0148-6071/90/1401-0023$0Z.00/0 JOURNAL OF PARENTERAL A N D ENTERAL NUTRITION Copyright 0 1990 by the American Society for Parenteral and Enteral Nutrition
Vol. 14, No. 1 Printed in U.S.A.
Growth Response to Enteral Feeding by Children with Cerebral Palsy KATHLEEN D. SANDERS, M.D., KENNETH Cox, M.D., ROBERTCANNON, M.D., DARLENE BLANCHARD, R.N., JANET PITCHER,R.N., PEGGY PAPATHAKIS, R.D., LINDAVARELLA, R.D., A N D RAMONA MAUGHAN, R.D. From the Department of Pediatrics, Section of Gastroenterologyand Nutrition, University of California, Davis Medical Center, Sacramento, California
ABSTRACT. This study evaluated the growth of 51 children with cerebral palsy after the initiation of enteral tube feedings. The children were divided into three groups according to how soon after their central nervous system (CNS) insult they were started on enteral feedings. Group 1 consisted of 14 children who were within a year of their CNS insult; they were underweight for age, but had normal length as well as weight for length. Within 6 months of initiating enteral tube feedings, most children in this group had normalized their weights. Group 2 consisted of 27 children whd were within 8 years of their CNS insult; they were stunted and were underweight for both their
age and their length. Within 6 months of initiating enteral feeds, the group increased both weight and weight for length to near normal, but their gains in length reached a plateau at 90% of ideal for age. Group 3 consisted of 10 children who were more than 8 years after their CNS insult. This group was severely malnourished but had some improvement in their weight for age and for length but, length for age showed no significant change. We conclude that the earlier adequate nutritional management of children with severe cerebral palsy is initiated, the more readily the nutritional deficits will reverse. (Journal of Parenteral and Enteral Nutrition 14:23-26, 1990)
Cerebral palsy is a nonprogressive neurological syndrome manifesting itself with motor impairment and a variable degree of developmental delay. Early intervention programs attempt to minimize the effects of spastic posturing and diminish the influence of primitive reflexes on movement in order to achieve maximal functional potential. Adequate nutrition would seem t o be the minimum requirement in order for these children to benefit from these programs. Unfortunately, children with cerebral palsy have a number of potential impediments to normal nutrition. Because of frequent paresis of facial, lingual, and pharyngeal muscles, they have difficulties with both swallowing and speech. Specific difficulties which have been noted include: weak or absent suck reflex, poor lip closure, hyperactive gag reflex, tongue thrust, chewing incoordination, and inability to self feed.',2 In addition, pathological gastroesophageal reflux (GER) is frequently present in these patients. This condition results in decreased caloric intake because of discomfort from esophagitis and increased losses because of ~ o m i t i n gOften .~ recurrent aspiration pneumonias due to reflux and oropharyngeal incoordination further contribute to the morbidity of this condition. All these problems combine to limit the intake of food by these children. The true growth potential of these children has been debated. Previous studied have noted that children with significant cerebral palsy tend to be both underweight and short for age. Mosier et a14 reported on the anthropomorphics of 2027 mentally retarded, institutionalized individuals and noted that stunting of length tended to
be proportional to the degree of mental defect. They postulated that there might be a CNS-mediated factor which was at least partially responsible for growth failure. Other investigators have speculated that the growth failure seen in children with cerebral palsy shares a common neurophysiologic cause with the mental retard a t i ~ n .These ~ . ~ studies did not adequately address the issue of what role inadequate nutrition might play in impeding the growth potential of these children. Our study addresses the following issues: (1)is there a component of reversible growth failure in children with cerebral palsy, 2) what are the realities of the timing for nutritional intervention, and 3) does this group of patients, with very little physical activity, but variable tone, have unusual caloric needs? METHODS
Patients All the children who were referred to the Pediatric Gastroenterology Service a t the University of California at Davis Medical Center from July 1980 to September 1986 were included in this study if they had: 1)cerebral palsy with significant involvement 2) weight/length < 5% or no weight gain for 6 months, 3) no documented kidney, cardiac disease, or gastrointestinal malabsorption. 4) no chromosomal abnormality or syndrome which is known to affect growth, such as fetal alcohol syndrome, and 5) adequate follow-up by our group to access the response to enteral feeds. Fifty-one patients are included in this study: 30 girls and 21 boys, with an age range of 3 months to 15.5 years. The causes for the severe developmental delay included pre- or perinatal events in 34, head trauma in five, and infection/hypoxia in 12. Four of the patients were hypotonic and the rest had spastic quadriplegia or diplegia.
Received for publication, November 10, 1986. Accepted for publication, May 1, 1989. Reprint requests: Kathleen Sanders, MD, Department of Pediatrics, Division of Gastroenterology -Rm JCP2640, University of Iowa Hospital and Clinics, Iowa City, Iowa 52240. 23
Downloaded from pen.sagepub.com at UNIV OF WESTERN ONTARIO on April 12, 2015
24
VOl. 14, No. 1
SANDERS ET AL
For the purposes of this study, the patients were categorized into three age groups: Group 1 (Early, n=14):those who were started on enteral feedings within 1 year of their CNS insult and the group had a mean age of 0.8 years (3 months-3 years), Group 2 (Middle, n=27): those who were started within 8 years of their insult with a mean age of 4.1 years (1.5-7.3 years), and Group 3 n=10): those who were started after 8 years with a mean age of 12.2 years (8.5-15.75 years). All of the children were living either in the home of their natural parents, were adopted, or were in small group care homes. The range of follow-up was 6 months to 5.5 years with the average being 2.4 years for the group.
dietician followed up by phone within 2 to 3 weeks of the clinic visit to determine if the instructions were understood and to estimate the compliance of the caregiver.
Statistics Statistical analyses, mean, SD, SEM were performed on an Apple Macintosh using Statview software. RESULTS
The benefit derived from enteral feedings by this population of children varied with age.
Early Group
Measurements Patients’ weights and height (or length, when appropriate) were carefully obtained during regular clinic visits and, from these measurements, we calculated the following: 1) % of ideal weight for age (observed weight as a percentage of the 50th% weight for children the same age), 2) % of ideal height (length) for age (observed length as a percentage of the 50th% height of children the same age), and 3) the expected weight for height (the observed weight as a percentage of the 50% weight for children of the same height). These calculations can then be utilized to estimate the degree of malnutrition as well as its chronicity (Table I):7,8
Enteral Feedings Four patients were fed enterally using only nasogastric tubes; the rest received gastrostomies, and all but three of these received fundoplications as well. Informed consents were obtained for all procedures and therapies used on these patients.
The average age of this group was 10 months when tube feedings were initiated and they were within a year of their CNS insult. They were underweight for age (71%), but they had, on the average, maintained their 96 length for age (90%) and weight for length (93%) near the normal range. They improved in all three measurements within 6 months of initiating tube feedings: % weight increased to 88%, % length increased to 94%, and % weight for length increased to 99%. Their average weight gain during this period was 25 g/day or 3.3 g/kg/ day. The calories required to achieve this growth varied considerably, from 45 to 150 cal/kg, and could not be predicted by activity level, tone, state of seizure control, or presence of infections. The average intake for the group was 88 cal/kg and 11 cal/cm. During the period of observation reported in this study, there was one death in this group, a child who had been followed for a year on nasogastric feedings, had become overweight, and died unexpectedly at home.
Diet
Middle Group
Daily caloric intakes were calculated from 3-day food records and diet recall at each clinic visit which occurred as often as monthly until the child was stable, then every 3 months thereafter. The caregivers were given specific instructions regarding feeding volumes and schedules based upon the child’s nutritional status. The majority of calories (80%) were provided by commercially available tube feeding formulas; the most frequently used were Complete Modified Formula (Sandoz) or lsocal (Mead Johnson), each providing 1 cal/ml. Additionally, small amounts of pureed fruits and vegetables were given. Enough whole milk was added to supply the recommended daily allowance of calcium and phosphorus. A
This group of children averaged 4.1 years of age (range 1.2-7.3 years) and were within 8 years of their CNS insult at the time of initiation of tube feeding. Their average % weight for age was 60% which placed them in a severely malnourished category. Their average % length for age was 86% and expected weight for length was 75%. Despite a more pronounced state of malnutrition than the early group, these children also had a rapid response to nutritional support with an average gain of 29 g/day or 2.8 g/kg/day. In the first 6 months of observation on tube feedings, the group’s average % weight for age increased to 82%,the % length for age improved to 90%, the % weight for length improved to 93%. Over the subsequent 18 months of observation there were further gains in %weight and %weight for length (89% and 104%),but no further improvement in % length. The caloric requirement for growth for individuals within this group was again quite variable. The range was from 40 to 110 cal/kg with a group average of 72 cal/ kg and 10 cal/cm. There were two deaths in this group of 27 patients and in both cases enteral feedings had been discontinued and oral feedings had been reinitiated with resultant aspiration pneumonia.
TABLEI Indices of undernutrition Measurement
% of Ideal Weight % Height for age ?4 Weight for height
% ’ of normal
Classification
76-90
Mild Moderate Severe Moderate, chronic Severe, chronic Normal Moderate Severe
61-75
Vol. 14, No. 1 Printed in U.S.A.
Growth Response to Enteral Feeding by Children with Cerebral Palsy KATHLEEN D. SANDERS, M.D., KENNETH Cox, M.D., ROBERTCANNON, M.D., DARLENE BLANCHARD, R.N., JANET PITCHER,R.N., PEGGY PAPATHAKIS, R.D., LINDAVARELLA, R.D., A N D RAMONA MAUGHAN, R.D. From the Department of Pediatrics, Section of Gastroenterologyand Nutrition, University of California, Davis Medical Center, Sacramento, California
ABSTRACT. This study evaluated the growth of 51 children with cerebral palsy after the initiation of enteral tube feedings. The children were divided into three groups according to how soon after their central nervous system (CNS) insult they were started on enteral feedings. Group 1 consisted of 14 children who were within a year of their CNS insult; they were underweight for age, but had normal length as well as weight for length. Within 6 months of initiating enteral tube feedings, most children in this group had normalized their weights. Group 2 consisted of 27 children whd were within 8 years of their CNS insult; they were stunted and were underweight for both their
age and their length. Within 6 months of initiating enteral feeds, the group increased both weight and weight for length to near normal, but their gains in length reached a plateau at 90% of ideal for age. Group 3 consisted of 10 children who were more than 8 years after their CNS insult. This group was severely malnourished but had some improvement in their weight for age and for length but, length for age showed no significant change. We conclude that the earlier adequate nutritional management of children with severe cerebral palsy is initiated, the more readily the nutritional deficits will reverse. (Journal of Parenteral and Enteral Nutrition 14:23-26, 1990)
Cerebral palsy is a nonprogressive neurological syndrome manifesting itself with motor impairment and a variable degree of developmental delay. Early intervention programs attempt to minimize the effects of spastic posturing and diminish the influence of primitive reflexes on movement in order to achieve maximal functional potential. Adequate nutrition would seem t o be the minimum requirement in order for these children to benefit from these programs. Unfortunately, children with cerebral palsy have a number of potential impediments to normal nutrition. Because of frequent paresis of facial, lingual, and pharyngeal muscles, they have difficulties with both swallowing and speech. Specific difficulties which have been noted include: weak or absent suck reflex, poor lip closure, hyperactive gag reflex, tongue thrust, chewing incoordination, and inability to self feed.',2 In addition, pathological gastroesophageal reflux (GER) is frequently present in these patients. This condition results in decreased caloric intake because of discomfort from esophagitis and increased losses because of ~ o m i t i n gOften .~ recurrent aspiration pneumonias due to reflux and oropharyngeal incoordination further contribute to the morbidity of this condition. All these problems combine to limit the intake of food by these children. The true growth potential of these children has been debated. Previous studied have noted that children with significant cerebral palsy tend to be both underweight and short for age. Mosier et a14 reported on the anthropomorphics of 2027 mentally retarded, institutionalized individuals and noted that stunting of length tended to
be proportional to the degree of mental defect. They postulated that there might be a CNS-mediated factor which was at least partially responsible for growth failure. Other investigators have speculated that the growth failure seen in children with cerebral palsy shares a common neurophysiologic cause with the mental retard a t i ~ n .These ~ . ~ studies did not adequately address the issue of what role inadequate nutrition might play in impeding the growth potential of these children. Our study addresses the following issues: (1)is there a component of reversible growth failure in children with cerebral palsy, 2) what are the realities of the timing for nutritional intervention, and 3) does this group of patients, with very little physical activity, but variable tone, have unusual caloric needs? METHODS
Patients All the children who were referred to the Pediatric Gastroenterology Service a t the University of California at Davis Medical Center from July 1980 to September 1986 were included in this study if they had: 1)cerebral palsy with significant involvement 2) weight/length < 5% or no weight gain for 6 months, 3) no documented kidney, cardiac disease, or gastrointestinal malabsorption. 4) no chromosomal abnormality or syndrome which is known to affect growth, such as fetal alcohol syndrome, and 5) adequate follow-up by our group to access the response to enteral feeds. Fifty-one patients are included in this study: 30 girls and 21 boys, with an age range of 3 months to 15.5 years. The causes for the severe developmental delay included pre- or perinatal events in 34, head trauma in five, and infection/hypoxia in 12. Four of the patients were hypotonic and the rest had spastic quadriplegia or diplegia.
Received for publication, November 10, 1986. Accepted for publication, May 1, 1989. Reprint requests: Kathleen Sanders, MD, Department of Pediatrics, Division of Gastroenterology -Rm JCP2640, University of Iowa Hospital and Clinics, Iowa City, Iowa 52240. 23
Downloaded from pen.sagepub.com at UNIV OF WESTERN ONTARIO on April 12, 2015
24
VOl. 14, No. 1
SANDERS ET AL
For the purposes of this study, the patients were categorized into three age groups: Group 1 (Early, n=14):those who were started on enteral feedings within 1 year of their CNS insult and the group had a mean age of 0.8 years (3 months-3 years), Group 2 (Middle, n=27): those who were started within 8 years of their insult with a mean age of 4.1 years (1.5-7.3 years), and Group 3 n=10): those who were started after 8 years with a mean age of 12.2 years (8.5-15.75 years). All of the children were living either in the home of their natural parents, were adopted, or were in small group care homes. The range of follow-up was 6 months to 5.5 years with the average being 2.4 years for the group.
dietician followed up by phone within 2 to 3 weeks of the clinic visit to determine if the instructions were understood and to estimate the compliance of the caregiver.
Statistics Statistical analyses, mean, SD, SEM were performed on an Apple Macintosh using Statview software. RESULTS
The benefit derived from enteral feedings by this population of children varied with age.
Early Group
Measurements Patients’ weights and height (or length, when appropriate) were carefully obtained during regular clinic visits and, from these measurements, we calculated the following: 1) % of ideal weight for age (observed weight as a percentage of the 50th% weight for children the same age), 2) % of ideal height (length) for age (observed length as a percentage of the 50th% height of children the same age), and 3) the expected weight for height (the observed weight as a percentage of the 50% weight for children of the same height). These calculations can then be utilized to estimate the degree of malnutrition as well as its chronicity (Table I):7,8
Enteral Feedings Four patients were fed enterally using only nasogastric tubes; the rest received gastrostomies, and all but three of these received fundoplications as well. Informed consents were obtained for all procedures and therapies used on these patients.
The average age of this group was 10 months when tube feedings were initiated and they were within a year of their CNS insult. They were underweight for age (71%), but they had, on the average, maintained their 96 length for age (90%) and weight for length (93%) near the normal range. They improved in all three measurements within 6 months of initiating tube feedings: % weight increased to 88%, % length increased to 94%, and % weight for length increased to 99%. Their average weight gain during this period was 25 g/day or 3.3 g/kg/ day. The calories required to achieve this growth varied considerably, from 45 to 150 cal/kg, and could not be predicted by activity level, tone, state of seizure control, or presence of infections. The average intake for the group was 88 cal/kg and 11 cal/cm. During the period of observation reported in this study, there was one death in this group, a child who had been followed for a year on nasogastric feedings, had become overweight, and died unexpectedly at home.
Diet
Middle Group
Daily caloric intakes were calculated from 3-day food records and diet recall at each clinic visit which occurred as often as monthly until the child was stable, then every 3 months thereafter. The caregivers were given specific instructions regarding feeding volumes and schedules based upon the child’s nutritional status. The majority of calories (80%) were provided by commercially available tube feeding formulas; the most frequently used were Complete Modified Formula (Sandoz) or lsocal (Mead Johnson), each providing 1 cal/ml. Additionally, small amounts of pureed fruits and vegetables were given. Enough whole milk was added to supply the recommended daily allowance of calcium and phosphorus. A
This group of children averaged 4.1 years of age (range 1.2-7.3 years) and were within 8 years of their CNS insult at the time of initiation of tube feeding. Their average % weight for age was 60% which placed them in a severely malnourished category. Their average % length for age was 86% and expected weight for length was 75%. Despite a more pronounced state of malnutrition than the early group, these children also had a rapid response to nutritional support with an average gain of 29 g/day or 2.8 g/kg/day. In the first 6 months of observation on tube feedings, the group’s average % weight for age increased to 82%,the % length for age improved to 90%, the % weight for length improved to 93%. Over the subsequent 18 months of observation there were further gains in %weight and %weight for length (89% and 104%),but no further improvement in % length. The caloric requirement for growth for individuals within this group was again quite variable. The range was from 40 to 110 cal/kg with a group average of 72 cal/ kg and 10 cal/cm. There were two deaths in this group of 27 patients and in both cases enteral feedings had been discontinued and oral feedings had been reinitiated with resultant aspiration pneumonia.
TABLEI Indices of undernutrition Measurement
% of Ideal Weight % Height for age ?4 Weight for height
% ’ of normal
Classification
76-90
Mild Moderate Severe Moderate, chronic Severe, chronic Normal Moderate Severe
61-75
