Upon writing a letter to a friend of my parents-in-law, who works in the medical profession, seeking advice as to how to move forward, I had to bring my records of Toby’s medical journey up to date. Here they are, in the hope that they can be helpful to parents out there who may be struggling with the same – or similar – issues…
Letter to parents’ friend, working in medical profession:
Thank you so much for allowing us to make contact with you and for being willing to take some time to give thought as to how we can move forward in our present situation with our son, Toby.
Toby was born at 32+2 weeks – for no known reason (our daughter was delivered at 40+6). Both SVD, no complications. Toby arrived breathing on his own and spent little more than 24 hours in ICU before being moved to SCBU. He made very quick progress in NNU but remained there for 5 weeks, mainly due to getting his feeding underway before discharge.
I have attached a thorough medical history and story of Toby’s journey to date. However, the reason we are now in touch is that Toby has been exclusively feeding by NG tube for three and a half months and we are increasingly at a loss as to what to do about it!
We are being seen at our local hospital, where Toby was born (in the Antenatal Ward with no-one present in the room, I might add! – doesn’t instill the greatest confidence, does it?!) and most recently – back in late February – have been referred to a gastroenterologist. By all accounts he has a brilliant reputation, working between two hospitals, as well as privately. However, we just feel as though things are moving so very slowly. All sorts of symptoms and worries crop up between appointments and I often find myself going quietly mad at home, not knowing who to talk to or where to turn with my thoughts and speculations in the waiting period.
To be quite honest, I am exasperated, tired, stressed and down about all this. I feel at a loss. I really am so desperate for some answers. I am desperate to try and get Toby feeding normally, to get the NG tube out and undergo some kind of ‘feeding therapy’ to overcome any psychological barriers that seem to be in place between him and oral feeding.
We wonder how much more quickly, if at all, things would move if we were to be seen elsewhere or, indeed, privately; and, if the latter, who you might advise us to see. We have got to the stage where we are questioning whether it is worth sticking at it with the people who have seen Toby to date, or going somewhere else, where someone can take on Toby’s case with fresh insight – and perhaps give Ed and I some fresh vision in the process, where things have begun to feel somewhat stagnant!
If you are able to help/advise in some way we would be very grateful. We are tired and longing to find some answers, rather than the endless further questions that seem to be thrown up at every ‘test’ and stage of Toby’s evaluation. We would so appreciate any thoughts you may have on the situation and we are extremely grateful to you for being willing to give this a glance.
I do apologise for the length of my attachment. It is difficult for me as a non-medic to know what is essential to the story and what becomes narrative and waffle! I did feel it important to include as much of Toby’s history as possible – and have mentioned things have that have cropped up over the last seven and a half months, even if they have since been ruled out or become non-issues.
Toby’s Medical & Feeding Journey – from birth until May 2014
Toby’s background
- Toby was born at 32+2 weeks on 29/09/13. He is now 32+5 (with a corrected age of 25 weeks today).
- He is being monitored for a moderate (3mm) VSD, although the cardiologist has assured us that Toby’s heart is not a contributing factor in any feeding or breathing difficulties. I can of course forward notes from our most recent visit with him.
- Toby has had two general anaesthetics for two inguinal hernia repairs.The first operation was on Thursday 31 October 2013, before Toby’s discharge from NNU – it was on his right side and the hernia only ever became a small lump in his groin area before the repair was made. He failed extubation and so was intubated again and overnight. During that time, a chest X-ray revealed that an upper lobe of his right lung, I believe it was, collapsed. By the morning after Toby’s operation he was having some assistance with breathing via CPAP but by lunch time he was fully recovered, breathing on his own again and was transferred back to our local hospital and discharged home the next day (Saturday 2 November 2013).
The second hernia was discovered the day after discharge from hospital but Toby’s operation was not until Friday 3 January – unfortunately the hernia had been left for nearly 9 weeks and had turned in to a very large bulge that descended in to Toby’s scrotum and was much more difficult to reduce, although it did remain soft. Post operation Toby did not experience any of the same difficulties with breathing that had manifested after his first op; his breathing struggles after the first op were attributed to Toby’s prematurity at the time.
[It is perhaps worth noting here that Toby’s feeding (which was oral at the time of both operations) dipped on each occasion and never fully recovered to what it had been prior to the ops; this is particularly true of the second, most recent operation at the beginning of this year.]
- Toby has also had a tongue-tie release, which was performed on the same day as his first hernia operation.
- Toby also had an umbilical hernia, which was left to sort itself out in time and no longer appears to be an issue.
- He received the RSV vaccine, Palivizumab, over the winter months to prevent chest infection, for which he was deemed to be at greater risk because of both his prematurity and VSD. He had his last dose at the beginning of March, receiving 5 doses in total from November of last year.
- He has received all his routine vaccines to date and the next are due at 1-year.
- He is on Nutramigen AA for suspected cow’s milk protein hypersensitivity (diagnosed on Friday 24 January 2014)
- He is nil by mouth with his milk feeds and NG tube feeding only (as from Wednesday 29 January 2014)
Hospital Admission
Toby was admitted to our local hospital on Monday 27 January 2014 – due to poor feeding and weight gain – and returned home, after three nights in the Paediatric ward, nil by mouth and NG tube feeding only because of fears that he may have an unsafe swallow and could be aspirating milk when he feeds orally. (He has since had a video fluoroscopy, which was rather inconclusive, though my understanding is that we are no longer as concerned about aspiration – although for as long as he is nil by mouth it is less of a concern, of course, so how black and white it is, I don’t know).
Prior to hospital admission and the NG tube being fitted Toby was becoming very fussy and uncomfortable at the teat – sometimes refusing to feed altogether, other times taking 10-20ml at a time. Every once in a while, I assume when the hunger mounted, he would take a full 90ml bottle, though this rarely happened. His average 24-hourly intake was 300ml, less than half of what it should be and he had been dropping off his centiles, beginning on the 50th and resting on the 2nd when he was admitted. He started to steadily climb again, with the NG tube in place and was hovering midway between the 2nd and the 9th centile, although most recently he has fallen just below the 2nd centile (however, he has been admitted to hospital twice over the last fortnight, with bronchiolitis and then, a week later, with a secondary bacterial lung infection, which may go some way in explaining his most recent dip in weight).
He is also now on Nutramigen AA, having been diagnosed with suspected cow’s milk protein hypersensitivity by an NNU consultant on Friday 24 January at a routine check-up. Prior to that point we had worked our way through various anti-reflux medications (Domperidone, Omiprazole), as prescribed by my GP, and also an anti-reflux milk, Enfamil AR, as suggested by the Nurse Practitioner from NNU, who used to visit us at home, when reflux was suspected to be the cause of his discomfort. I had not been able to put Toby down due to his discomfort and fussiness; he spent all day on me in a baby carrier; he cried and fussed a lot, seemed to have abdominal pain etc. – though it was my concerns with his breathing which took me in for an early cardiology appointment, back on Thursday 9 January, and where the cardiologist told us that his heart was doing well, was not responsible for his breathing issues and that we might consider reflux as being responsible (he also followed up this appointment with a letter to the gastroenterologist, requesting that Toby be seen in his feeding clinic). None of the anti-reflux meds or milk seemed to be making a difference to Toby’s apparent and continuous discomfort and after trying Nutramigen Lipil 1 – to no avail – we ended up on Nutramigen AA.
The problem was that by this point Toby’s feeding itself had become so dire, to the point that he was hardly feeding at the bottle at all – but I desperately wanted to see if the milk was going to make a difference to Toby’s comfort and over all wellbeing. I opted to orally syringe feed Toby full 90ml feeds 3-hourly over a weekend (25, 26 Jan) just to determine if we were on to a good thing with the milk. He screamed all the way through the feeds but we had a much happier baby in between. For the first time we were able to sit him in a baby bouncer and he seemed content and pain-free. However, by Monday morning (27 Jan) I knew I could not continue oral syringe feeding and neither did I want to perpetuate any possible feeding aversion Toby may have by ‘force feeding’ him. It was at this point that the nurse practitioner came for a home visit at the NNU consultant’s instruction to try a few test feeds (different teats, a spoon, cup, etc.) to determine for herself that Toby was a baby who did not want to feed. It took her rather longer to reach that conclusion than I would have liked, considering we’d had weekly visits from her since Toby’s discharge from NNU and I had expressed my concerns both with the volume Toby was taking and also his discomfort. Much to my relief, she was finally seeing clearly what I had been observing for some time.
That is the run-up to Toby’s hospital admission and the NG tube being fitted.
[It is worth noting here that an MRI was done to determine whether there could be any neurological cause for his feeding or suspected swallowing difficulties. The MRI scan was clear and he also had a chromosome check in NNU, the results of which came back as normal.]
Feeding History:
It may be worth mentioning that Toby began his life on my expressed breast milk and came home both bottle and breast feeding. I breast-fed our first child for one year, with no bottles or formula required, so have some experience of ‘successful’ breastfeeding, however with Toby it never seemed to get off the ground and it gradually became more and more difficult. Toby would come off the breast screaming and I was convinced he was not satisfied – and pretty sure my once plentiful milk supply was diminishing in the mean time. I struggled to keep up the regular expressing that I had managed when visiting in NNU now that I was back at home with my toddler vying for my attention as well. I stopped breast feeding and – after my frozen EBM supply had run out – Toby started on SMA Gold Prem 2 on his due date, November 22 2013, at 7+5 weeks of age. At this stage I was not keeping a feeding diary but Toby’s feeding certainly continued to go downhill – and more so. I was told that I probably just had a ‘colicky’ baby and even reflux was dismissed at that stage (Toby was very rarely sick).
I remember thinking Christmas at home with my family in Oxford was a nightmare! For the first time, other people were witnessing just how difficult things were with Toby. Feeding was a struggle and it was so hard to put him down, before he would appear to be in some kind of seemingly acute pain/discomfort. He still had the left inguinal hernia at this point – and it was really rather large – so in my limited medical knowledge I did wonder to what extent that might be bothering him and I wrote a strong letter to the hospital pleading with them to bring the date of his operation forward, which they managed to do by a week.
After Toby’s second hernia op on 3rd January Toby’s feeding had got much worse. I remember the nurse looking after us, as we spent the night at hospital, was well aware that things were not going well with feeding and I could tell she was a little concerned. However, I was desperate to get home to my husband and toddler (our daughter does not cope well when I am not around, particularly after the 5-weeks of visits to NNU without her, after having been used to spending every day with one another) and when the registrar came round to talk about Toby’s discharge – what with knowing that feeding had already been an ongoing struggle, coupled with me thinking that at this point I was simply dealing with ‘colic’ – it was deemed okay for us to leave.
I began a feeding diary on Wednesday 8 January, after things just seemed to have reached rock-bottom. Toby would refuse the teat, or play with the teat, or sometimes suck just 10-20ml – and very rarely complete a 90ml bottle (I imagine now that this took real courage on his part!) Toby was still crying a lot, nearly impossible to put down so usually on me in the baby carrier, difficult to settle. I guess that, as well as being in pain, he was probably actually hungry a lot of the time, too, given how little he was eating (on average 300ml/24 hours).
On Thursday 9 January we started Toby on Domperidone (my GP prescribed at the suggestion of the Nurse Specialist where we were seen for Toby’s heart, who we saw that day and who suspected Reflux).
On Saturday 11 January we stopped Domperidone and started Omeprazole, after my friend had mentioned having most success with this – and because Domperidone was not making a difference.
On Tuesday 14 January we stopped Omeprazole and began Toby on Enfamil AR formula milk – at the recommendation of the Nurse Practitioner from NNU, who was still doing home visits at this stage.
On Wednesday 22 January, I raised with the nurse practicioner the possibility that it could be a cow’s milk allergy. I had mentioned this some weeks prior – towards the end of 2013 – but it had been dismissed as being unlikely because Toby did not have any of the ‘classic’ symptoms, such as dry skin, diarrhoea, blood in stools, etc. Once again, she told me that she thought it very unlikely and to continue as we were. However, later that day she called me at home and said she had been thinking about it and decided that she thought it was worth a try, as we had tried everything else. She brought me a few tins of Nutramigen Lipil 1 and Toby started on this.
On Friday 24 January Toby had a routine check-up with the NNU consultant. It was the first time I had opportunity to speak with a paediatric consultant about Toby’s feeding difficulties. We had not noticed an improvement with the Nutramigen Lipil 1 and it was here that Toby was diagnosed with ‘suspected cow’s milk hypersensitivity’ and was started on Nutramigen AA.
Knowing how reluctant Toby was to feed, I orally syringe fed him his feeds for two days over the weekend, to discover that he seemed content with the milk. However, the feeding was a nightmare and not sustainable and if left to his own devices, Toby would still not feed enough for himself.
On Monday 27 January, the nurse practicioner did a home visit to witness first-hand that Toby did not want to feed and she recommended that we go to A&E with a view to having an NG tube fitted and getting Toby admitted.
Video Fluoroscopy:
We had a very frustrating video fluoroscopy on Tuesday 11 February. As my friend put it, “they want him to do the thing he can’t do in order to find out why he can’t do it!” Toby was unable to suck at the bottle for long enough to record anything of any value for analysis. Perhaps he was out of practice, though his feeding on Tuesday was not very unlike how it had been before the NG tube went in, so I’m not sure how much that is responsible.
A very minute amount of aspiration was seen but it was so small an amount and only happened once in the footage that was obtained and the SALT specialist was not convinced it was at all representative of Toby’s problem. She was, in fact, rather frustrated it happened and that she was, therefore, obliged to mention it in her report, as she feels it may have been a ‘red herring’.
It was decided that the study was inconclusive and the gastroenterologist certainly does not seem overly concerned about the suspicions of an unsafe swallow – though of course Toby is tube fed so at present it does not have to be so much of a concern!
Toby’s breathing:
Toby’s ‘normal’ has been to breathe slightly on the fast side and he does seem to breathe abdominally to some degree, with mild recessing under his rib cage, although it is not – and has never been – observed on his throat.
He has always seemed to be a little congested and he has always had an intermittent – though ongoing – cough and often his breathing has sounded ‘grunty’ (he is a noisy breather generally), occasionally wheezy and his chest rattly (which I’ve got used to).
As I mentioned above, the cardiologist is not concerned about Toby’s heart and does not attribute Toby’s breathing or feeding difficulties to his heart. It has, at times, made me worry about his little lungs, however there has never seemed to be anything of any concern when he has had a chest X-ray; and every time our GP has listened to his chest it has sounded clear, so it seems to be upper respiratory.
[Over the last few weeks Toby has had a chest infection. On Tuesday 29 April he was admitted to the paediatric ward of our local hospital, with suspected bronchiolitis. His respiratory rate was up to 72 and he’d had a fever for five days. He had assistance with oxygen for about 24 hours before returning home. Six days later we were back there with him, after a suspected secondary infection – this time bacterial, possible pneumonia – and he spent one night there, after having been started on antibiotics. However, my comments above regarding what seems to be ‘normal’ for Toby are made quite apart from this recent episode of chest infections. At present, Toby is recovering well; off antibiotics; still sounding a bit crackly under the stethoscope and still coughing but all a recovery from the bronchiolitis, we’re led to believe.]
I had wondered to what extent – if any – the RSV vaccine Toby received over the winter months (Palivizumab) could have masked anything untoward going on – I don’t know, perhaps lessened or disguised any damage being done… But I have been told this is not a concern. However, it is worth bearing in mind that the very month the RSV vaccine stopped was the same month he became ill with a chest infection.
And despite the frustrating and inconclusive video fluoroscopy I have still had concerns about aspiration of milk.
Back at the beginning of April I ‘aired’ my concerns about the possibility that Toby could perhaps sometimes be aspirating refluxed milk, as opposed to milk when it first enters the mouth. Although he has not shown the symptoms of extreme discomfort that he used to – when we first explored reflux being an issue – it could be that the Nutramigen AA has sorted out the symptoms associated with cow’s milk protein hypersensitivity and the discomfort, abdominal pain etc. – but that some non-painful reflux is still happening, in which case it is not impossible that Toby could perhaps be aspirating some milk when it travels back up his oesophagus. It would perhaps explain his breathing struggles if that were true; it would also explain why his breathing has often been particularly affected after a feed. I would have expected this if Toby had to work for his feed – but he doesn’t as he has been nil by mouth; it is all through the NG tube. He, therefore, has no reason to be tired after a feed, which says to me that any breathing difficulties as a result of a feed by NG tube must be something to do with milk being displaced somehow. Does that make sense? But if this were true I suppose we would have expected ongoing chest infections – and the X-rays he has had would have shown something.
I am just laying everything on the table, so you know the complete history, the concerns that I have had – even if they are not so current – and ‘thinking out loud’ because I feel I must!
Vomiting:
On coming home with the NG tube I observed that Toby was bringing up milk – both during and after a feed – much more than prior to the NG tube being fitted; I had supposed because for the first time he was dealing with larger (i.e. the correct!) volumes of milk.
At first it was a delicate balance for me trying to get the volumes of milk as well as the time between feeds right. I played around with this a lot, as it seemed that Toby was struggling with larger volumes. However, I was beginning to wonder whether some of the ‘intolerance’ seen was not merely to do with volume overload in Toby’s tummy but rather a problem with reflux, though he did not appear to have any of the associated pain one would expect with reflux – no arching of the back etc. In the early days after the NG tube being fitted, the forceful vomits happened infrequently; for the most part he was just bringing up small and frequent regurgitations both during and for some time after a feed.
We had our first appointment with the gastroenterologist on Thursday 27 February. He referred Toby for a 24-hour pH probe study, which Toby had the following week, on Thursday 6 March. The results of this indicated very mild reflux of only 1.3%. For me, although I should have felt relief, I was most frustrated by this result. I would have loved to have something to ‘pin’ Toby’s troubles on!
However, since that time, Toby’s vomiting has got worse and it has become progressively worse since. He vomits about two to three times a day. We now see very forceful vomits, rather than the smaller regurgitations I mentioned we used to see. Milk will come out of Toby’s nose, as well as a gushing fountain from his mouth. His vomits quite often push the NG tube from his nostril.
It has made feeding such a palaver. I have felt inhibited at times to do anything, for fear of him vomiting! I met my mum and brother for lunch – and Toby vomited in the restaurant; I went to the park with our daughter – Toby vomited. It has made going out and doing anything a real hassle and I start each feed with such trepidation, uncertain of whether he is going to vomit it all up (bearing in mind for some time he was bolus feeding and so I was holding on to a syringe with one hand when all this happens, which made handling the situation a whole lot trickier!)
I have, at times, had concerns about how little he poos. Once every 24 hours is pretty standard; and I have often had to help him with that by drawing his legs back and wiping his bottom to help things along, as I may have noticed him straining earlier on but not found anything in the nappy when I come to change him. Though I must say this does seem to have improved. He still doesn’t poo a lot but I don’t have to help him to pass stools anymore.
The intolerance of much volume of milk, combined with infrequent and often difficult to pass poos, did make me wonder about Pyloric Stenosis back in late March/early April. I read that a baby can develop it during the first six months of age (despite that being very rare) and Toby’s corrected age was just four months at the time of my concern. However, Toby has always appeared a very healthy baby – not at all lethargic or dehydrated – and he was not vomiting every feed, so my GP thought this a most unlikely diagnosis and it is no longer a concern as we would know about it by now!
I had been unable to decipher between discomfort caused by an over-stretched stomach and discomfort that could be as a result of reflux or some other underlying problem. However, I am less and less convinced that the problem lies with how little/much I feed Toby and the timings between feeds per se – but rather think that there must be something else responsible for what we are seeing.
Feeding Pump & Weaning:
We received delivery of a feeding pump on 3rd April, as ordered by Toby’s dietician, with a view to administering the feeds over a longer period of time than gravity allows for with bolus feeding. However, I must say that for me it feels like a step backwards and I really do not want to get stuck in these temporary solutions – I am desperate to get to the bottom of what is causing all this trouble for Toby.
I have from time to time tried offering Toby a bottle again – purely out of interest – and Toby was not at all able/willing to suck at the bottle and became uncomfortable and unhappy with me trying so I have stopped.
[By the way, he has no problems with his sucking ability. He will suck on a pacifier fine and has a strong suckle if you place a finger in his mouth. And he enjoys suckling – but just not at the bottle.]
I now take my cues from the dietician, with less room to ‘tweak’ volumes and timings myself. He has 5 feeds of 154ml of slightly concentrated formula (so as to reduce volume per feed) over an hour. I have been asked not to administer the feeds over any longer than one hour, to allow Toby adequate breaks between meals and try to let hunger mount.
We were instructed back in late February, when we first saw the gastroenterologist, to wean Toby early, taking it slowly and gently. We started this on Monday 10 March (Toby would have been 23+1 weeks, corrected age of 15+3 weeks). We would offer a few teaspoons of pureed fruit/veg from time to time. Toby was still thrusting his tongue forward a lot and would never voluntarily open his mouth for food. He was also gagging/choking quite a lot on what was offered. I took things gently and tried this on and off for a few weeks but decided that he was probably not ready and so took a break.
We had just begun offering solids again before Toby became ill with bronchiolitis. There had been some improvement, in that Toby was not tongue thrusting so much and would sometimes open his mouth as though he was interested. Sometimes he would take a few spoonfuls with no apparent unease – but more often than not it was clearly not a particularly comfortable or happy experience; or rather it would quickly deteriorate. He would easily gag and sometimes choke – and I was finding it difficult to know what was ‘normal’ for the weaning experience and what was individual to Toby and any particular difficulties he may have.
We stopped offering solids whilst Toby was poorly as he was coughing so much and had a lot of mucous/phlegm that was coming up with his vomit and we felt it best to take another break.
Now that Toby is markedly better, we began offering solid food again on Monday 12 May. However, my experience is that Toby is simply unhappy with anything that is offered to him orally. He seems to show some initial interest when the flavour of what is offered hits his tongue, however as soon as anything hits the back of his throat he becomes distressed. He gags, chokes and tends to only swallow out of necessity if food builds up at the back of his throat. Once he ‘cottons on’ to the process of what is being introduced and realises he’s not comfortable with the experience, he becomes over all unhappy and clearly does not want me to continue – and so I don’t!
Barium X-ray / delayed gastric emptying:
Due to the sheer amount of vomiting that we witness, we were concerned that there may be an issue with the rate at which Toby’s stomach empties. This is something we raised with the gastroenterologist last time we saw him, back in early April. We requested that a barium X-ray be done to determine to what extent, if any, this could play in to Toby’s vomiting and feeding issues. His opinion was that the study was not necessary but he booked it in anyway – to appease us I think. We had a letter through a few days ago, confirming that the study will be done on Monday morning. I will be interested to know of the results.
Tube dependency/tube weaning and moving forward:
Quite apart from what comes back from that barium X-ray, my most current thoughts/concerns are that it is the very presence of the NG tube that is working against our being able to move forward with weaning Toby on to solids with any success.
It strikes me that the NG tube risks perpetuating and in fact worsening any feeding aversion that Toby may have.
The only oral experience that Toby has of food in his mouth is that which is propelled back up from his stomach in forceful vomiting. All he knows is a build up of backed-up food in his throat, making him gag and choke. That and the fact that he has something constantly down the back of his throat and having to be often reinserted, which makes him distressed. No wonder his instinct is to gag when food offered on a spoon reaches the back of his throat.
We long for Toby to feed normally; to enjoy the process of weaning on to solids, to enjoy flavours and textures; to be able to manipulate the food in his mouth effectively and to swallow easily. We long to be able to take the NG tube out.
I have been tempted myself to risk taking it out and leaving it out and to see how things go if we allow his hunger to mount to the degree that he perhaps feels able to drink from a bottle again or accept food from a spoon. But I am aware that I would be taking matters in to my own hands, that Toby would be at risk of dehydration and would certainly lose weight (which would of course need careful monitoring, especially given that it is something we are trying to work on getting up at the moment!) As another mum put it, it would perhaps be a rather drastic ‘sink or swim’ method and not necessarily helpful at this stage.
Increasingly, however, this is where we are at in terms of the direction we would like to go with Toby. We have read a little around the area of tube weaning – there appear to be programmes in place, however these don’t seem to be endorsed or facilitated by the NHS. Perhaps I am wrong. Perhaps there is support for this exact kind of thing.
These are all things that we intend to raise with the gastroenterologist at our next meeting on Thursday 22 May – and I will ask him for his opinion, as well as whether he knows of where we could go for support along these lines.
If we were to do something as drastic as to take Toby’s tube out, ideally we would have the blessing, support and advice of the medical staff who have been involved in Toby’s journey to date, rather than to be left feeling isolated and as though we were going against their advice.
We have recently read an article published by SAGE, entitled ‘Prevention and Treatment of Tube Dependency in Infancy and Early Childhood’ – the online version can be found at: http://can.sagepub.com/cgi/content/abstract/1/2/73
We would like to be able to discuss its findings as we move forward with all-things-Toby and all-things-NG-tube and for it to be taken seriously as we express our concerns as to the problems we are facing with his feeding at present.
florencejoy 