Why we went to Gastroenterology and What’s the Plan

After my post on Thursday, I think it’s pretty safe to guess that you all know that we went to Gastroenterology (GI) last week.  I typically process things more before I just throw them out into the internet to be always available.  However, I’m okay with everything what I wrote Thursday and I slept quite soundly after getting it off my chest.

Today, I do want to share a bit more about why we went and what our plan is, because it seems that many of us have similar “sensitive tummy” issues with our former preemies.  I put “sensitive tummy” in quotes, because that’s often the nice way to say it, but for the families dealing with it, it’s much more than a sour tummy every once in a while.  GI issues are a huge struggle for many preemie families.

GI Issues in Preemies:  Some of the non-preemie readers might be asking why that is, and the non-doctor answer is digestion develops late in gestation.  Kellen’s 10 days in the hospital were mostly due to digestion.  He knew how to eat (suck, swallow, breath), but his stomach and intestines didn’t know what to do with it yet.  The food just pooled in his stomach and turned foul (it was removed via his nasal feeding tube).

Another problem that is prevalent in preemies is reflux.  If you walk into a feeder grower unit in a NICU, you will see almost all of the babies swaddled into their bed at an incline because keeping the head up can help reduce reflux.  It seems that nearly all of the preemies that I’ve gotten to know have had reflux treated with Prevacid, Reglan or some other alternative.  Reflux is painful for the babies and often makes them fussy.  Also it often inhibits their desire to eat.  In some cases, like Owen, reflux can be silent (doesn’t come all the way up) and they aspirate on it, causing dangerous damage to the lungs.

The digestion process not being mature enough is also one of the leading causes of death and long-term disabilities in premature infants.  In many of these cases, the bowels become inflamed to the point that the tissue dies (Necrotizing Entercolitis – NEC) .  When that happens, the intestines can perforate leading to intestinal fluids filling the body with infection requiring immediate and high risk surgery.  Those that survive the surgery and the days following it, are at greater risk for Short Bowel Syndrome (not enough bowel to properly digest food) or, like Owen, neuro (brain) development issues.

Owen’s GI History:  Owen has had very significant GI issues.  As I understand it, he didn’t actually have NEC,  There wasn’t dead tissue, but there were several perforations in the top part (jejunum) of his small intestine.  When they went in for surgery, they also discovered that Owen’s small intestine was not connected to his large intestine (Ileal Atresia).  It’s unknown if this was a deformity Owen had from birth, or it was caused by the virus that attacked his intestines.  Most of the perforations were sewn up, however, a few were bigger and so the surgeon had to cut out a few small sections of bowel.  Seven weeks later, Owen went back into surgery to have his bowels reattached.

After Owen started making bowel movements, he begin getting breast milk feedings.  It started at something like 1 mL an hour and slowly moved up.  At first, Owen exceeded everyone’s expectations and he was able to increase his volume daily.  However, he reached a point, where he could not take an increase for several days.  Interestingly, this change occurred at the same time that my breast milk ran out and he was switched to formula.  At the same time, Owen developed severe reflux, a raw bottom and a reputation of being high maintenance.

Eventually, Owen stopped breathing and dropped his heart rate two days in a row with feedings.  I was there for both.  I demanded that they stop feeding him until a solution was determined.  He was switched back to donor breast milk and his feeding tube was moved down past his stomach into his jejunum to help make reflux less severe.  We slowly ramped up on his breast milk volume (with me deciding when and by how much) and waited until his lungs had recovered enough to do a Nissen surgery to more permanently prevent reflux and to give Owen his g-tube.  The surgery did wonders for Owen, he came home from the NICU 3 weeks later, at six months old.

Compared to the issues in the NICU, his GI issues were relatively under control for the next year.  Whenever we were admitted to the hospital the nutritionist would want to increase his feedings and then we had issues with dumping (yes, that is a medical term) where Owen would barely process his food and send it out the other end in liquid form (sorry if you’re eating lunch).  I got good at managing how much he could tolerate at a time and the doctors allowed me to control how much we changed, as long as I was willing to keep inching towards the nutritionists targets.  When dumping wasn’t an issue, Owen struggled with constipation in that he cried every time he pooped, however, he pooped daily and was very sensitive to miralax or pear juice being causing diarrhea, so we just kind of lived with it.  He was growing well and happy except for his 1-2 poops each day.  At the same time it was a careful balancing act and everyone knew that I was the supreme ruler on all things feeding.

This last fall, Owen became mobile and started eating orally at the same time.  As he at orally, I backed off on his tube feedings a little.  Not surprisingly, he lost weight.  However, being a former micro preemie, weight loss is taken very seriously, so his calories were slowly increased with the addition of Pediasure to his diet.  The NP in the NICU F/U clinic and I managed his diet increases together, but it seemed no matter how slow we went, we struggled to keep him from retching.  With her monitoring, I tried slowing down how quickly he got his foods, when he got his foods, what mixture of Pediasure and regular formula he got; we tweaked and tweaked, but couldn’t get him comfortable.  By retching, I don’t mean a little coughing.  I mean violent, eyes bugging out, body convulsions that would last several minutes at a time.  I felt like I was forcing food into him and several days made the decision to back off on how much he got because I didn’t want him retching.  As a result, we were constantly playing the “weight game”.  I knew why he wasn’t gaining weight; I wasn’t giving him all his calories because it was making him miserable.  Also, during all of this time, Owen stopped eating orally.  He went from 300-400 calories a day to nothing and it all started when we introduced the Pediasure.  I reached the point that my knowing Owen best was no longer working.  I asked for a GI referral.

GI Consult:  By the time we got into GI, I had it to the point that Owen was “only” retching once a day.  The GI doctor had never seen quite the combination or technique in giving him his food that I used, but it’s the best that we had.  And it was “working” in that his growth was looking pretty good.  Last week Owen was 22.5 lbs and a little over 32 inches.  That means he’s gained about two pounds since December.

I was relieved to hear that the doctor wants to come up with a solution that isn’t “Mom slowly tweaking”.  It shouldn’t be this difficult.

The doctor suspects that Owen has an allergy to the formula.  Even though Owen has had a blood test that didn’t indicate a milk protein allergy, he said it could still be milk that’s causing the problems.  Or, it could be some other ingredient in formula.  The problems are worse with Pediasure, but he still had severe eczema and constipation with the other formulas.  In terms of ingredients, Pediasure and Neosure, that Owen had been on previously, aren’t that different except that Pediasure is shelf stable and 30 calories per ounce and Neosure is a powder and we mixed it at 24 calories per ounce.  He suspects there may be a preservative that is causing further irritation for Owen with the Pediasure.  While it could also be the greater calories, the doctor is less inclined to believe that’s the problem because Owen had much denser calories with purees and that didn’t cause him issues.

Our Plan:  We will give Owen one month on Elecare Jr, a formula that is hypoallergenic.  He will not eat any other foods during this time.  If he improves; eczema, stooling and retching, then we will slowly add in foods.  We go back in one month to plan the next steps.  If things clear up nicely, we will hopefully avoid an endoscopy.  If there are still questions, we will probably schedule that procedure in the coming weeks.

Four days of the new formula in, Owen still has some retching but it’s less severe when he does it.  Now it’s more the cough and less the convulsions and bugged eyes.  He also has diarrhea 1-2 times a day instead of constipation.  I’m giving that another week before I call the doctor, because most kids do have stool changes with food changes.  Eczema hasn’t changed dramatically for the better or worse.

Formula Cost:  Our insurance does not cover formula, however, because Elecare Jr is very expensive, they are reviewing his case and may cover it.  If we ordered his formula through our medical equipment supplier, it would cost $1800 a month!  There are no stores in the metro that carry Elecare Jr (infant is available at select Walgreens), so I am ordering it through Amazon.com for a little more than $20 per can.  He goes through 18 cans a month!  Pediasure suddenly feels inexpensive!  For perspective, here’s a picture of the size of Elecare Jr can of formula next to a can of coke.

the size of a can of elecare Jr

Fingers crossed insurance will cover it!  More importantly, fingers crossed Owen is feeling more comfortable soon.

I know that’s a really dense post, so thanks to those that made it through.  However, I wanted to share, because I know we aren’t alone in these issues.  I’ll take advice from those ahead of us on this stuff too!

 

© Copyright Tatum, All rights Reserved. Written For: Ain't No Roller Coaster

12 thoughts on “Why we went to Gastroenterology and What’s the Plan

  1. “Supreme ruler on all things feeding” – good job, Momma!! Keeping our fingers crossed that the Elecare works wonders AND that insurance will cover it. Exciting to hear about the weight gain, he’s bigger than Emma! Woohoo!!

  2. For the last couple months in the NICU, if they rounded on Owen before I arrived, the attendees wouldn’t let the residents change Owen’s feeding rate or volume until I was called or arrived in person. Even though they didn’t agree with my allergy suspicion, they really did try to make sure I felt part of the decision making.

  3. Hi! My baby was on donor milk while in the NICU. She was switched to Neosure (mixed at 24 cal/ox) a week before discharge. That is when our problems started. I talked to the neonatalogist and asked if she could have an intolerance or an allergy. I was told that “All preemies have digestion issues and reflux. Her pediatrician will start her on a med.” When she came home, we had one horrible month. She was screaming constantly. She would startle from her sleep screaming. She was on three reflux meds and the head of her bed was elevated. She had to sleep in a bouncer. She was constantly vomiting. My pediatrician was great (one of the many reason why I love her). She did not dismiss my concerns as a “preemie thing”. She spent so much time trouble shooting with me.

    Finally, my baby started projectile vomiting. Her pediatrician was out of answers and had her readmitted. In the hospital, the GI looked at her for one minute and said, “This baby is allergic to milk proteins.” Her formula was changed to Nutramigen AA (it’s now called something else but we switched to Neocate because insurance). Overnight, my baby’s “reflux” had disappeared and for the first time she smiled. I’m so mad at myself for letting that go on needlessly for a month.

    Good for you, mom! Job well done! 🙂

    Oh, I found this helpful as far as insurance coverage. Also, you may want to ask a preemies group about elemental insurance coverage in your state. They were so helpful in teaching me what I needed to know to get it covered. Each state is different.

    http://www.neocate.com/reimbursement/

    Good luck to you guys! 🙂

  4. GI issues with micropreemies is no joke, is it? My little man is almost 10 mos actual/7 adjusted. We’ve dealt with severe reflux, projectile vomiting, screaming while pooping, bad gas, etc. for months and months. His pedi just kept saying it’s normal or it’s a preemie thing. (Ugh!) Our GI took one look at him and she too suspected a milk protein intolerance. After he completely stopped eating and was on the verge of being admitted for an NG, we did the endoscopy and they found gastritis and duodenitis – apparently it can be caused by the milk proteins and/or the reflux. We switched from Neosure to Neocate and 6 weeks later, he is doing better. Not perfect, but better. Stick it out – it took us at least 2 weeks to see much of a difference. I’ve read it can even take as long as 2-3 months for the elemental formulas like Neocate and Elecare to heal the gut. Good luck!

  5. Mya is on Elecare and we were told when we left the NICU that by law since she is only able to be fed by tube feedings the formula is covered. We have never paid for formula. When we were in the nicu Mya was having the reflux issues and they thought it was too the milk allergy…that was a day Ill never forget cuz I spoke up and said “she doesnt have a milk allergy. ..its reflux!” They wanted to put her on the Elecare for 8 days and see if that helped. 2 days later she had a huge apnea spell during a feeding and they ruled out milk allergy and sajd severe reflux. Well now we have tried to switch her off elecare and she cant tolerate the formula change very well so we are still on it. As long as insurance is covering it we should be ok. When you talk about the increase of the calories and volume we have the same issues. GI is pressuring us to do more but we know OUR child best and we need to do it gradually. Her small tummy can not tolerate it. She will start retching and coughing and need to be vvented right away and air just come out! We will increase her feedings by 2 mls and that is too much for her. We are always cheering for owen and your family!! Praying for progress and that your insurance will cover it!!!!

  6. Reflux apnea episodes are so scary. Plus, it just hurts to know that their feeding is hurting them so much that they shut down. I hope Owen gets some relief and he can enjoy eating and mama can enjoy peace of mind. There are so many times when it feels like we are told to just let our kids deal with things that could be fixed, but are dismissed as “preemie things”. Very frustrating, and it makes it so hard to be a good advocate.

  7. Wow, this makes me so glad our pediatrician listened to me the first time I suggested the formula could be causing problems with reflux. We were switched from fortified breastmilk to formula less than two weeks before discharge and our first weeks home were filled with severely increased reflux, screaming, vomiting and constipation; why do they DO that? I don’t think they’d change meds and discharge a baby right away, why do they do it with nutrition?

    Anyway, I’m so glad you finally got something to try to make Owen feel better. I have to say that you’re very inspiring as a preemie mama to be strong and advocate for your child.

  8. Does Owen qualify for Medicaid? My son is a former 24 weeker and he qualifies for TEFRA Medicaid which is based on his disabilities and not our income. Because he qualifies for Medicaid he qualifies for WIC. WIC, here in SC, paid for our Elecare and Neocate. I had a lady I would call each month and she would special order it for us and I would pick it up at the health department.

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