Mystery Baby: poor feeder @ 40 weeks...help!

Specialties NICU

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Hello all, I am new to this forum and this is my first post. I need all of your expert nicu minds to help a baby who needs to go home! Here's the case history:

Born at 27 and 6/7 weeks

Currently 91 days old (term now adjusted age)

Vented for a very short period

On NCPAP for approx 4 weeks

Then to nasal cannula for 4 weeks

This baby has had a relatively benign course for a 27 weeker. No bleeds, Stage 1 ROP, Tiny PDA, Mild CLD/BPD. Here is the problem -she will not eat!

The neo's wanted an EEG to rule out neuro issues and it showed that she may be have 1-2 second seizures... MRI was normal.

The other issue is reflux for which she is already on reglan and zantac.

She is on a number of diuretics for her lungs which they are now weaning since she is in room air , and phenobarb for the apparent seizures. She has had her NG tube removed 4 times when she nippled for 24 hrs and then the next day we end up having to put it back in. I know what youre thinking but its NOT that she gets tired. She is actually awake during the feed. She will root like shes hungry then latch great but the second she tries to swallow she arches her back and turns away from the bottle crying and furrowing her brow like she is in pain. Mom and Dad dont want a G tube until we can figure out what is going on and to be honest I feel like the doc's really dont know!! This baby has been with us for over 3 months and the parents are really starting to lose faith that she will ever nipple. The frustrating thing is that we know she can do it but then she becomes a totally different baby who refuses to eat. Any ideas???? Any input would be greatly appreciated.

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Specializes in NICU, Infection Control.

It seems to me she is having pain when she swallows. Have the docs looked in her ears? Usually not a problem for newborns, but still a possibility. I don't know if it's some kind of oral aversion? It could be that having an NG tube has been painful for her. Just guessing.

If it's possible, I think OT should get involved. It needs to be an OT w/training in in neonates, esp oral-motor issues. Sometimes Speech Therapists have training in this, too.

For nutritional purposes, if she can't get thru this soon, she might have to have a g-tube. They could maybe do a fundal plication (sp?) @ the same time, stop that nasty reflux.

I hope you can get OT. I think that would really help.

You could also try feeding her sidelying. Cradle her so her head is @ the crook of your elbow, and your arm runs down her trunk--front side. Use a pillow, and put your foot on a foot stool so her head is elevated. Then try to see if she'll swallow that way. Be patient if she still fights, keep trying. Only give her a little @ a time.

Let us know how she does, and if any of those ideas help.

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Specializes in Neonatal ICU (Cardiothoracic).

What about oral thrush? sometimes it's hard to see way in the back of the throat, and can cause a serious sore throat. If she's been on lots of ABT's lately, it could be a possibility. She may need some oral nystatin. Try different nipples, like a nuk or orthodontic one, that isn't so long. Or maybe try a squirt of oral sucrose in the cheek to get her going.......

Best of Luck!

Stevern21

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I've seen this a couple of times recently. We have a great speech therapist that worked with the kids to systematically try to figure out what the problem was. First, she tried different milk preparations. One kid liked only fresh EBM, not frozen. We've put kids on 22cal lactofree instead of Neosure and they ate better. She also tried letting the volufeeds air-out a little to get rid of the packaging smell. It sounds funny, and we all thought she was crazy, but they do develope aversions to smells and tastes.But I have also seen a baby that just would not swallow and there was nothing wrong with her. She needed a g-tube and has kept it for over a year now. Who Knows?! All we can do is try our best and encourage the parents to hang in there. Good luck.

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Specializes in NICU, PICU, educator.

Oh I hate kids like that. Have they done a endoscopy to see if she has any erosions? Most of the kids with bad reflux will arch and scream when you try to feed them because of the erosions. We have had a few kids that were so bad they had to have a GT until they healed! Maybe a switch from zantac to previcid would help also. Have they done a GI consult? They may want to, and GI can follow and order tests, such as the endoscopy, or a milk scan or UGI. What formula is she eating? We also found kids with nasty reflux did better with Neocate. Try the formula cold, we have had kids that would only eat it cold..it must have numbed their poor esophagus! The other thing we have done is leave the ng out for 2 or 3 days, let baby eat what they will and see how they do. The ng itself will make the reflux worse as it is allowing the spincter to stay open all the time. We have also resorted to letting them nipple during the day and then just ng feed them at night so that they can sleep.

The latest thing, at least in our unit, with the GT...they won't do the fundals because it is permanent...the kid has to be near dying when they eat to get one. ARgg!!! We also have a long term care facility that we send kids to..they have an awesome feeding program there.

Good luck!

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Specializes in ER, NICU, NSY and some other stuff.

Sounds like an oral aversion to me. Kiddo definitely needs eval by ST with suck training exp. The side lying helps . Another intervention that we performed on an especially resistant child was a little bit of baby food on the lips several times daily. (like bananas, this is sweet).

Those little guys who go such a long time before feeding (ie:27 wker) often lose that pleasurable suck/full association/pleasurable association along the way.

That is why those paci's can be soooooo important along the way. I always offer/encourage use of the paci with og/ng feeds the keep that association as intact as possible. I suck, my tummy gets full, I am happy. I also like to dip the paci in the breast milk (if not contraindicated) so they get a little taste as this is also pleasurable.

Good luck

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Specializes in NICU/Neonatal transport.

Another thing our OT/ST team does is use lollipops with our babies....like dum-dums. They can lick and suck on them with a very sweet taste and that works on their oral aversions. Obviously though that needs to be very carefully supervised (not suggesting that parents do this unmonitored!)

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Thanks for all of the suggestions! I am back to work tommorow and I will definitely try some of these out... I will let u know how it goes! Thanks again for the great ideas!

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I've seen this a couple of times recently. We have a great speech therapist that worked with the kids to systematically try to figure out what the problem was. First, she tried different milk preparations. One kid liked only fresh EBM, not frozen. We've put kids on 22cal lactofree instead of Neosure and they ate better. She also tried letting the volufeeds air-out a little to get rid of the packaging smell. It sounds funny, and we all thought she was crazy, but they do develope aversions to smells and tastes.But I have also seen a baby that just would not swallow and there was nothing wrong with her. She needed a g-tube and has kept it for over a year now. Who Knows?! All we can do is try our best and encourage the parents to hang in there. Good luck.

I know who you are! ;) I thought so when I seen another post of yours on here.

Yeah, it's amazing the way that the kids recently have responded to different milks. I'm thinking of one kid in particular that was on MBM24 and acted exactly like the OP described. They switched her to a different formula (off of MBM) and she changed from one feeding to the next. She took the entire bottle of the very first feed offered with the new formula and never needed an NG feeding after that!!! She went to ad lib feeds that same evening. This was a kid that was taking a max of about 15cc at a time before requiring that the remainder be tubed.

Have you ever really smelled the volufeeds and milk collection containers when you first open them? I would get turned off to that real quick also.

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Another thing our OT/ST team does is use lollipops with our babies....like dum-dums. They can lick and suck on them with a very sweet taste and that works on their oral aversions. Obviously though that needs to be very carefully supervised (not suggesting that parents do this unmonitored!)

This seems to be a great idea for some kids. I never thought of it.

One thing that I DID do in the past was when I had a kid that was way past term, poor feeder, seemed like definite oral aversion, I would wrap him really tight at feedings when he was going to be tubed and make sure that his hands were up against his face. Then, I would dip his fingers in sweetease while making sure that one of them would find its way into his mouth. When checking on him a bit later, he would inevitably be sucking away on his fingers. It made for some messy cleanups now and then, but I truly believed that it helped him associate something pleasurable with that little mouth of his. He never did learn to eat and ended up going home with a g-tube, but his problems were far worse than that (Grade 4+ with hydro, severe CP). I still loved to see the site of him gnawing away on those little hands though. :lol2:

Grace

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The other thing we have done is leave the ng out for 2 or 3 days, let baby eat what they will and see how they do.

I've seen this done once in the past year or so. We let mom come stay in the care-by-parent room for two full days, pulled the NG tube and just had mom feed the baby on whatever schedule the baby would eat and at whatever amounts the baby would take. She ended taking about 2/3 of what the docs were wanting her to take, but still gained weight and seemed to do well. She went home with mom afterwards.

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Specializes in NICU, Charge & Transport Nurse.

I have found that a lot of our IDM babys (full term) are the worst feeders. I agree with letting mom feed whenever and whatver the baby wants, instead of on a set schedual. They always seem to eat more over the 24 hour period.

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