Nutrition-Related Comorbidities in Children with

Cerebral Palsy: Dysphagia, Malabsorption, and

Constipation

Lauren Lippert

Readings in Research

April 13,2015

Identify the types, causes, and characteristics of cerebral palsy

Define dysphagia and malabsorption in cerebral palsy

Evaluate whether a modified diet should be the answer to constipation

Discuss methodology of research findings in nutrition-related comorbidities of cerebral palsy

Evaluate various types of nutrition support that are effective in cerebral palsy children

Recognize our role as future dietitians in improving nutrition in cerebral palsy

Learning Objectives

What is Cerebral Palsy?

Cerebral Palsy Alliance, 2014

Cerebral Palsy is an umbrella term used to identify a group of non-progressive disorders in movement caused by damage of motor control centers in the brain during prenatal, delivery, and postnatal periods up to age 2.*

Definition of Cerebral Palsy

Polzin, Odle, & Davidson. 2011*

“Cerebral palsy is a disorder of movement and posture that results from brain injury or non-progressive lesions of the brain.”*

Motor control disorder in the brain

affecting coordination from an early

development injury **

Continued Definitions

Clawson, Kuchinski, & Bach (2007)* Cloud (2012)**

Prenatal, perinatal, or immediately postnatal*

Later Childhood**

Polzin et al., 2011* Wilson 2007**

Maternal infections*

Low birth weight (main cause)

Impaired blood flow

Traumatic events**

Insufficient Oxygen to the brain***

What causes cerebral palsy?

Polizin & Davidson, 2011* Pellegrino, 2007** Wilson, 2007***

Diabetes or hyperthyroidism

Malnutrition*

Radiation or toxins*

Medication usage (thyroid, estrogen)

Seizure disorder or mental retardation

Previous fetal loss**

Genetic disabilities

Prenatal Causes

Polzin & Davidson, 2011* Fang-Samson & Bell, 2013**

Prematurity*

Low birth weight

Umbilical Cord

Placenta

Heart Rate

Multiple births**

Infection

Asphyxia *

Perinatal (During Delivery)

Polzin & Davidson, 2011* Wilson, 2007**

Postnatal

Pellegrino, 2007* Wilson, 2007**

Toxicity

Infection

Trauma

Spastic

•Muscles **

•Movement

Dyskinetic

•Movement **

•Stability

Ataxic

•Balance*

•Coordination

Types of Cerebral Palsy

NINDS, 2011* Cloud, 2012**

Monoplegia Diplegia Hemiplegia Triplegia Quadriplegia

Patterns Cerebral Palsy

Pellegrino, 2007

Prevalence of Cerebral Palsy

oLeading cause of childhood disability

o1.5- 4 of every 1000 births*

o60 out of 1000 with VLBW*

o6.2-7.6 out of 1000 births with LBW*

oMalnutrition and poor growth are prevalent**

CDC, 2015* Clawson et al., 2007**

Head control*

Stiff arms and legs (spastic)*

Impaired posture

Excessive sleeping

Seizures

Visual and Auditory Impairment**

Characteristics of Cerebral Palsy

Fung et al. 2002 Workinger, 2005

Fung et al. 2002* Bell & Samson-Fang 2013**

Dysphagia*

Malabsorption

Constipation*

Nutrition Support

Nutrition-Related Characteristics of Cerebral Palsy

Salghetti & Martinuzzi (2012)*

Diagnostic tool

Successful management is key*

Found in 40% of cerebral palsy children*

What is dysphagia?

Calis et al. 2008

Phases of swallowing

Santos et al., 2012

Delayed swallow reflux

Tongue thrust

Coughing

Excessive drooling

Difficulty chewing

Poor lip closure

Aspiration

Characteristics of dysphagia

Calis et al. 2008* Santos et al. 2012** Dahlseng et al. 2011***

Kuperminic, et al. found four key questions to ask parents in dysphagia assessment

1. How long does it take to feed your child?*

2. Are meal times stressful to child/parent?*

3. Is your child gaining weight accurately?*

4. Are there signs of respiratory problems in your child?*

Identifying Dysphagia in Cerebral Palsy Children

Kuperminic et al., 2013*

Poor growth*

Inadequate vitamin/mineral intake

Insufficient amount of calories**

Impaired Immune System****

Dehydration and electrolyte imbalance ***

Malabsorption

Bell & Samson-Fang, 2013* McGowan et al., 2012** Snider et al., 2011***

Kuperminic et al., 2013****

Indicate if child is at nutritional risk

Energy requirements*

Type of food selected

Protein Intake

Vitamin and Mineral Intake

Hydration and electrolytes**

Nutrition Intervention in Malabsorption

Bell & Fang, 2013* Peterson et al, 2014**

Consistency

Frequency

Patterns

•Bristol Stool Chart*

•< 3 times per week

•Defecation Diaries

Constipation

Veiugelers et al., 2010*

Methodology

1. Dysphagia 2. Malabsorption 3. Constipation 4. Nutrition Support

Snider et al. 2011

Sample: 7 Children (8-17 y); 3 males & 4 females

Aim: To find if the Castillo-Morales device is a sufficient tool to improve dysphagia

Intervention: Castillo-Morales device (CMD)*

Results: Improved deglutition as evidenced by decreased penetration, aspiration

Increased bolus formation and control

Improved bolus and saliva management

Dysphagia

Snider et al., 2011*

Where is the hard palate?

Castillo-Morales

Snider et al., 2011*

Bar Graph of Results

Snider et al., 2011*

Schoendorfer et al., 2013

Subjects: Control group - 24 subjects: 13 male and 11 female

Cerebral palsy children: 24 subjects: 16 males and 8 females; 9 fed through a G-Tube and 15 fed Orally between the ages of 4-12 years

Aim: To compare anthropometrics in the control group to the cerebral palsy children by measurements of nutritional markers

Malabsorption

Schoendorfer et al., 2013

Materials and Method: Obtained Plasma hemoglobin, serum C-Reactive protein, cholesterol, zinc, protein carbonyls, alpha-tocopherol, and antioxidant capacity as serum levels to determine nutritional markers

Results: Marker volumes are lower than the control children due to physiological impact of the impaired absorption in cerebral palsy

Malabsorption

Schoendorfer et al., 2013

Peterson et al. 2014

Subjects: 112 adults with cerebral palsy between ages : 21-48 years, 52 males 60 females

Aim: To identify the correlation the serum levels of vitamin D (25-hydroxy vitamin D) and abdominal obesity

Malabsorption

Peterson et al, 2014* Holick et al., 2011**

Materials and Methods: Anthropometric data was obtained BMI, hip/waist circumference, height/weight and measurements of serum levels of vitamin D (25-hydroxy vitamin D)

Results: Robust association was found between high visceral adiposity and lower levels of vitamin D in cerebral palsy

33.9% were deficient in Vitamin D and 20.9% had insufficient levels

Malabsorption

Peterson et al., 2014

McGowan et al., 2012

Subjects: 20 hospital nonambulatory tube fed children ages 2-17 years old *

Aim: To examine the sodium, potassium, phosphate, and fluid status in primarily tube fed nonambulatory children with severe CP

Malabsorption

McGowan et al., 2012*

Materials/Methods: Serum sodium, potassium, phosphate, and chloride levels among many other parameters were obtained.

Osmolality and sodium concentration were evaluated in urine test

Results: 6 out of 20 (30%) children were sodium deficient and had high urine osmolality, therefore they were potentially dehydrated.

Malabsorption

McGowan et al., 2012

Veiugelers et al., 2010

Subjects: 152 children with severe generalized cp between ages 5-13 years of age

Aim: Identify the appearance of constipation in children with cerebral palsy

Constipation

Veiugelers et al., 2010

Materials/Method: Two week intervention of defecation patterns obtained through diaries on laxative use, anthropometrics, and toilet training status by caregivers/parents

Results: Constipation is a common problem in children with cerebral palsy as evidenced by 57% of the sample population regardless of laxative usage *

Constipation

Veuglers et al., 2010*

Khoshoo, Sun, & Storm, 2010

Subjects: 14 with compromised gastrointestinal function associated with cerebral palsy. Gastrointestinal dismotility (n=9), Chron’s Disease (n=3), and short bowl syndrome (n=2)

Aim: To determine if children can tolerate enteral formula consisting of insoluble prebiotic fiber formula compared to standard formula

Constipation

Khoshoo et al., 2010

Procedures: Children were randomized into two groups receiving fiber formula and standard formula

5 day washout period, groups switched formulas

Daily fecal consistency and stool frequency were recorded

Results: 95% of children tolerated the fiber supplemented formula *

Constipation

Khoshoo et al., 2010*

20% of cerebral palsy children require enteral nutrition**

Arrowsmith, F. et al 2010 found children with cerebral palsy receiving enteral nutrition had increased TBP and weight gain

Cerebral palsy children have increased weight gain by 25% with 1.0-1.5 kcal/mL enteral formulas*

Nutrition Support

Arrowsmith et al., 2010* Dahlseng et al., 2011**

Enteral nutrition may cause weight gain and positive nitrogen status in children therefore obesity is a factor

Vernon-Roberts et al 2010 found a formula containing 25% less energy, micronutrient complete, and high fiber increased weight without fat mass

Study was done over a 6-month period

in children with SQCP*

Nutrition Support: Enough and No More

Vernon-Roberts et al., 2010*

Enteral nutrition is not always the answer to every child with cerebral palsy’s situation

According to Clawson et al., 2007 improved oral intake is possible for children

The intervention included parental training in food preparation and caloric boosters*

Children participated in oral motor exercise training and therapeutic meals*

Nutrition Intervention

Clawson et al., 2007*

Statistics

Clawson et al., 2007

Guidelines include:

Eliminate preventable disease, injury, and premature death*

Achieve health equity and eliminate health disparities*

Promote healthy development and healthy behaviors during every stage of life*

Healthy People 2020

Riper, 2010*

Prevention

Medical Nutrition

Interventions

Improved Formula

composition

Monitor

Implications and Conclusions

Andrew et al., 2010* Biscof et al., 2014