Feeding Intolerance in Children with Severe Impairment of the Central Nervous System: Strategies for Treatment and Prevention
2. A Framework
- Problems with tests that are “fixable”: urinary tract infection (UTI), acute pancreatitis, cholecystitis, nephrolithiasis, volvulus, helicobacter pylori.
- Problems with tests that can be modified and empirically managed: GERD, dysmotility.
- Problems without tests due to the altered nervous system that can be modified, require empirical trials, and can remain intractable: autonomic dysfunction, altered enteric nervous system, visceral hyperalgesia, central neuropathic pain, altered vomiting center in the medulla.
- Problems due to a wide range of needs in the same group of children: calorie and fluid estimates.
3. Testable Causes
4. Causes Due to the Altered Nervous System
4.1. Visceral Hyperalgesia and Central Neuropathic Pain
4.2. Autonomic Dysfunction
4.3. Emetic Reflex and Vomiting Center
- Limited movement of extremities at baseline.
- A decrease in movement following improvement in symptoms (increase in baseline tone and movement are common features associated with pain) .
- Hypothermia due to impaired central regulation of body temperature.
- Gradual decline in activity when there is a decline in function and health over months to years.
6. Empirical Trials
6.1. Medication Trials
6.2. Home Care Plans
- Presenting symptoms (vomiting, retching, pain).
- Initial routine interventions (vent G-tube).
- Interventions for triggers due to GI tract distention (use as-needed suppository, use enema if no results within 1-h of suppository, hold feeds for 2 h, hold feeds and give electrolyte replacement overnight, reduce total feeds/fluids).
- Use of as-needed medications (options include as needed antacid, ondansetron, clonidine, or benzodiazepine).
- When to call (call the clinic during the day or the on-call clinician after hours if symptoms persist despite use of the interventions outlined).
- Vent G-tube, hold use × 2 h.
- If no stool that day, give fleet enema.
- Give pedialyte at 40 mL/h × 4 h, then 70 mL/h × 24–36 h.
- Give acetaminophen every 4–6 h × 3–4 doses.
- Use morphine as needed, as often as every 4 h.
- Update team.
7. Acute on Chronic Symptom Events
- “Most recent tests have been negative, and I have the option of increasing the dose of his gabapentin or clonidine (I have the option to add a medication that targets the same symptoms in a different way). It might make sense to adjust medications while considering tests. You know your son best and I want you to feel comfortable with the plan. What makes best sense to you at this time?”
- “I imagine this is hard as I talk about sources that can be improved but not fixed”.
- “It must be hard as I talk about his nervous system being a reason for these symptoms when I don’t have a test to tell you with certainty. What are your thoughts as we discuss this information?”
8. Intractable Feeding Intolerance and Features at End of Life
Conflicts of Interest
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Milk of Magnesia
|Colonic distention from constipation can trigger pain symptoms due to visceral hyperalgesia and central neuropathic pain|
|H-2 blockers and PPIs|
Protective barrier: sucralfate
Promotility drugs: erythromycin, metoclopramide
Jejunostomy feeding tube
|Motility disorders can be a result of impaired input from the CNS to the enteric nervous system|
Suggested by bloating, distension, retching, vomiting, discomfort
Other problems can contribute, including constipation and pain
|Vomiting reflex||Medications that block the 5HT-2, 5HT-3, H-1, Ach, and D-2 receptors|
Cyproheptadine (5HT-2, H-1, Ach)
|Suggested by retching, forceful vomiting, and associated symptoms of sweating, pale skin, and appearing distressed|
|Visceral hyperalgesia, central neuropathic pain||Gabapentin|
|Suggested by pain, retching, and emesis associated with feedings, intestinal gas, flatus, and bowel movements|
|Suggested by pain and emesis associated with tachycardia, hyperthermia, diaphoresis, and skin flushing|
Neostigmine or pyridostigmine
|Suggested by recurrent episodes of abdominal distension, pain, emesis, and severe constipation, in the absence of mechanical obstruction|
|Treat constipation||Minimizes colonic distension and further slowing of motility|
|Assess for over-feeding||Children at highest risk: intermittent hypothermia, minimal movement of extremities, decreased movement following symptom reduction, gradual health decline|
Initiate 30% reduction and monitor for 2–4 weeks
|Review bolus volume and feed rate||Suggested guidelines: bolus < 15 mL/kg per bolus, continuous rate < 8 mL/kg/h [ 34]|
|Review osmolarity of feeds||Minimize use of elemental formulas or dilute, use additives to add calories without adding osmotic load (microlipid)|
|Gastric acid reduction and protective barrier: H-2 blockers, PPIs, sucralfate, antacids||Consider 8–12 weeks treatment course: chronic use of PPIs associated with
Clostridium difficile, small bowel bacterial overgrowth, pneumonia, bone fracture, and hypomagnesemia|
Anticipate gastric acid rebound when a PPI is stopped; consider managing with short-term use of antacids or H-2 blocker
|Gabapentin, pregabalin||Treatment of visceral hyperalgesia and dysautonomia|
|Tricyclic antidepressant||Treatment of visceral hyperalgesia and central neuropathic pain|
|Clonidine||Treatment of symptoms due to dysautonomia|
|Cyproheptadine||Blocks receptors that trigger the VC (5HT-2, H-1, and Ach)|
|Ondansetron||Blocks receptors that trigger the emetic reflex (5HT-3)|
|May improve gastric emptying and intestinal motility|
No clear benefit of one over the other
Limit use of metoclopramide due to risk of dystonic reaction and lower seizure threshold
|G-tube venting and equipment that allows venting during feedings||Minimizes gastric distension and associated discomfort|
|Gastrojejunal tube (GJ-tube)||Lessens gastric distension|
G-tube venting possible while feeding through the J-tube
GI pain may not improve with J-tube feedings
|Soy, partially hydrolyzed, or elemental formula||Management of protein hypersensitivity|
Higher omolarity with elemental formula
|Select antibiotics||For Helicobacter pylori identified by stool antigen or endoscopy, or empirical trial for small bowel bacterial overgrowth|
|Anti-reflux surgery (fundoplication)||Consider empirical medication trials for problems outlined above before elective surgery|
Some children will develop retching, bloating, and pain following fundoplication
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Hauer, J. Feeding Intolerance in Children with Severe Impairment of the Central Nervous System: Strategies for Treatment and Prevention. Children 2018, 5, 1. https://doi.org/10.3390/children5010001
Hauer J. Feeding Intolerance in Children with Severe Impairment of the Central Nervous System: Strategies for Treatment and Prevention. Children. 2018; 5(1):1. https://doi.org/10.3390/children5010001Chicago/Turabian Style
Hauer, Julie. 2018. "Feeding Intolerance in Children with Severe Impairment of the Central Nervous System: Strategies for Treatment and Prevention" Children 5, no. 1: 1. https://doi.org/10.3390/children5010001