 201727
• Mediation
– Miralax - polyethylene glycol is an osmotic laxative
– Polyethylene glycol works by retaining water in the stool, resulting
in softer stools and more frequent bowel movements
– Polyethylene glycol does not affect glucose or electrolytes in the
body
• Clean out
– High dose oral laxatives
– PEG 1-1.5 g/kg/day x 3-6 consecutive days
• Maintenance therapy
– Lower dose PEG 1 g/kg/day
– 1-2 months
– d/c when no more hard stools or withholding behavior
Constipation Treatment
DOS Course 201728
• Four week old male 32 week premie
• Breastfed exclusively
• Was stooling every 2 hours yellow seedy
• Now stooling every 5 days
• Mom has noticed straining over the past week and today
noticed blood in the stool
• What is your assessment and plan?
Case Study #2
DOS Course 201729
• http://pediatrics.aappublications.org/content/136/3/596
• http://pediatrics.aappublications.org/content/early/2013/04
/24/peds.2013-0421
• http://www.naspghan.org/files/documents/pdfs/cme/jpgn/
Evaluation_and_Treatment_of_Functional.24.pdf
References
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DOS Course 201731