Thursday, 23 July 2015

Feed histories in refluxy babies

Over feeding?  Is that really a thing?

One of the questions that I asked most often is “where do I start when treating reflux in babies?”  This assumes two things.  The first assumption is that it is reflux that you are dealing with and second is that you want to treat it.  Each of those assumptions is worth articles of their own, so I may come back to those two issues at a later date.  However, if we are going to start our treatment somewhere, let’s start as always, by doing as much nothing as possible.  The place to start is by taking a feeding history.


I would like to say now that I do not like the term over-feeding as I feel it implies blame if it is heard in a critical way.  I don’t have a better term (yet) and it is commonly used so it will have to do.  Over-feeding is the phenomenon seen in many babies which involves them taking considerably more milk than they need or can keep in their stomachs.  As a result of this their stomachs are distended enough to cause them pain and are likely to have distressing regurgitation.

Why does this happen in some cases?  Because: the understanding between a baby and the person feeding them is that if the baby cries, that might be because they are hungry.  As a result, they are offered a feed.  Babies are fairly reflexive about feeding and so may suckle even when not hungry, leading to overfeeding.  Being overfull, they will find that they are not comfortable.  They need to let someone know about this unsatisfactory situation and so they cry, at which point someone may offer them a feed.  This is called the feed-cry cycle.

The NICE guideline ‘gastro-oesophagealreflux disease (GORD) in children and young people’ (NG1) acknowledges the possibility that a reduction in feeds might help in their recommendations:

In formula-fed infants with frequent regurgitation associated with marked distress, use the following stepped-care approach:
  • review the feeding history, then
  • reduce the feed volumes only if excessive for the infant's weight, then
  • offer a trial of smaller, more frequent feeds (while maintaining an appropriate total daily amount of milk) unless the feeds are already small and frequent, then
  • offer a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum). (1)


The devilment is however most definitely in the detail…
If we are going to be scientific about this we need to define our terms.  What is an excessive volume of feed?  Ooh, I know the answer to this one…  Nobody knows.  What we do have is a consensus that approximately 150ml/kg/day is a ‘normal’ amount.  The thing about norms is that they tend to have standard deviations and no one knows what that number is either.  So where does that leave you?

I have read through the detail of the full NICE NG1 guideline in the hopes of finding the answer and there is no centile chart of feed volumes, since one doesn’t exist.  Instead we are left with the responsibility of deciding for ourselves.  My approach is to take the feed history and calculate the volume of formula milk fed thus:
  1. No of fluid ounces taken on average per feed x 28 equals mls of milk per feed
  2. mls of milk per feed x average daily number of feeds equals daily intake in mls/day
  3. Daily intake divided by weight (Kg) gives feed volume by weight in mls/Kg/day

If I believe that the child has GORD and the feed volume is quite a lot more than 150ml/kg/day then I will recommend a trial period of reducing the daily feed volume to 150ml/kg/day and make sure that no one feed is greater than 30ml/kg.  If they get better, it might be by random fluctuation or it might be my intervention.  Either way the child is better.  If they don’t get and stay better, I move on to the next intervention.

You might notice that I still haven’t given you a number that would qualify as “excessive for the infant's weight.”  Well spotted.  Please let me know if you find one that is evidence based.  In the meantime I will continue to believe that my number is correct.

Edward Snelson
Senior Spitilomancer
@sailordoctor

Disclaimer: You can't trust my number.  I came up with it by throwing three darts at a dart board.  It was a very good score though.


If you found this helpful you might also like to read:

Why I need GPs to be medical leaders (Easter egg - GORD in babies)


References:
  1. NICE guideline ‘gastro-oesophagealreflux disease (GORD) in children and young people’ (NG1) 

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