Disabled Child Suffers Bone Loss From GI Tube Feeding Regimen

This case involves a female child with cerebral palsy and reflux who required G-tube feeding. She was not gaining enough weight and was not tolerating many types of formulas. When the child was 2-years-old, a GI put her on nutritional toddler formula. The patient seemed to tolerate it well. Several months later, the child developed multiple bone fractures with no trauma, including femur and ulnar shaft fractures. Despite being bedridden, the patient broke 10 bones over the course of a few weeks. Around this same time, the child’s phosphorus levels were dangerously low and she was hospitalized. After months of working with an endocrinologist, it was determined that the nutritional toddler formula caused the child’s hypophosphatemic state. The child was weaned off the formula but was left with severe osteopenia. An expert in pediatric gastroenterology was sought to discuss whether or not the GI should have better monitored the child’s phosphorus levels.

Question(s) For Expert Witness

1. How frequently do you treat developmentally delayed patients who are G-tube fed?

2. What type of regimen do you typically recommend for patients like this?

3. What is the standard of care with regards to monitoring phosphorus levels in patients like this?

Expert Witness Response E-026174

I'm a pediatric gastroenterologist with expertise in GI disease, hepatology, and nutrition. Regarding the patient you described, I have taken care of many severely developmentally delayed patients dependent on gastrostomy tube feedings, including children with spastic quadriplegia and reflux. I have published in this field regarding the Angelchik prosthesis which was once used to treat GER in such patients. I also published a long-term follow-up in these patients, documenting the frequent complications which contributed to the withdrawal of this device from use. Regarding nutrition, these children are generally fed a completely nutritious formula or a completely nutritious blenderized diet which can be given through a G-tube. It's hard to generalize a "typical" regimen for these cases. The standard of care with regards to monitoring phosphorus levels in patients like this is also hard to generalize. I would need to review the medical files more closely.