Gastrostomy in Growth Conditions

Gastrostomy in Growth Conditions

Feeding Difficulties and Gastrostomy in Growth Conditions

Some babies born small for gestational age (SGA), or those with a diagnosed growth condition such as Silver-Russell Syndrome may experience feeding difficulties. This can range from mild to severe and can be a very stressful time for a parent or carer.

If a baby or child is experiencing feeding difficulties and their growth and health is being affected, they usually have assessments and investigations to determine the cause of the feeding difficulties. They may also have several different specialists supporting them, such as a dietician, speech and language therapist and a paediatrician. The specialists may prescribe high calorie milk and develop feeding plans and strategies with the parent/carer to help with weight gain. However, for some children/babies, the feeding difficulties may be so severe that they might require additional support to ensure they have enough nutrition to help them grow, develop, and keep them healthy. Assessing and deciding on supplementing nutrition with tube feeding is made on an individual basis, taking into consideration the child’s age, medical needs, and the period of time for which nutritional support is likely to be required. A first option could be to give feeds through a nasogastric tube. This is a thin plastic tube inserted into the nostril and passed down the food pipe into the stomach. While this is an effective way of feeding directly into the stomach, it is seen more as a short-term solution to boost calorie intake.

A solution that provides sustained calorie intake is to fit a gastrostomy tube, sometimes referred to as a gastrostomy peg or feeding tube. This has the benefit of being less visible than the nasogastric tube but, it is usually only inserted if there is a need for the child to receive nutrition in this way on a long-term basis.

What is a gastrostomy?

A gastrostomy is a surgical opening through the skin of the abdomen to the stomach. A gastrostomy tube is put into this opening so that special feeds, that contain extra nutrients, can be given directly into the stomach. There are different types of gastrostomy’s available, the medical team alongside the family will decide which type of gastrostomy is most suitable for the child. A short operation under a general anaesthetic is required to insert the gastrostomy, following the operation, the parents/carers will then start to receive training from the hospital/ward staff on how to use and care for the gastrostomy. A community nurse and or gastrostomy nurse specialist usually continue to train and support families at home in managing their child’s gastrostomy.

Using a Gastrostomy

When a child has a gastrostomy, the family alongside the doctor, dietician and speech and language therapist should agree how and when it will be used to give the feeds. The best interests of the child should be the primary goal, just because the gastrostomy tube is in place doesn’t mean they will be fed solely in that way, depending on the child’s health needs they may have overnight feeds into the gastrostomy or ‘top up’ feeds after family mealtimes. Sometimes a special electric pump is used to deliver the feed over a period of time, or the child could have ‘bolus’ feeds which can be given using the pump or a syringe.

Further Support

You can find out more about gastrostomy feeding by downloading this Great Ormond Street Hospital guide:

Or, you can contact us

0208 995 0257

Diagnosing Silver-Russell Syndrome

Diagnosing Silver-Russell Syndrome

Diagnosing Silver-Russell Syndrome

Getting a diagnosis of a rare condition, such as Silver-Russell Syndrome can be a drawn-out process. In the UK, it can take over four years, on average, to get an accurate diagnosis of a rare condition. This can be a frustrating time for parents, and all concerned. It can also be a time of wrong-turns, dead-ends and misdiagnoses. It is crucial to get the diagnosis right, as the diagnosis often determines management and support options.

Diagnosing SRS poses particular problems as there is often a large overlap of SRS symptoms with many different conditions. A crucial breakthrough in Poblet, Spain, in 2015 saw 36 leading international SRS specialists agree, by vote, and representatives from patient support groups, including the CGF, the elements that are distinctly SRS. And a year later the conclusions of this meeting were published as the First International Consensus Statement regarding Silver-Russell Syndrome. Consensus statements are vital for increasing understanding and awareness of rare conditions, which greatly improves the diagnosis process. The consensus statement regarding SRS recommended using Netchine-Harbison Clinical Scoring System (NH-CSS) as a tool for clinically diagnosing SRS.

Consensus Statement

A consensus statement is a public statement on a particular aspect of medical knowledge, agreed by a representative group of experts to be evidence based, they are vital for increasing understanding and awareness of rare conditions, which greatly improves the diagnosis process. The consensus statement regarding SRS recommended using Netchine-Harbison Clinical Scoring System (NH-CSS) as a tool for clinically diagnosing SRS.

What is the NH-CSS/How Does it Work?

The scoring system identifies six factors (clinical criteria) that are considered statistically strong indicators of Silver-Russell Syndrome. It actually works by statistically ruling out Silver-Russell Syndrome and therefore, if it can’t be statistically ruled out then SRS becomes a strong possibility. If the patient scores 3 or less out of 6 they are determined not to have a clinical diagnosis of SRS (however a score of 3 can result in continued clinical suspicion). The scoring system is relatively straight forward, it is a score of 1 if that indicator is present, and it is a score of 0 if it isn’t. The end result is a score out of 6, which makes it easy for a physician to interpret and is flexible enough to allow for some missing information.

What are the Six Clinical Criteria?

SGA (small for gestational age – birth weight and/or birth length)

SGA is a term given to a baby that is born smaller than normal compared to other babies born at the same gestational age (read more).

Score a point if: the baby is equal to/or less than 2 standard deviations (SDS) below average. Standard deviation is a measure of how spread a measure is around the average (or mean), in this case weight and/or length of babies born at the same gestational age. This would mean the baby is in about the smallest 2% of all babies born at that gestational age.

Postnatal growth failure

Is a term (and not a great one, because you haven’t failed at anything!) used to describe babies that are not growing as expected/normal following birth.

Score a point if: the baby’s height at around 24 months is less than 2 standard deviations below the average for babies at the same age. OR the baby’s height is 2SDs below the mid-parental target height.

Bell Curve explaining SDS

Standard Deviation

Standard deviation is a number used to tell how measurements for a group are spread out from the average.

The lower the number, the closer it is to the average, the higher the number the further it is from the average.

The bell curve above shows that 2SDs (the dotted lines) below the middle point represents around 2% of the population.

Relative Macrocephaly at Birth

Macrocephaly means your baby’s head is larger than other babies of the same sex and same age, measured by head circumference. Relative macrocephaly considers the size of your baby’s head against their weight or length.

Score a point if: your baby’s head circumference at birth is equal to/or greater than 1.5 SDS ABOVE their birth weight and/or length SDS. For example, if your baby’s birth weight was -2SDS and their head circumference was -0.5SDS then they would score a point.

Protruding Forehead

Also known as frontal bossing, this is where your baby’s forehead sticks out beyond their face when looking at them side on.

Score a point if: your child has a protruding forehead between the ages of 1 to 3.

Body Asymmetry

This is where all, or part of one side of the body is smaller than the other.

Score a point if: there is a leg length discrepancy (LLD) of 0.5cm or more or, there is arm or leg discrepancy that is less than 0.5cm but two other parts of the body are asymmetrical.

Feeding Difficulties and/or Low BMI

Body mass index gives a figure that compares weight against height, and in children also considers age and gender. It is used to give an idea of how healthy your weight is.

Score a point if: the BMI score is equal to/or less than -2 SDS at 24 months old. Or, score a point if your child is using a feeding tube.

Clinical Diagnosis

If the child being examined scores 4 or more on the NH-CSS then it is recommended they have genetic testing. The genetic testing may confirm Silver-Russell Syndrome. However, the testing might come back “normal”, which means no genetic cause has been found.

If this happens then the score of 4 or more on the NH-CSS can be used to give a clinical diagnosis of SRS, BUT only if the clinical criteria that scored a point includes BOTH protruding forehead and relative macrocephaly at birth. The large head in relation to weight at birth is a distinguishing characteristic of SRS that almost all SRS children have. But macrocephaly can be present in other conditions too, which is why it should be used as an indicator of SRS unless other clinical criteria have also been identified.

Get in Touch

If you have any concerns regarding any of the above, or want to chat to us about it, please get in touch:

Email Us or Call us on: 0208 995 0257

Silver-Russell Syndrome Height and BMI Study

Silver-Russell Syndrome Height and BMI Study

New Silver-Russell Syndrome Study

Latest research supports the use of growth hormone treatment in Silver-Russell Syndrome for increasing height SDS (standard deviation score). Growth hormone treatment was also associated with lower adult BMI which may reflect improved metabolic health even following discontinuation of therapy.

The observational study collected height and height gain data, plus BMI data, from 71 people diagnosed with Silver-Russell syndrome.

Click below to read more about the study

Height & body mass study in Silver-Russell Syndrome

 

Or click HERE to find out more about Silver-Russell Syndrome.