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Malnutrition in neurologically impaired children

Malnutrition in neurologically impaired children. Koen Huysentruyt. BeSPGHAN – BelAPS conference October 2016. Introduction Nutritional assessment Nutritional support Outcome Conclusions. Classification. Spastic syndromes Diplegia, hemiplegia or quadriplegia Increased tone

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Malnutrition in neurologically impaired children

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  1. Malnutrition in neurologically impaired children Koen Huysentruyt BeSPGHAN – BelAPS conference October 2016

  2. Introduction Nutritional assessment Nutritional support Outcome Conclusions Classification • Spastic syndromes • Diplegia, hemiplegia or quadriplegia • Increased tone • Signs of upper motor neuron syndrome • Contractures of affected muscles • Dyskinetic syndromes • Involuntary movements • Contractures not common • Ataxic syndromes • Hypotonia & incoordination • Ataxic movements Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers. Surveillance of Cerebral Palsy in Europe (SCPE). Dev Med Child Neurol 2000;42(12):816-24.

  3. Introduction Nutritional assessment Nutritional support Outcome Conclusions Prevalence of malnutrition in CP Pascoe J, Thomason P, Graham HK, et al. Body mass index in ambulatory children with cerebral palsy: A cohort study. J Paediatr Child Health 2016;52(4):417-21.

  4. Introduction Nutritional assessment Nutritional support Outcome Conclusions Prevalence of malnutrition in CPBelgian data Undernutrition according to GMFCS classification Alliet P, Verspeek L, Devolder H, Aerssens P, AchtenA. Undernutrition in ambulatory children with cerebral palsy: anthropometrics vsSTRONGkids nutritional screening tool, Poster at ESPGHAN conference, 9-12 June 2014, Jerusalem, Israel

  5. Introduction Nutritional assessment Nutritional support Outcome Conclusions Nutritional assessment:Schematic overview Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr 2013;37(4):460-81.

  6. Introduction Nutritional assessment Nutritional support Outcome Conclusions CP patients are at increasednutritional risk Fung EB, Samson-Fang L, Stallings VA, et al. Feeding Dysfunction is Associated with Poor Growth and Health Status in Children with Cerebral Palsy. Journal of the American Dietetic Association 2002;102(3):361-73.

  7. Introduction Nutritional assessment Nutritional support Outcome Conclusions Nutritional assessment:Aspects applied to CP patients • Medical history & medication use • Anthropometric measurements • Biochemical assessment • Assessment of intake • Assessment of energy expenditure • Assessment of bone mineral density • Assessment of dysphagia Bell KL, Samson-Fang L Nutritional management of children with cerebral palsy. Eur J ClinNutr 2013;67 Suppl 2(S13-6.

  8. Introduction Nutritional assessment Nutritional support Outcome Conclusions 4 key questions to ask... • How long does it take to feed your child? Red flag: more than 30 minutes • Are meal times stressful to child or parent? Red flag: Yes, if one or other, or both • Is your child gaining weight adequately? Red flag: Lack of weight gain over 2-3 months in young child, not just weight loss • Are there signs of any respiratory problems? Red flag: Increased congestion at meal times, ‘gurgly’ voice, respiratory illness Kuperminc MN, Gottrand F, Samson-Fang L, et al. Nutritional management of children with cerebral palsy: a practical guide. Eur J ClinNutr 2013;67 Suppl 2(S21-3.

  9. Introduction Nutritional assessment Nutritional support Outcome Conclusions Medication:GI side effects of anticonvulsants *Due to anorexia

  10. Introduction Nutritional assessment Nutritional support Outcome Conclusions Anthropometric measurementsWhich reference curves ? • Growth charts specific to children with CP have been published • However not necessarily the optimal growth pattern • May offer insight into the broad range of growth seen in CP • Growth in the lower range of the CP chart should raise alarm, in contrast to ‘normal charts’

  11. Introduction Nutritional assessment Nutritional support Outcome Conclusions Anthropometric measurementsWhich reference curves ? Brooks J, Day S, Shavelle R, et al. Low weight, morbidity, and mortality in children with cerebral palsy: new clinical growth charts. Pediatrics 2011;128(2):e299-307.

  12. Introduction Nutritional assessment Nutritional support Outcome Conclusions Anthropometric measurementsUse of segmental measures Rempel G The importance of good nutrition in children with cerebral palsy. Phys Med RehabilClin N Am 2015;26(1):39-56. • Segmental measurements are preferred • Standard height or recumbent length measurements are complicated by joint contractures, scoliosis, involuntary muscle spasms and poor cooperation • Calculated heights should not be used to assess BMI • Error is magnified when squared • Assessing growth velocity also unreliable when using calculated heights

  13. Introduction Nutritional assessment Nutritional support Outcome Conclusions Anthropometric measurementsUse of segmental measures Samson-Fang L, Bell KL Assessment of growth and nutrition in children with cerebral palsy. Eur J ClinNutr 2013;67 Suppl 2(S5-8.

  14. Introduction Nutritional assessment Nutritional support Outcome Conclusions Anthropometric measurementsMUAC & TSF • MUAC measurement • Good alternative when weight/height is difficult to obtain • Better indicator of lean body mass than BMI in a general population • Belgian reference values available • TSF measurement • Indication of fat reserves, but may underestimate in children with CP (fat distributed more centrally) • No Belgian reference values • High inter-rater variability American Academy of Pediatrics. Pediatric Nutrition Handbook, 6th edition. Chapter 24: Assessment of the nutritional status

  15. Introduction Nutritional assessment Nutritional support Outcome Conclusions Assessment of dysphagia • Clinical feeding evaluation • Observation during mealtime setting • Evaluation of oral sensimotor deficits • Pharyngeal swallow status can only be inferred • Cave fatigue during mealtimes can be caused by chronic hypoxemia! • Criteria for instrumental evaluation of swallowing • Risk of aspiration (history/observation) • Prior aspiration pneumonia • Suspicion of pharyngeal or laryngeal problem • Gurgly voice quality Arvedson JC Feeding children with cerebral palsy and swallowing difficulties. Eur J ClinNutr 2013;67 Suppl 2(S9-12.

  16. Introduction Nutritional assessment Nutritional support Outcome Conclusions Assessment of dysphagiaInstrumental evaluation • Videofluoroscopic Swallow Study (VFSS) • Dynamic visualisation or oral, pharyngeal and upper esophageal phases of swallowing • Radiation • Flexible Endoscopic Evaluation of Swallowing (FEES) • Direct visualisation of some aspects of the pharyngeal phase • Usefull in case of concerns for possible upper airway obstruction and/or vocal fold paresis or paralysis Arvedson JC Feeding children with cerebral palsy and swallowing difficulties. Eur J ClinNutr 2013;67 Suppl 2(S9-12.

  17. Introduction Nutritional assessment Nutritional support Outcome Conclusions Nutritional interventionsWhat should we aim for ? • Nutritional interventions in CP patients should focus on: • Providing a “safe” feeding strategy • Striving for the optimal social situation for the child and his/her family during meal times • Finding an efficient feeding strategy • Correcting deficits • Providing adequate energy and macronutrient delivery • Providing adequate micronutrient delivery

  18. Introduction Nutritional assessment Nutritional support Outcome Conclusions Nutritional interventionsthe ESPGHAN algorithm • Oral supplements • First line, but often a “temporary fix” • Enteral feeding • If feeding time >4-6h/day • Insufficient oral intake • Insufficent weight/height gain • TSF < 5th centile • Often perceived as failure by caregivers/parents! • Consider PEG if >3 months Braegger C, Decsi T, Dias JA, et al. Practical approach to paediatric enteral nutrition: a comment by the ESPGHAN committee on nutrition. J PediatrGastroenterolNutr 2010;51(1):110-22.

  19. Introduction Nutritional assessment Nutritional support Outcome Conclusions Nutrition status and outcome • Poor nutritional status in CP children is associated with: • Increased health care utilization • Stunting • Increased severity of gastro-esophageal reflux • Limitation in social activities for both the child and the parents • Decreased motor function • Poor healing from infections and decubitus ulcers • Diminished bone health American Academy of Pediatrics. Pediatric Nutrition Handbook, 6th edition. Chapter 36: Nutritional support for children with developmental disabilities

  20. Introduction Nutritional assessment Nutritional support Outcome Conclusions Undernutrition in CPincreased health care utilization • each SD decrease in mid-upper arm fat area was associated with a 28% increase in doctorvisits and a 86% increase in hospitalizations Samson-Fang L, Fung E, Stallings VA, et al. Relationship of nutritional status to health and societal participation in children with cerebral palsy. J Pediatr 2002;141(5):637-43.

  21. Introduction Nutritional assessment Nutritional support Outcome Conclusions Undernutrition in CPdiminished growth Early group Middle group Late group Sanders KD, Cox K, Cannon R, et al. Growth response to enteral feeding by children with cerebral palsy. JPEN J Parenter Enteral Nutr 1990;14(1):23-6.

  22. Introduction Nutritional assessment Nutritional support Outcome Conclusions Undernutrition in CPincreased GI problems • After 6 month nutritional rehabilitation: 50% of previously malnourished children succesfully weaned off their medication Campanozzi A, Capano G, Miele E, et al. Impact of malnutrition on gastrointestinal disorders and gross motor abilities in children with cerebral palsy. Brain Dev 2007;29(1):25-9. Lewis D, Khoshoo V, Pencharz PB, et al. Impact of nutritional rehabilitation on gastroesophageal reflux in neurologically impaired children. J PediatrSurg 1994;29(2):167-9; discussion 69-70.

  23. Introduction Nutritional assessment Nutritional support Outcome Conclusions Conclusions • 4 key questions in nutritional history • How long does it take to feed your child? • Are meal times stressful to child or parent? • Is your child gaining weight adequately? • Are there signs of any respiratory problems? • Segmental measures are preferred • Advantages and disadvantages in the use of CP-specific growth charts • Malnutrition is linked with outcome in children with CP

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