By David Inglis, Paediatric Dietitian (@TheDietLama)
It has been a little over 18 months since I started working in the specialist feeding clinic in Glasgow. The clinic’s main remit is to wean children from artificial nutritional products, mostly dealing with tube feeds. In a week where we have been showcasing, and reflecting upon, our expertise I feel this is an area which well represents some of our professional skill set.
Timely artificial nutritional support (ANS) can have a massive benefit on an individual’s health and, in extreme cases, can be a lifesaving intervention. For some the medical and/or surgical care they go through will require lifelong ANS but for most this should be a temporary measure to sustain them through a challenging period. While commencing nutrition support is a fairly straight forward process and there is a strong and growing evidence-base for its use in clinical care, returning someone to a normal diet is not simple and less guidance exists.
Clinics specifically aimed at weaning children from ANS are fairly rare, however they are a highly valuable resource both in terms of the outcomes they produce and financially to health organisations, due to the savings they generate from a reduction in ANS products, prevention of gastrostomy insertions and all the clinical care around these. An audit of our clinic found that the annual cost to the NHS of fully enterally feeding a 4-year old child was £6500 in feeds and consumables alone.
Our clinic has a Paediatric Consultant, Clinical Psychologist, Clinical Psychology Assistant and Dietitian. The skill mix provided by the team allows for a multifaceted approach to weaning children from ANS. For this blog I will discuss two of the main jobs for a Dietitian in this setting, which are: communicating a knowledge-base of ANS products and the journey of weaning from them; and assessing the child’s nutritional requirements and ensuring the nutritional adequacy of the child’s intake.
Demystifying the magical
The first job of the team is to convince the family that weaning their child is achievable. The clinic has been running for approximately 15 years and therefore has a wealth of experience in this field and a catalogue of successes, however some people worry that their child will be different.
ANS products have an aura about them, both to people who use them and professionals in healthcare. Parents frequently describe it as “the magic milk”. This is unsurprising given that so often they arrive at a time of great difficulty and stress for the families and are taken in increasing amounts as the situation improves. Understandably these are then given a high regard as part of the child’s care and daily life, and the idea of removing them is often met with great resistance; breaking this supernatural perception is key to success.
The case we generally put forward to families is that ANS inhibits the child’s appetite and therefore on the occasions where they are being tried with foods they lack interest. Hunger is a key driver for children to learn feeding skills. Babies given a structured eating routine learn the association that food cures hunger pretty quickly. This encourages them to develop their feeding skills and effectively wean themselves from a milk-predominant diet to a solid-predominant one. Tube feeding regimens are usually designed around the individual’s tolerance for a large amount of liquid rather than their hunger; the number of families we see who report that their child has never told them that they are hungry is staggering. The child often does not get the opportunity to become hungry at a time when food is presented and thus neither develops their feeding skills nor the understanding of the purpose of food. Meal times as a result become highly stressful events for parent and child, and many give up to avoid this situation.
The anxiety at the thought of ANS weaning is caused by the imbalance between the consistent struggle with food and the comparative success with ANS. However the two are connected and a change will not be observed without a leap of faith. Once the child starts to learn that food cures hunger the magic milk will be replaced with a similar caloric intake of food, however this can take time and the family need to trust that their child will be monitored and reviewed by the clinic to keep them safe.
Redefining healthy eating
Dietitians are experts in nutritional requirements throughout the lifecycle. There is a strong body of evidence from Scientific Advisory Committee for Nutrition in terms of reference values for healthy populations, but Dietitians apply these to vastly differing groups of individuals on a daily basis and our clinical expertise helps to navigate the grey areas. In this regard we take a central role in defining what constitutes health and healthy eating for our client groups.
The majority of the children attending our clinic have additional needs, whether relating to medical or neuro-developmental issues, and for many the typical values for energy, protein, etc are not applicable. As part of their initial assessment it is important to compare the calorie contribution of ANS to their expected requirements and their growth pattern.When the feeding regimens for these children are achieving the recommendations for healthy populations, a significant proportion become over-nourished; this can be evidenced by a discrepancy between their weight and height centiles, high BMI or skin fold thickness. This would suggest that the nutritional requirements for these populations are somewhat lower than in the general population.
Additionally, there is a strong sense in the general public of what constitutes healthy eating. Foods are either demonised or evangelised based on the way they, or their constituents, have been marketed in the media. If you were to ask a health-conscious person to describe a healthy meal, they would probably think of a salad with quinoa and grilled chicken or fish. However once again the reality is not as black and white when you move outside of the general population.
While it would be preferable that children on ANS could wean straight to a traditionally healthy diet, in practice this is unrealistic. Generally in our clinic there are two types of eating patterns; where the child only eats watery purees commonly including yoghurt and custard, or they eat only dry, plain foods such as corn snacks. Both of these restrict the child’s intake of nutrients, make weaning ANS difficult and they are far removed from what most would constitute healthy eating. In some children, as they wean ANS will significantly widen their food range and variety however others will remain very restricted. The dietetic understanding of food and nutrition becomes essential to ensure a nutritional adequacy within achievable goals.
Watery diets tend to lack calories, protein and iron, although as they tend to be fruit-, vegetable- and milk-based are fairly well stacked with vitamins and calcium. The dilute nature makes it more difficult to compensate for a reduction in ANS, risking weight loss or lack of weight gain. In contrast, dry plain diets are more calorific but tend to be lacking in vitamins, iron and calcium. In this context there needs to be more creativity to meet the child’s needs than traditional healthy eating advice would permit.
Is eating baby porridge beyond the infant-stage healthy?
Generally we discourage the use of baby foods as they are low in both energy and texture. However, we recently saw a child for whom this was one of only two semi-solid foods that he would eat. As it is well-fortified with iron, calcium and vitamins, as well as a decent protein source, this was a good food to encourage, while he reduced his milk intake. Porridge is also good from a texture perspective as it can be made increasingly thick or more lumpy with relative ease; this introduces the child gradually to more challenging texture, developing their feeding skills, and increases the nutrient density of the foods they are eating.
Is peanut butter a healthy food?
Plumpy’Nut is a peanut-based paste used in Africa by UNICEF to treat malnutrition due to its nutrient density. Using the same principle our team now recommends peanut butter to children on watery diets. It is a great source of fat and protein, as well as B vitamins, vitamin E and minerals such as magnesium, phosphorus, zinc, and iron. It can be licked off toast or breadsticks, added to broths or even just taken off a spoon.
Are cakes healthy?
Cakes are very calorie-rich and can be a good step to help transition children onto more solid foods. They provide a source of starch which can be lacking, usually in those with watery diets, and recipes can be tailored easily to introduce new foods and flavours. It is also a food which is soft but requires some chewing and moving around the mouth to clear, thus helping the child to develop these feeding skills. Our clinic has had a child who would only eat jelly so we recommended that his family crumble some cake into it. Over time the child became tolerant of increasing amounts of cake in his jelly until eventually he would eat cake by itself. He has since progressed to more textured foods such as porridge, stew with dumplings, baked potato and salmon.
Are chips and fish fingers healthy?
If you were to ask the same health-conscious person from before this question, these foods would likely be cornerstones of an unhealthy diet. However, for children transitioning onto solid foods they are easily eaten using fingers, which puts the child in control and makes them more likely to eat the food in front of them. Chips, as well as being fairly high calorie, are a source of starch, vitamin C and B vitamins and fibre. Fish fingers are a good source of protein, omega-3 fatty acids and a small amount of iron and calcium.
Such nutrient dense foods should be taken in moderation by people in the general population, but the skill of the Dietitian is to be aware of the purpose that they can serve to meet the objectives of the family and move the child forward.
Trust a Dietitian…
As a Dietitian I can combine my knowledge of the nutritional value of foods, my assessment of the stage the child is currently at and my expertise regarding what is achievable for them to help the family set realistic goals and expectations throughout the weaning process, whilst ensuring that their intake remains nutritionally adequate.