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Etiology
Unclear etiology, but thought to be caused by
Birth asphyxia (~10% cases) Abnormailties of brain development Genetic disorders Disease (e.g., rubella, genital herpes simplex) Very low infant birthweight Injury or physical abuse Maternal smoking, alcohol and/or drug use
Common Complications
Dysphagia Chronic Lung Disease Respiratory Distress
Gastroesophageal Reflux Disease Aspiration Pneumonia Osteopenia/osteoporosis Malnutrition Constipation Mental retardation and seizure disorders common co-morbidities
Feeding skill development Self-feeder vs dependent feeder Behavior Oral Aversion, distractibility Positioning for feeding and special utensils High demands on the caregiver
Did these have an effect on development? Oral feeding and feeding skill development? Current feeding skills or route, time it takes to feed, and types of foods consumed Food aversions? Choking, coughing, gagging?
Feeding problems in adolescents with low caloric intake may result in poor growth and decreased muscle mass at maturity.
These childhood and adolescent nutritional profiles are relevant to adult patients, since they result in an adult with low fat-free mass.
Standard weight for height ratios shown to be poor indices for reduced fat stores.
Most studies indicate that retarded growth is closely associated with inadequate food intake due to self-feeding difficulties and/or to inadequate control of the tongue and mouth
Growth Assessment
Weight, Length/Height, and HC plotted over time to determine growth adequacy Children often low stature and weight for their age (below 5 th percentile) Upper arm and lower leg limb length appropriate to assess linear growth
Accuracy confounded by contractures, scoliosis, inability to stand Assessment of weight for length/height indicates individual proportionality
Nonambulatory children 10 to 25th percentile is acceptable weight-for-length Accurate linear growth assessment confounded by contractures, scoliosis, inability to stand Head Circumference can skew height-for-weight and weight-for-length parameters
Growth Assessment
Weight, Length/Height, and HC plotted over time to determine growth adequacy Plot on NCHS Charts, unless concurrent conditions (ie., Downs Syndrome)
Assessment of weight for length/height more appropriate which indicates individual proportionality Nonambulatory weight-for-length 10 to 25th percentile acceptable Visual Clinical Assessment important Midarm circumference and skinfolds provide additional information
Children often small for their age (below 5th percentile) 10 to 25th percentile acceptable Accurate linear growth assessment confounded by contractures, scoliosis, inability to stand Head Circumference can skew weight-for-age and weight-for-length parameters
Standard BEE * Activity and Stress factors These are guidelines and individual requirements should be based on:
RDA using chronologic age or height-age if growth significantly below chronologic age
Fluids
Iron, protein, vitamin D, calcium and phosphorus Inadequate po intake Drug-nutrient interactions Decreased mobility
Feeding and mobility skills are powerful prognostic factors related to survival
Respiratory disease common cause of death Inability to lift chest or head in prone position and complete dependence of oral feeding from caregivers shown to have highest mortality rates
Cerebral palsy patients should be offered food that they can eat with least frustration and distress. Feeding interruptions, duration of feedings, and consumed food textures are useful historical estimates of feeding efficiency
PO Diet Considerations
Caregiver Burden
On average, mothers of children with swallowing problems spend 3.5 hours/day feeding their children as compared to 0.8 hours spent by mothers with children who do not have cerebral palsy; this increased feeding time can be as high as 7.5 hours/day. Malnutrition usually presents in early infancy and is rarely resolved by continued oral feedings Parents may be unaware that PO feedings are inadequate Many may believe that long time feeding = nutritional adequacy Many other factors as mentioned prior, such as aspiration
Aspiration
Common airway abnormalities include hypotonia of the hypopharynx, extraesophageal reflux disease, and tracheobronchomalacia
Aspiration commonly results in chronic lung disease (recurrent wheezing, bronchitis, atelectasis, and need for supplemental O2) Acute aspiration pneumonia not as common
Swallow delay, food residue after swallows, pharyngeal dysmotility, and aspiration Aspiration more common with thin liquids and usually silent without coughing or choking Oral feeding requires team approach with speech and language pathologist
Enteral feeding via gastrostomy tube is increasingly being used to provide nutrition to children with oral-motor dysfunction and feeding problems CP high risk for aspiration and malnutrition Respiratory-related problems and deaths high among the population Caregiver burden Etc Oxford Paediatric Nutrition Group (Sullivan et al., 2000) 89% (238 out of 269) needed help with feeding 55% (142 of 257) regularly choked during feeding
Oral motor dysfunction associated with poor growth, poor nutritional status, and poor health status Inconclusive evidence to support tube feeding with disabilities
Some suggest improvement in growth and nutritonal status (Patrick et al., 1986; Brant et al., 1999) Question of increase in mortality G-tube complications been described in 4% to 26% of cases (Marin et al., 1994)
Summary
Children and adults with CP are at high risk for malnutrition and aspiration Greater number of nutritional risk factors associated with greater nutrition risk CP patients are shorter in stature than typically-developing population Growth and energy assessment confounded by many factors
GT feeding shown to be effective in improving weight gain, growth and fat deposition in CP population, as well as decreasing caregiver burden; however, evidence supporting GT feeds as an effective intervention is weak. Different methodologies, outcome measures and populations TFs most appropriate for severely disabled Needs can be met orally, but require caloric enhancers and must be texture appropriate
References:
Manual of Pediatric Nutrition, 3 rd Edition, 2000
Chad et al. (2005). Body composition in nutritionally adequate ambulatory and non-ambulatory children with cerebral palsy and a healthy reference group.Developmental Medicine and Child Neurology, 47, 334-339. Sullivan et al. (2005). Gastrostomy tube feeding in children with cerebral palsy: a prospective, longitudinal study. Developmental Medicine and Child Neurology, 47, 77-85. Sullivan et al. (2004). Impact of gastrostomy tube feeding on the quality of life of carers of children with cerebral palsy. Developmental Medicine and Child Neurology, 46, 796-800. Patrick et al. (1986). Rapid correction of wasting in children with cerebral palsy. Developmental Medicine and Child Neurology, 28(6):734-739. Brant et al. (1999). Improvement of children's nutritional status after enteral feeding by PEG: an interim report. Gastrointestinal Endoscopy, 50, 183-188.
Cerebral Palsy
Cerebral palsy (CP) is a disorder of motor control or coordination resulting from injury to the brain during its early development. Among the causative agents of CP are prematurity; blood type incompatibility; placental insufficiency; maternal infection that includes German measles; other viral diseases; neonatal jaundice; anoxia at birth; and other bacterial infections of the mother. fetus. or infant that affect the central nervous system. The problem in CP lies in the inability of the brain to control the muscles, even though the muscles themselves and the nerves connecting them to the spinal cord are normal. The extent and location of the brain injury determine the type and distribution of CP. The incidence of CP varies with different studies, but the most commonly used rate is 2 to 3 per thousand live births. The prevalence of premature births has contributed to maintenance of this figure despite electro-fetal monitoring. There are various types of CP, which are classified according to the neurologic signs involving muscle tone and abnormal motor patterns and postures. The diagnosis of CP is generally made between 9 to 12 months of age and as Iate as 2 years with some types (Box 45-1).
Health Concerns
Poor nutrition status and growth failure, often related to feeding problems, are common in children with CP. Meeting energy and nutrient needs is particularly difficult in children and adults with more severe forms of CP such as spastic quadriplegia and athetoid CP. For example, bone mineral density of children and adolescents with moderate tosevere CP was reduced in those with gross motor function and feeding difficulties (Henderson et al., 2005). Other health problems include constipation, usually caused by inactivity and lack of fiber and fluids, often connected to feeding problems. Dental problems occur and are often related to malocclusion, dental irregularities, and fractured teeth. Lengthy and prolonged bottle-feedings of milk and juice promote the decay of the primary upper front teeth and molars (see Chapter 25). Hearing problems and especially visual impairments, mental retardation, respiratory problems, and seizures impact nutrition status. Seizures are controlled with anticonvulsants, and a number of drug-nutrient interaction problems occur (see Chapter 16 and Appendix 31).
balance such as unsteady gait Athetoid dyskinetic CP-normal intelligence but difficulty walking, sitting, speaking clearly
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Nutrition Assessment
Anthropometrics. This is an important area of assessment because of the growth failure of the more severely involved child or adult with CP. Children with CP are often shorter, and depending on the level of severity,
Intervention Strategies
A high percentage of children with CP have feeding problems that are largely the result of oral-motor, positioning, and behavioral factors. fu infants they have difficulty swallowing and coordinating swallowing and chewing, so that the normal progression to solid foods is later than usual. All this may lead to inadequate intake and growth limitations. For those infants and children in IEPs, the team of dietitian, speech therapist, occupational therapist, and physical therapist should evaluate the problem and work together in planning therapy. Gastro esophageal reflux also is frequently seen in these infants and toddlers and a tube feeding may be required if a modified barium swallow reveals aspiration. This then requires that the formula prescribed be evaluated for caloric and nutritional value and volume required and directions be given for inclusion of solid foods in addition to the formula. The most usual problems identified in the evaluation will be altered growth, inadequate energy provided, inadequate fluid intake, drug-nutrient interaction problems, constipation, and feeding problems. Working out an intervention plan is most successful when it involves the parent as part of the team, addresses cultural issues, and recognizes the importance of the feeding problem. Children with CP have complex problems that will require continuing follow-up with the family and in the community and will take time to correct. There are agencies within the state that provide tube-feeding formulas and special wheelchairs and equipment to assist with feeding problems These agencies vary from state to state and are addressed in the section on resources.