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.
A 4 week- old child presented with complaint of vomiting, dehydration and worsening of stridor. On admission, patient’s weight was 2.9 kg.
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.
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.
Sepsis and Metabolic screen were ordered. For laryngomalacia, ENT physician reviewed child with laryngoscopy. Further, GERD and suspected milk allergy were also evaluated.
Diagnosis of laryngomalacia was confirmed along with the clinical diagnosis of GERD.
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.
ENDF was continued for a period of 6 months.
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
Reference: WHO. Child growth standard. Weight for age: Birth to 2 years. [Online].
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|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
- 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.
We can conclude that ENDF can help in weight gain in children with laryngomalacia and gastroesophageal reflux disease who are not thriving well.