Nutrition In Cerebral Palsy

By Chris Theberge & Angela Illing
NAFWA HOME
 

What Is Cerebral Palsy?

•      Cerebral palsy (CP) is a disability caused by brain damage before, during birth, or in the first years of life, resulting impaired muscular control/coordination and speech/learning deficits

•      Incidence: 1 out of 3,000 children


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 


Types of Cerebral Palsy

•      Spastic cerebral palsy (70 to 80% of cases)

•      Athetoid, or dyskinetic cerebral palsy (10-20% of cases)

•      Ataxic cerebral palsy (5-10% of cases)

•      Mixed forms


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


Who is Involved in Treatment?

•      Speech Therapist

•      Physical Therapist

•      Occupational Therapist

•      Behavioral Management Specialist

•      Nurse

•      Developmental Pediatrician

•      NUTRITIONIST


Nutritional Risk Factors

•       Altered growth

–    Failure to thrive

•       Gastrointestinal problems

–    D/V/C; GER

•       Drug-nutrient interactions

–    Anticonvulsants, laxatives, diuretics

•       Delayed/altered oral motor skill development

–    Poor food/fluid containment

–    Tone abnormalities

–    Altered oral sensory response

•       Feeding skill development

–    Self-feeder vs dependent feeder

•       Behavior

–    Oral Aversion, distractibility

•       Positioning for feeding and special utensils

•       High demands on the caregiver


Bone Health and CP

•      Osteopenia high among CP

•      Poor vitamin D and Ca++

–    Inadequate sunlight

–    Poor oral/supplemental intakes

•      Poor ambulation

–    Little to no weight-bearing exercise

•      Use of anticonvulsant medications

–    Increased Vitamin D needs

–    Affect fluid intake; cause constipation and lethargy

•      Malnutrition

–    Macro/micronutrient deficiencies


Common Nutritional Deficits

•      Energy (kcal/d)

•      Protein

•      Calcium and Vitamin D

•      Copper

•      Folic Acid

•      Iron

•      Phosphorus

•      Magnesium

•      Vitamin B12

•      Zinc


ASSESSING NUTRITIONAL STATUS

History and Current Intake

•      Complete review of birth, past medical/surgical, and feeding history

–   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?


Detailed Diet History

•      Studies have documented that many immobilized or partially immobilized children with cerebral palsy consume enough food to meet their energy needs but not enough to meet their nutritional needs, leading to a deficiency of fat free mass.

 

•      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.


Energy vs Nutritional Adequacy

•      Measures of fat stores using skinfold thickness proven useful in determining if nutritional needs being met

–   Deposition of subcutaneous fat a sign of nutritional needs being met

 

•      Standard weight for height ratios shown to be poor indices for reduced fat stores.

 

•      Midarm muscle circumference is highly correlated with weight


ASSESSING GROWTH STATUS

Growth Assessment

•      Estimated that about 1/3 of children with cerebral palsy related disabilities have growth disorders and nutritional inadequacy

 

•      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 5th 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


Growth Assessment Considerations

•      Nutrition and ambulation factors affect growth

–   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., Down’s 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


Growth Assessment Considerations

•      Nutrition and ambulation affect growth

–   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


DETERMINING NUTRITION NEEDS

Energy

•      Several ways to assess

–   Kcals/cm height or length

•    Cerebral palsy with severely restricted activity

–   10 kcal/cm Height

•    Cerebral palsy with mild to moderate activity

–   15 kcal/cm Height

•    Athetoid cerebral palsy, adolescence

–   Up to 6,000 kcal/day

•      Catch-up growth equations

•      Standard BEE * Activity and Stress factors

•      These are guidelines and individual requirements should be based on:

–   Changes in weight over time and/or indirect calorimetry


Protein and Fluids

•      Protein

–   RDA using chronologic age or height-age if growth significantly below chronologic age

 

•      Fluids

–   Higher needs

•    Constipation

•    Drooling

•    Excessive sweating

 

–   Use Holliday-Segar Method


Vitamins and Minerals

•      Most common deficiencies

–  A, D, C, folate, iron and calcium

•      Monitor

–  Iron, protein, vitamin D, calcium and phosphorus

•   Inadequate po intake

•   Drug-nutrient interactions

•   Decreased mobility


CHOOSING A FEEDING METHOD IN THE CP PATIENT

Why Feeding is Crucial

•      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


Can Needs Be Met PO?

•      Even though oral feedings may be difficult, they are important to children and families

•      Adding nutritional “Boosters” increases caloric density and allows for different textures

•      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


Assessing Swallowing Difficulties

•      Videofluoroscopic swallow study helpful in assessing pharyngeal motility and airway protection during swallowing

•      Most common abnormalities

–   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

–   Feeding and texture recs


To Tube Feed Or Not

•      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

•      TF’s most appropriate for severely disabled

•      Needs can be met orally, but require caloric enhancers and must be texture appropriate


References:

 
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