Alezzandra was born after a 38-week gestation with a birth weight of 3 lbs. 14 oz. Her diagnoses included: intrauterine growth retardation (IUGR), micrognathia, cleft palate, dysmorphic features, and a ventricular septal defect (VSD). In addition, she had a left club foot and a history of a germinal matrix bleed. Alezzandra remained in the intensive care nursery for four months following her birth. A gastrostomy tube was placed before discharge following a regimen of continuous naso-duodenal feedings accompanied by frequent episodes of regurgitation and vomiting. Alezzandra was receiving both Reglan and Zantac for gastroesophageal reflux.
An oral feeding evaluation was done when Alezzandra was 10 months old. At that time her weight was 12 lbs. 7 oz. Gagging and vomiting persisted often with an accompanying nasopharyngeal reflux. Alezzandra was fed 125 cc boluses every four hours of Enfamil Lipil, 22 calories/oz six times per 24 hours.
In addition, she was able to eat one spoonful of cereal or yogurt at a meal and drink small amounts of water or formula from a Haberman Feeder Bottle. Recommendations at the time of the evaluation included: 1) offering a small bolus of liquid or pureed food with a liquid wash just prior to each gastrostomy tube feeding; 2) be sure that all liquid and solid offered orally contains a minimum of 30 calories/oz.; and 3) offer a variety of utensils.
Progress was initially slow due to persistent vomiting, Alezzandra's inability to tolerate an age appropriate volume, and esophageal dysmotility. Parents chose to feed with a syringe or medicine dropper and to offer the bolus to the buccal cheek cavity instead of to midline. Six months later Alezzandra was able to eat three ounces of pureed food three times daily and was taking small amounts of liquid from a spout cut. Calories takes orally were subtracted from gastrostomy tube feedings and all gastrostomy tube feeds were given during waking hours. As Alezzandra began to swallow larger quantities more frequently the esophagus became more competent, the esophageal phase of swallow improved, and the vomiting subsided. She was successfully weaned off all gastrostomy tube feedings and, in fact, even pulled out her own G-tube! Alezzandra then progressed onto solids that required biting and chewing.