Infant Feeding (Part 3)

Posted on March 1st, 2013 by Denise | No Comments

Infant Feeding (Part 3)

By

Denise Koonce OTR

 How much if any is the baby spitting up, when are they spitting up in relation to the feed, and is the spit up curdled or liquid?  If an infant is spitting up it is useful to know the time line.  You want to know when they are spitting up in relation to the feed because it can provide you information regarding how their digestive system is working.  It is normal for infants to spit up, at times, after a feeding.  During the process of nipple or bottle feeding it is inherent for the infant to also swallow air.  In order to release or expel the air it is customary for the caregiver to help the infant to burp.  Sometimes in the process of burping the infant will also spit up a teaspoon or so of formula, which is within normal limits.  Infants will experience this because their tone at birth is still maturing and will continue to do so until about 3 months of age.  It is during this same time period that the infant is moving out and away from their flexed position and learning to move into extension and against gravity.  Tone is what helps our muscles and body stay alert and upright with the skeletal system and is throughout the body including our esophagus, stomach and intestines.  It also has a role in keeping the lower esophageal sphincter closed unless the infant needs to burp and helps to maintain an internal pressure gradient stasis to aide in digestion.  Until about 3-4 months of age it is also normal for an infant to spit up if they cough, strain, or cry because their tone in still maturing.   Another contributing factor can be the infant’s prominent horizontal position which can make it easier for contents of the stomach to reflux back into the esophagus.   If an infant is spitting up significant amounts of formula during the feeding, immediately after the feeding, several minutes following a feeding or from simply being moved, this could be a sign of a more significant problem and should be evaluated by a physician.  If these symptoms exist, they could be an indicator of transient lower gastroesophageal sphincter relaxation which is a primary cause of gastroesophageal reflux disease (GERD).  If they are spitting up immediately following their feeding it can be because of reflux and the lack of internal tone needed to keep the lower esophageal sphincter closed.  This can be especially true for infants born premature because of the lack of tone maturity in their body overall.  The lack of tone can affect the lower esophageal sphincter from staying closed especially when pressure builds up in the stomach.  For these patients it is important to educate and direct the parent to not move or even burp the patient right after a feed.  If they spit up over an hour after they feed and its appearance is unchanged or minimally changed and not curdled then their stomach may be slow to emptying and slow to begin the digestive process.  The stomach should begin digestion and move the food into the small intestines and be essentially empty within sixty to ninety minutes after the initiation of the feed.  So if the infant is spitting up liquid or liquid and curdled formula after this time period the physician should be made aware.

Is the infant unable to burp?  For children with severe reflux and vomiting or gastroesophageal reflux disease (GERD) a surgical procedure, called a fundoplication, is an option.  This surgical procedure takes the upper part of the stomach, wrapping it around the lower part of the esophagus including the lower esophageal sphincter; it is then sutured in place preventing the contents of the stomach from traveling back up the esophagus.   This same procedure also prevents the infant from burping, so air and gases have to travel through the body and exit through the lower digestive track.  It is important to note that a fundoplication is a mechanical barrier in preventing the contents of the stomach from refluxing (backward movement) into the esophagus but it does not correct the internal abdominal pressure gradients, tone or any physiological diagnosis of increased acid production or milk protein allergies that might disrupt the normal stomach environment during digestion.  When a patient has severe gastroesophageal reflux disease (GERD) and has the presence of a fundoplication the patient may continue to exhibit gagging and retching without reflux of the stomach contents but the stomach environment can continue to cause discomfort for several reasons.    Many times it is in relation to the digestive process itself and involves the chemicals the body produces to initiate digestion of which their bodies either over produce or under produce.  It is important that the child be evaluated by a gastrointestinal physician to determine if medication is warranted to decrease these symptoms.     

How many bowel movement do they have a day and what is the consistency?  Are they passing a lot of gas?  How long after a feed before their bowels move?  Are they experiencing diarrhea or constipation?  This information gives you an idea of how their small and large intestines are working.  A full term infant (0-3 months) should have 6-9 wet diapers a day and 4-5 dirty diapers a day and will vary in consistency depending on whether or not they are receiving breast milk or formula.  If the infant is having ongoing excessive gas and fussiness, diarrhea, or bloody stools then they should be evaluated by their physician. 

Working with infants who have feeding difficulties and their families is very rewarding but it requires looking at the details to best “put the pieces together.”  Over the last few blogs we have discussed some of the details that go into the initial and ongoing assessment of an infant with a feeding disorder.  From these details and additional observations you can begin to formulate a successful treatment plan.   However, a therapist is only one part of the team, and I want to reiterate how important it is to also have open lines of communication with the medical team involved in the infant’s formula selection and feeding method.  Together, along with the parents, you can assist the infant, in what should be an enjoyable early bonding experience; feeding and therefore thriving.  If you have additional questions or details that you focus on during the assessment of a patient with feeding difficulties please share them with us.

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