by AliRae

Hi all! I'm currently working as a pediatric nurse on board a charity hospital ship in West Africa. We've currently got a little baby who had a massive teratoma removed from her left jaw (adherent to the mandible and carotid, but fully dissected). I think the tumor weighed around 700g, leaving us with a weight for her of around 2.75kg (weighed on a produce scale from the galley because we don't have a baby scale at the moment!)

The anatomy of her mouth is quite deformed - her tongue is curled and the side of her jaw is weak, so she's really pokey at bottle feeding, and tends to aspirate quite a bit. We're trying to get her on a feeding schedule that will allow her to be discharged home without the NG tube she currently relies on, but we can't seem to get her to gain any weight. We also don't have a pediatrician at the moment, so we're kind of making things up as we go along.

Currently, shes on Q3 feeds of fortified EBM, 50 mL per feed during the day, 70 mL at NOC. We bottle every other and rest her on the off feeds. Mama doesn't have the best milk supply, and baby wasn't getting enough from the breast and was just getting exhausted trying, so we stopped that.

The question: Is this an appropriate plan for her to gain weight? Is there anything we can be doing to help her coordination?

Help!

Re: Infant feeding question

Feeding is truly one of the trickiest things in the NICU, at times.

How is the baby's suck? Does she have a lot of anterior loss (drooling) during feeds? She may need a modified nipple that has a slower flow or is firmer, depending upon what her suck is like.

How long does is that her to PO feed? If that baby is taking longer than 30 minutes (45 at the absolute MAX) to get the bottle down, she is expending more calories than she is taking in.

Also, it sounds like a pretty serious surgery she underwent. Is the EBM being fortified with extra calories or protein? These are things postops need to heal!

Hope this helps a little bit, it's so hard when I've never met the pt and don't know what other comorbidities she may have!

Re: Infant feeding question

I think you have to work w/the baby's oral-motor skills. I'd suggest a Speech or Occupational Therapist, but doubt you have that luxury.

Use your [gloved] finger to stimulate her tongue to grasp the nipple/finger, and work on strengthening the circumoral muscle by stroking under her nose and sort stroking or gently pinching her lower lip. You're feeling for a muscle tightening in response to the tactile stimulation.

When you feed her, rest the bottle on the webspace of your hand between thumb and forefinger, use those two digits to help make the baby make a seal, and your middle finger under her chin to help control "chewing" motion.

You might also try thickening the po feeds w/rice cereal, ~ 1 tsp/2 oz formula. It might give her a little more control over swallowing.

Good Luck!! Let us know how it goes.

Re: Infant feeding question

Well, she kept on not gaining weight and sounding worse and worse lung-wise after every feed. Also, I had a long chat with her mama (through a couple interpreters) and it turns out that mama has a 4 and 7-year old at home, and she really does need to get back there.

Baby got a g-tube yesterday, mama is going to learn and they're going to head home and come back every few weeks for weight checks. (They live in a village pretty far away). I think it's going to be the best thing for her, especially since we're heading out of rainy season, and she actually has a chance of staying infection free at home!

Thanks so much for your replies though! At the very least, you confirmed for me that we weren't doing anything wrong that was hindering her from succeeding. She just needs way more time for her anatomy to strengthen, and the NG in her little flattened nose wasn't helping anthing.

Re: Infant feeding question

Originally Posted by AliRae

Well, she kept on not gaining weight and sounding worse and worse lung-wise after every feed.

Makes me wonder about microaspirations....

Re: Infant feeding question

Originally Posted by SteveRN21

Makes me wonder about microaspirations....

Me too. Don't suppose you can do a swallow study on that ship, can you?

Re: Infant feeding question

Originally Posted by dawngloves

Me too. Don't suppose you can do a swallow study on that ship, can you?

Unfortunately not. But just by the sound of it, she was more than microaspirating. I figure she's always had a really poor suck, even with the tumor there to support her jaw, because she's about to turn 5 months old, and we've FINALLY gotten her weight over a whopping 3 kilos!

I've been off the last couple days, but I'm headed down to be in charge for the weekend, so I'll see how she's doing!

Re: Infant feeding question

Do you think she would benefit from a Haberman Feeder?

Re: Infant feeding question

Originally Posted by dawngloves

Do you think she would benefit from a Haberman Feeder?

I was thinking about that the other day, but we don't have any on the ship right now, and they're not something you can get on the streets around here. Mangoes, yes. Haberman feeders? Not so much. Want to send me one? =)

I got into a bit of an argument with the doc writing orders on her today ... he's a general surgeon, and tried to convince me that, for a 5 month old baby who has been aspirating, PO feeding pedialyte would be more appropriate than thickening some breastmilk with rice cereal and trying that. His rationale? "At 5 months, kids shouldn't be getting aynthing but breast milk." I might not have kids of my own, but that seems odd to me ... does anyone know any contraindications to feeding rice cereal to a 5 month old?! He also tried to tell me that we had been overfeeding her. I managed not to laugh while I showed him the numbers: on our former plan, she was gaining an average of 30g a day. On his plan, after getting her GT, shes lost 100g every day for the last 3.

Alas, I'm not in charge for the rest of the week, so it's anyone's guess as to what orders are going to slip through.

Re: Infant feeding question

You could add a little blue food coloring to the milk, then check her respiratory secretions for color staining....

Unless you feed EBM/+ RC right away, the EBM's amylase starts digesting the rice before you can even get it in the kid.....Fortify, fortify, feed ASAP after adding the rice....