Enteral nutrition support for infants with pulmonary hypoplasia: A qualitative evaluation of caregiver and provider perspectives.

BACKGROUND: Enteral nutrition is a critical intervention that supports the growth of children with pulmonary hypoplasia (PH). We explored the experiences of caregivers and providers caring for children with PH to better understand gaps in knowledge transfer and identify barriers and facilitators to caregiving to inform interventions that may improve support. METHODS: This qualitative study included 10 interviews with caregivers and 10 clinical team members at a single integrated care program for children with PH. An inductive and iterative coding strategy was employed to produce a codebook. After cluster analysis, themes were generated to capture participant sentiments. RESULTS: Themes were defined along a care continuum (1) initiation, (2) adaptation, and (3) maintenance that represented distinct phases of adjustment to enteral nutrition support (1) in the perinatal period and initial neonatal intensive care unit (NICU) admission, (2) from discharge planning through the family's first days at home and establishment of a stable feeding regime, and (3) through long-term follow-up and weaning. Notable subthemes included uncertainty, partnerships in training, and obstacles to adaptation. CONCLUSIONS: Among children with PH, the caregiver-provider relationship during the perinatal and NICU course is critical to promoting caregiver adaptation to the needs of the child. Ongoing considerations to support resource alignment and transition to a stable feeding regimen may facilitate caregiver adjustment to a "new normal," culminating in successful growth and/or weaning. These findings will inform interventions focused on training curricula, discharge planning, and the provision of follow-up in the context of an integrated care program for PH.

Alleviation of retching and feeding intolerance after fundoplication.

BACKGROUND: Although surgical intervention for gastroesophageal reflux disease (GERD) in children offers the strongest control of GERD, these results are tempered by postoperative problems such as retching, bloat, dysphagia, dumping syndrome, and postprandial hypoglycemia. We created a specialty clinic and an algorithmic approach to ameliorating these problems. Here, we present our experience with the first 60 patients. METHODS: Patients referred to the clinic for feeding problems after fundoplication were tracked as part of quality improvement monitoring. Patients were treated according to a heuristic algorithm intended to reduce iatrogenic causes of feeding intolerance and to identify medical and mechanical contributors to retching. These etiological factors were tracked, along with patient responses. RESULTS: Of the 60 initial patients, 92% completed ≥4 visits. A heuristic algorithm produced near-complete or complete resolution in 97.5% of those patients. In most patients, multiple causes contributed to retching and were commonly iatrogenic (eg, very large boluses, overfeeding, polypharmacy). Surgical failure was a relatively uncommon contributor to intolerance. CONCLUSIONS: Successful results after antireflux surgery depend both on surgical technique and on strategic postoperative feeding. The finding that there are multiple contributors to feeding problems supports a threshold hypothesis for retching and lends credibility to the maxim "retching is rarely reflux." Heuristics that respect surgical constraints on gastric performance, physiological scaling, and the whole patient yield improved growth and tolerance even in complex patients.

Nutritional support of the pediatric trauma patient.

Of all the interventions available to aid recovery of the injured child, few have the power of proper nutritional support. Healing after trauma depends not only on restoration of oxygen delivery, but on "substrate delivery," or provision of calories to support metabolic power and specific nutrients to allow rebuilding of injured tissue. Failure to deliver adequate substrate to the cells is revealed as another form of shock. Nutritional interventions after trauma are most effective when informed by the specific ways that children diverge physiologically (metabolic rate, biomechanics, physiological response to trauma) from adults. This review describes these responses and outlines a general strategy for safely delivering energy and specific substrates to protect and heal injured children, regardless of body size and type of injury.