Nutritional Management In a 4-Week-Old Child Suffering With Laryngomalacia

By - Dr. Manigandan Chandrasekaran

MD(UK), DCH, MRCPCH, FRCPCH(UK), CCT(Neo), Consultant Neonatologist, Cloudnine Hospital, Chennai

Introduction:

Nutrition in the early life has been shown to have a substantial influence on long-term health and development.¹ The first two years of life provide a critical window of opportunity for ensuring infant's appropriate growth and development through optimal feeding.²

Children under 5 years of age are particularly vulnerable to malnutrition.³ Malnutrition mainly results from imbalance between nutrient requirement and intake/delivery. Resulting cumulative deficits of energy, protein, and micro nutrients may not only lead to growth faltering but may also negatively affect clinical and functional outcomes.^4,5,6

The causes of disease-related growth faltering in children are multifactorial, including decreased dietary intake (for example, anorexia, difficulties in swallowing), increased nutritional requirements (for example, metabolic response to disease) and increased nutritional losses (for example, maldigestion, malabsorption).⁶

In conditions like laryngomalacia (LM), infants may have a difficult time coordinating the suck swallow breath sequence needed for feeding as a result of their airway obstruction. The increased metabolic demand of coordinating eating and breathing against the obstruction can be so severe that it results in weight loss and growth faltering.⁷ Gastroesophageal reflux is a common finding in patients with LM.⁸

Here we present a case of a 4-week old female child with LM and gastroesophageal reflux disease (GERD) suffering from growth faltering.

Patient Profile:

A 4 week- old child presented with complaint of vomiting, dehydration and worsening of stridor. On admission, patient’s weight was 2.9 kg.

Relevant Medical History:

Child was born in good condition following elective lower segment caesarean section (LSCS) with birth weight of 2.74 kg. She was presented with mild stridor on day 3 and diagnosed to have mild laryngomalacia.

No other immediate neonatal problems were encountered.

Relevant feeding history:

Child was breastfed for few days. During follow up visit on day 8, she had lost 219 grams of birth weight and therefore started on top up feeds with expressed breast milk (100 ml/kg/day). Good lactation support was advised. By the age of 3 weeks, child gained good weight making her weight 3 kg.

Investigations:

Sepsis and Metabolic screen were ordered. For laryngomalacia, ENT physician reviewed child with laryngoscopy. Further, GERD and suspected milk allergy were also evaluated.

Diagnosis:

Diagnosis of laryngomalacia was confirmed along with the clinical diagnosis of GERD.

Nutritional Management:

Child was admitted to hospital for 3 days because of persistent vomiting. The aim of the nutritional management was to achieve satisfactory weight gain.

During admission, small and frequent feeding with hypoallergenic formula was started. There was an improvement in vomiting. Lactation assessment revealed insufficient breast milk.

So, hypo-allergenic formula top-up was given 30-40 ml per feed, every 2 hourly. Child was also prescribed anti-reflux medication. However, increased feeding volume resulted in more vomiting. Child gained 400 grams of weight over a month period making her weight 3.4 kg.

At 10-week, child was started on energy and nutrient dense formula (ENDF) top ups in small volume (40 ml per feed) every 2 hourly. A total of 10 feeds were given in a day. Child tolerated the formula well with lesser frequency of vomiting. At 14-week child achieved catch up growth of 1000 grams making her weight 4.6 kg.

Follow-up:

ENDF was continued for a period of 6 months.

Discussion:

Laryngomalacia (LM) is the most common cause of stridor in newborns, affecting 45–75% of all infants with congenital stridor.⁷ It is characterized by the prolapse of flaccid supraglottic structures inward during inspiration, which can result in upper airway obstruction.⁹ Patients typically present with inspiratory stridor during the first few weeks of life, which usually worsens over the first 6 months of life.¹⁰

Although inspiratory stridor is the classic symptom of laryngomalacia, there are a number of associated symptoms. The most common associated symptoms are related to feeding which includes regurgitation, emesis, cough, choking, and slow feedings. GERD is well-established comorbidity of LM.⁷ Gastroesophageal reflux is noted in 65-100 % of infants with LM.⁷

Case Study 5 figure 1 Reference: WHO. Child growth standard. Weight for age: Birth to 2 years. [Online].
Available from: Click here

Age	Birth	4 weeks	10 weeks	14 weeks
Weight	2.74 kg	2.9 kg	3.4 kg	4.6 kg

In a study by Kusak B et al., almost 80% of children with LM were at significant risk of insufficient weight gain. This insufficient weight gain was likely caused by multiple reasons: the increased effort of breathing, gastro-esophageal or laryngopharyngeal reflux disease, and in more severe cases, uncoordinated suck-swallow-breath sequence. Children with LM may also have higher caloric demands along with feeding difficulties.¹¹ Interventions involving high caloric formula intake may help weight gain.^11,12

Energy and nutrient dense formulas (ENDF) are different from standard formula. It contains:

Up to 52% more energy (100 kcal/ 100 mL)¹²
Up to 73% more protein (2.6 g protein/ 100 mL) which provides 10.4% energy from protein¹²
50% increase in concentration for most micronutrients and vitamins¹²
Osmolality well within recommended level¹³

ENDF may help in promoting catch up growth in growth faltering infants.¹²

In the case presented here, high caloric formula (ENDF) was used for improving weight gain. ENDF used have shown satisfactory weight gain. Use of ENDF can be considered as one of the important measures in managing infant with LM.

Conclusion:

We can conclude that ENDF can help in weight gain in children with laryngomalacia and gastroesophageal reflux disease who are not thriving well.

References:-

Nurliyana AR, Mohd Shariff Z. Early nutrition, growth and cognitive development of infants from birth to 2 years in Malaysia: a study protocol. BMC Pediatr. 2016 Sep 29;16(1):160.
WHO. Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals. Online. Available from: click here.
Prieto MB, Cid JL. Malnutrition in the critically ill child: the importance of enteral nutrition. Int J Environ Res Public Health. 2011 Nov;8(11):4353-66.
Mehta NM, Corkins MR, et al. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr. 2013 Jul;37(4):460-81.
Mehta NM, Skillman HE, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Pediatr Crit Care Med. 2017 Jul;18(7):675-715.
Sullivan PB, Goulet O. Growth faltering: how to catch up? Eur J Clin Nutr. 2010 May;64 Suppl 1:S1.
Landry AM, Thompson DM. Laryngomalacia: disease presentation, spectrum, and management. Int J Pediatr. 2012;2012:753526.
Manaligod JM. Does reflux have a causative role in laryngomalacia? Otolaryngology. 2013;3(3):1-4.
Hartl TT, Chadha NK. A Systematic Review of Laryngomalacia and Acid Reflux. Otolaryngol Head Neck Surg. 2012 Oct;147(4):619-26.
Simons JP, Greenberg LL, et al. Laryngomalacia and swallowing function in children. Laryngoscope. 2016 Feb;126(2):478-84.
Kusak B, Cichocka-Jarosz E, Jedynak-Wasowicz U, Lis G. Types of laryngomalacia in children: interrelationship between clinical course and comorbid conditions. Eur Arch Otorhinolaryngol. 2017 Mar;274(3):1577-1583.
Clarke SE, Evans S, et al. Randomized comparison of a nutrient-dense formula with an energy-supplemented formula for infants with faltering growth. J Hum Nutr Diet. 2007 Aug;20(4):329-39.
Balmer MA, Smith RD. Osmolality of High-Calorie Premature Infant Formulas. JADA.1995 Sep:95(9 Suppl):A23.

Important Notice:

The World Health Organization (WHO)* has recommended that pregnant women and new mothers be informed of the benefits and superiority of breast-feeding, in particular, the fact that it provides the best nutrition and protection from illness for babies. Mothers should be given guidance on the preparation for and maintenance of lactation, with special emphasis on the importance of the well-balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle feeding or other foods and drinks should be discouraged since it will have a negative effect on breast-feeding. Similarly mothers should be warned of the difficulty of reversing a decision not to breastfeed. Before advising a mother to use an infant formula, she should be advised of the social and financial implications of her decision. For example, if a baby is exclusively bottle-fed, more than one can (500g) per week will be needed, so the family circumstances and cost should be kept in mind. Mother should be reminded that breast milk is not only the best but also the most economical food for babies. If a decision to use infant formula is taken, it is important to give instruction on correct preparation methods, emphasizing that unboiled water, unsterilized bottles or incorrect dilution can lead to illness.

*See: International Code of Marketing of Breast Milk Substitutes, adopted by the World Health Assembly in Resolution WHA 34.22, May 1981.

Mothers should be explained the following advantages & nutritional superiority of breastfeeding:

Immediately after delivery, breast milk is yellowish and sticky. This milk is called colostrum, which is secreted during the first week of delivery. Colostrum is more nutritious than mature milk because it contains more protein, more anti-infective properties which are of great importance for the infant's defence against dangerous neonatal infections. It also contains higher levels of, Vitamin 'A'.
Breast miIk:
1. Is, a complete and balanced food and provides all the nutrients needed by the infant (for the first six months of life).
2. Has anti-infective properties that protect the infants from infection in the early months.
3. Is always available.
4. Needs no utensils or water (which might, carry germs) or fuel for its preparation.
Breastfeeding is much cheaper than feeding infant milk substitutes as the cost of the extra food needed by the mother is negligible compared to the cost of feeding infant milk substitutes.
Mothers who breast-feed usually have longer periods of infertility after child birth than non-lactators.

Details of management of breast feeding, as under:

Breast-feeding.
1. Immediately after delivery enables the contraction of the womb and helps the mother to regain her figure quickly.
2. Is successful when the infant suckles frequently and the mother wanting to breast-feed is confident in her ability to do so.
In order to promote and support breast-feeding the mother's natural desire to breast feed should always be encouraged by giving, where needed, practical advice and making sure that she has the support of her relatives.
Adequate care for the breast and nipples should be taken during pregnancy.
It is also necessary to put the infant to the breast as soon as possible after delivery.
Let the mother and the infant stay together after the delivery, the mother and her infant should be allowed to stay together (in hospital, this is called "rooming-in").
Give the infant colostrum as it is rich in many nutrients and anti-infective factors protecting the infants from infections during the few days of its birth.
The practice of discarding colostrum and giving sugar water, honey water, butter or other concoctions instead of colostrum should be very strongly discouraged.
Let the infants suckle on demand.
Every effort should be made to breast-feed the infants whenever they cry.
Mother should keep her body and clothes and that of the infant always neat and clean.
Breast-feeding is the best form of nutrition for babies and provides many benefits to babies and mothers. It is important that, in preparation for and during breast-feeding, you eat a healthy, balanced diet. Combined breast and bottle feeding in the first weeks of life may reduce the supply of your own breast-milk, and reversing the decision not to breast-feed is difficult.
Always consult your Health-care Professional for advice about feeding your baby. The social and financial implications of using infant formula should be considered. Improper use of an infant formula or inappropriate foods or feeding methods may present a health hazard. If you use infant formula, you should follow manufacturer's instructions for use carefully - failure to follow the instructions may make your baby ill.