Nutrition In Cerebral Palsy

By Chris Theberge & Angela Illing

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 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

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., 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

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 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.

 / Krause's Food & Nutrition Therapy (9781416034018)

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).

Different Types of Cerebral Palsy

Spastic CP-increased muscle tone, persistent infant reflexes, increased deep tendon reflexes in one of three patterns: hemiplegia (arm and leg on one side of the body), diplegia (involving the lower extremities), and quadriplegia (all four extremities and may include the trunk, head, and neck) Dyskinetic CP-abnormalities in muscle tone that affect the entire body; includes athetoid CR which includes uncontrolled and continuous involuntary movements Mixed CP-a condition in which both athetosis and spasticity are present Ataxic CP-abnormalities of voluntary movement and

balance such as unsteady gait Athetoid dyskinetic CP-normal intelligence but difficulty walking, sitting, speaking clearly
Data frorn 4Mychild: what type of cerebral palsy dnes my chil.d haae? fromw. cerebralpalsy.orgltypes-of-cerebral-palsya/,c cessedJu ne I 8, 2007. Cf; Cerebral palsy.

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.