Transitioning to bolus feeds

RylanDakota · #1 09-29-2010, 10:49 PM

Rylan is currently on continous feeds 24 hours a day. She is at 40mL/hr.

We are trying to get her to take food by mouth, but why eat by mouth if your belly is always full?

How do you transition to bolus feeds??

saywhatyouwill · #2 09-30-2010, 08:18 AM

by trial and error. look at how much volume you give in 24 hours, then try to come up with a possible schedule for bolus: how much volume over how long a period? how many times per day?

for us, continuous feeds were to try to reduce vomiting, so switching to bolus was pretty tricky: too much in one go and it just all came back.

can you dietician suggest a starting point?

good luck.

RylanDakota · #3 09-30-2010, 09:31 AM

Quote:

Originally Posted by saywhatyouwill

by trial and error. look at how much volume you give in 24 hours, then try to come up with a possible schedule for bolus: how much volume over how long a period? how many times per day?

for us, continuous feeds were to try to reduce vomiting, so switching to bolus was pretty tricky: too much in one go and it just all came back.

can you dietician suggest a starting point?

good luck.

Our insurance doesn't cover one...nice huh? We see Pulm. in November and they are going to sneak one in for us and just bill it different. No one wants to start bolus...won't give me a reason why. We are trying to get her to eat by mouth, but are basically being set up for failure since she never feels hungry.

saywhatyouwill · #4 09-30-2010, 09:51 AM

Quote:

Originally Posted by RylanDakota

We are trying to get her to eat by mouth, but are basically being set up for failure since she never feels hungry.

we had that same problem, and ALSO the attitude that so long as emily was gaining weight they weren't concerned how. from a medical point of view they just wanted to see her grow; from a parent's point of view we wanted to see her eat!! it's so important. continuous feeds are unnatural...teaching emily to recognise hunger even once she must have been feeling it wasn't easy.

why is rylan getting a continuous feed? i'm asking because wondering if there's any reason you can't adjust her feeds yourself? (e.g. our hospital wanted emily to be on 3 hourly 1 hour feeds...not happening at home!! we needed sleep!)

RylanDakota · #5 09-30-2010, 10:26 AM

Quote:

Originally Posted by saywhatyouwill

we had that same problem, and ALSO the attitude that so long as emily was gaining weight they weren't concerned how. from a medical point of view they just wanted to see her grow; from a parent's point of view we wanted to see her eat!! it's so important. continuous feeds are unnatural...teaching emily to recognise hunger even once she must have been feeling it wasn't easy.

why is rylan getting a continuous feed? i'm asking because wondering if there's any reason you can't adjust her feeds yourself? (e.g. our hospital wanted emily to be on 3 hourly 1 hour feeds...not happening at home!! we needed sleep!)

I know what you mean about the gaining weight...but this kid gains an ounce a day now!

It's time to back off a bit!

I would say she is continous because of reflux. It is either under control with meds, or she outgrew it. She spits up maybe twice a day. It's definently the reflux, back arching, crying though.

It's time to be a big girl!

Niff · #6 09-30-2010, 01:17 PM

Mackenzie was on a continuous feed back in February because of her Nissen and we worked up to bolus feeds without any outside guidance.

My advice is to come up with a goal. For us, it was 4 boluses and a continuous at night. The continuous carried the bulk of her calories. Then we picked the times that we wanted everything to happen. We wanted boluses at 9am, 12pm, 3pm, and 6pm and the continuous to run from 10pm to 6am. Math came into play as we decided how many cals/ounces we wanted during the day versus night. We settled on 90 cc (the equivalent of 90 cals) for the bolus and the rest to go over her continuous feed. We increased her rate by 5 to give her a couple hours of the pump, and those hourse were our starting points for boluses. For instance, she had an hour off the pump at 8am, since 9 was going to be her first bolus.

Then we started increasing the rate of the boluses by 5ml an hour while keeping the dose the same. Some days she didn't tolerate it well, so we hung out at that the previous day's rate... some days we had to slow it back down. We went with how Mackenzie acted and steadily pushed to increase her stomach size. I think it took us 2 months to get her on the bolus schedule we wanted. Then we worked on getting her off the continuous at night by building up on the volume of her boluses while simultaneously getting her to transition to gravity boluses instead of pumped. We had been pump free for almost a month, but with her sick again I've turned to the pump at night to get in the cals she can't take during the day. (Which reminds me, don't push things when she's sick... her gastric motility will be slower, and it's entirely common for kids not to tolerate the same rate/dose as they did before getting sick.)

The big thing to remember is you don't want to do too much at once. Take small steps and you'll do just fine.

kadiera · #7 09-30-2010, 01:50 PM

I think I'd work it similar to Niff, and just sit down and do the math. We shifted Alexander from 8 bolus feedings when he came home (every 3 hours) to 5 feedings over the course of maybe 6 weeks, and had to increase calories to match his growth part way through it, and we just sat down with paper and wrote it all out.

Right now you're at 40/hour * 24 hours - that's 960 ml. Maybe start by doing 45/hour and figuring up how much time you need to get everything in, and taking 2 breaks, an hour each? Then in a couple weeks, go to 50/hr and so on.

drct1245 · #8 10-01-2010, 12:13 AM

Quote:

Originally Posted by RylanDakota

Our insurance doesn't cover one...nice huh? We see Pulm. in November and they are going to sneak one in for us and just bill it different. No one wants to start bolus...won't give me a reason why. We are trying to get her to eat by mouth, but are basically being set up for failure since she never feels hungry.

Amazing that your child who has a g-tube isn't allowed an RD... blows my mind when insurances thinks parent are expected to be nurses, doctors, RD, etc.

Do you have an IFSP? Can you get an RD in through that? We were able to receive an RD though Ayden's IFSP and then now we actually use the county health service. She comes max every 2 months, but if all is well, she only comes in about ever 6 mo.

We have never transitioned since Ayden has always been on "meals". Ayden never handled true boluses, we always had to feed him over an hour's time or it all came back. He was allowed to take his bottle orally for 20-30 minutes and then he got the last of his food over 1/2 hr to 45 minutes depending upon how much was left. He never really figured out what hunger was though.

good luck... just go slow... it may take an entire month to transition. You may not want to call it a "bolus", some Drs freaked out about that word with us.

saywhatyouwill · #9 10-01-2010, 08:01 AM

dawn: same here!! we considered emily to be on "bolus" but really given that it took min one hour for us, too, it probably shouldn't have been called that!

RylanDakota · #10 10-01-2010, 01:25 PM

She is still NGT fed, but will be getting a G-tube probably in November/December.

For some reason Pulm is all about her eating, so when I called yesterday they told me to try bolus feeds (40mL over 30mins). I started at 40mL over 45mins and am cutting it back 5 mins each feed to see what she can handle. She is eating right now for 35mins and seems to be fine!

Over the weekend we will be at 40mL over 30mins and then Monday, I will up the 40mL to 45mL and see how she is...

Hopefully this will work!