Special needs: realizing potential: nutritional needs in cerebral palsy.
For children with cerebral palsy (CP), additional factors affecting their growth include central nervous system abnormalities, alteration in muscle tone, limited physical activity and skills, and immobilization and disuse.
The primary health care provider is in a unique and desirable position to obtain and review longitudinal growth data over time. When the following factors are documented in a child with CP--if the child falls below the 10th percentile for weight/height ratio on the Centers for Disease Control and Prevention growth charts, if the child is over the 85th percentile, or if the child crosses percentiles rapidly--then a referral to a nutritionist is suggested.
The June 2000 version of the CDC growth charts can be downloaded onto your hand-held computer for free at www.statcoder.com. This program also has precalculated the z scores, which reflect standard deviations from the median and allow an accurate assessment of discrete changes from one measurement date to another.
In 1996, several colleagues and I developed a growth reference for children with spastic quadriplegia to facilitate uniformity in clinical assessment. Quadriplegia is the most common pattern of CP and is found in 27% of cases. These charts can be used in conjunction with the CDC charts, and also are available for free by contacting me or Patricia Miller, R.D., at the Kennedy Krieger Institute, 707 a. Broadway, Baltimore, Maryland, 21205.
After determining adequacy of growth, we next look at calorie needs and intake. Factors specific to the child with CP include oral motor skills and the ability to coordinate breathing, muscle tone, constipation, respiratory effort, sitting skills, seating and positioning during a meal, food and fluid loss, mealtime length, vision and hearing, cognitive and communication skills, medications, orthopedic and other surgeries, dental and gum disease, and family supports and stresses.
The primary health care provider should be alerted to nutrition concerns when parents report that the child is eating everything but is having trouble gaining weight, when a mealtime lasts 1 hour or more, or when coughing, choking or gagging occurs with most meals. Other red flags are when parents describe more than the usual food selectivity in their child, when drooling is a major concern, or if the child presents to the office wearing a bib.
In their efforts to increase calories and improve growth, parents often exceed the delicate balance of energy consumed versus energy expended, ultimately increasing the caloric needs of the child. I recommend setting a time limit of 20-30 minutes for meals and snacks, and ensuring that the child is well positioned so he or she isn't fatigued by the work of eating.
Parents can boost the caloric density of the diet or increase the child's total intake by increasing the concentration of formula if appropriate, by adding energy boosters to meals, by using high-calorie foods, or by adding oral supplements. Foods that can be used to increase energy intake include powdered skim milk, instant breakfast products, baby cereals, instant mashed potatoes, wheat germ, peanut butter, fruits canned in heavy syrup, vegetables frozen in cream or cheese sauces, or meats cooked in oil with breading or with added sauces or gravies.
Constipation is a very common and troublesome problem for children with CR and it's significantly mediated by muscle tone. Many parents don't want to use medications, but it is warranted in many situations. To estimate if the fluid intake is adequate, the rule of thumb used is based on actual body weight following these guidelines:
* For the first 10 kg of the child's weight, fluid intake should be 100 cc/kg.
* For the next 11-20 kg of the child's weight, fluid intake should be 50 cc/kg.
* For the amount of weight exceeding 20 kg, fluid intake should be 25 cc/kg.
For example, 100% of the estimated fluid needs for a 32-kg child would equal 1800 cc: specifically, (100 x 10 = 1000 cc) for the first 10 kg, plus (50 x 10 = 500 cc) for the next 10 kg, plus (25 x 12 = 300 cc) for the remaining 12 kg.
Bone mineral density is markedly reduced in nonambulatory children with CP, placing them at increased risk for fractures and osteopenia.
Therefore, the clinician should review the adequacy of micronutrients in the child's diet, specifically calcium. Supplementing the diet to meet the dietary reference intake standard for calcium is essential, and may be required for other nutrients.
Tube feedings are a consideration for many children affected by CR especially for those with the more involved forms. Tube feedings are considered when airway protection is necessary, but failure to thrive also should raise a red flag. During the first 3 years of a child's life, adequate nutrition is critical for the expected growth in brain cells.
Parents are understandably fearful of tube feedings and often feel they have failed in nurturing their child. Pediatricians can help parents understand that tube feedings allow for assurance that the necessary nutrition is safely delivered. At the same time, parents and therapists can work on skill development necessary for eating.
Providing nutrition services and promoting healthy behaviors in children with CP are tasks best suited to an interdisciplinary team and can be carried out in a variety of health care, school, vocational, home, and community settings. It is the responsibility of the family, in concert with the health care team members, to promote nutrition care planning.
Ms. KRICK is director of nutrition at the Kennedy Krieger Institute, Baltimore.
An international leader in the fields of research, treatment, and education for disorders and injuries of brain and spinal cord, Kennedy Krieger Institute provides a wide range of services to over 12,000 children each year with developmental concerns mild to severe. For more information, visit www.kennedykrieger.org.
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|Title Annotation:||Clinical Rounds|
|Date:||Nov 1, 2006|
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