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Nutritional
SOLUTIONS

Nutritional Strategies

Providing optimal nutrition to children with cerebral palsy (CP) helps improve their nutritional status and their overall general health.1

Children with CP often require specific nutritional interventions. Indicators that can help you determine if the child is in need of a nutritional intervention include:2

  • No weight gain or growth
  • A deviation from an established “growth pattern”
  • Low body fat-stores with low weight in respect to height or length
  • Prolonged or stressful oral feeding
  • Signs of pulmonary aspiration or dehydration
  • Evidence of micronutrient deficiencies

Once you identify the medical need caregivers play an influential role in providing the recommended nutritional solution. In fact, children with CP are very dependent on the caregivers’ understanding and adherence to your recommendations.1


The more you communicate with caregivers, the higher the chances of successful implementation of the nutritional plan at home.

In the following section, we will provide you with helpful information related to both the nutritional assessment and the nutritional recommendations for children with CP.

The choice of a nutritional strategy, as well as the method of administration, depend on:2

  • The child’s nutritional status
  • The child’s nutritional requirements
  • The child’s ability to consume adequate quantities of food and fluids orally
  • The risk of pulmonary aspiration

Before recommending a nutritional strategy, nutritional requirements need to be carefully assessed. Several specialists may take part in this overall assessment to help determine the best nutritional strategy. It is critical to include dietitians and speech language pathologist as part of the team in order to provide a complete nutritional solution.


Nutritional requirements vary depending on physical impairments, feeding difficulties, body composition and physical activity levels.2

Anthropometric assessment is the first step needed to calculate energy requirements. Preferably, weight measurement should be obtained on a digital scale; but, if the child is unable to stand, the use of a wheel chair scale is recommended.3 The height of children younger than two years of age or unable to stand should be obtained through reclining length or through segmental measures.3

For body composition, the best way to estimate it is via the DXA (dual energy X-ray absorptiometry). When this method is too expensive or unavailable, skin fold thickness and bioelectric impedance are suggested.3


→TAKE A LOOK AT OUR EDUCATIONAL VIDEOS THAT CAN HELP YOU IN THE ANTHROPOMETRIC ASSESSMENT OF CHILDREN WITH CP


It is advisable to routinely measure and monitor the weight, height, body composition and nutritional status of children with CP in order to adapt nutritional requirements accordingly.3 Following clinical assessment, the child’s nutritional needs should be discussed with their caregivers.

Introducing thickeners if indicated, or oral nutrition supplements (ONS), while ensuring adequate position and physical support during meals, is usually the first approach.2 If, despite these strategies, the child is not gaining weight, then more advanced solutions need to be considered, such as a gastrostomy tube for feeding.

Below we have covered each nutritional strategy in more detail.



References:

  1. Verrall TC et al. Children with Cerebral Palsy: Caregivers' Nutrition Knowledge, Attitudes and Beliefs. Can J Diet Pract Res. 2000;61(3):128-134.
  2. Bell KL and Samson-Fang L. Nutritional management of children with cerebral palsy. Eur J Clin Nutr. 2013;67 Suppl 2:S13-6.
  3. Scarpato E et al. Nutritional assessment and intervention in children with cerebral palsy: a practical approach. Int J Food Sci Nutr. 2017;68(6):763-770.

Children with cerebral palsy (CP) who have dysphagia may have challenges swallowing regular foods and liquids. Solid foods may need to be chopped, minced or pureed to decrease the amount of chewing required and to reduce the risk of blocking the airway. Drinks and other liquids may need to be thickened so they are more easily managed by children with oropharyngeal dysphagia. Commercial thickeners are convenient and can be easily added to hot and cold fluids. Juices and soups are examples of liquids that can be thickened. Explaining the measuring and simple mixing techniques when using thickeners is an important part of caregiver education to consider. The thickness of liquids and the textures of food recommended to manage dysphagia vary according to the individual child’s needs.


Liquids can be thickened to different consistencies depending on the needs of the child.
Some examples of liquid consistencies are:1,2


consistency chart

Foods may be modified to different textures depending on the needs of the child.
Some examples of modified food textures are:1-2

consistency chart

References:

  1. National Dysphagia Diet Task Force. National Dysphagia Diet: Standardization for Optimal Care. American Dietetic Association, 2002.
  2. IDDSI Framework - Detailed definitions. www.IDDSI.org. (International Dysphagia Diet Standardisation Initiative).
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When a child is losing weight, oral nutrition supplements (ONS) may be necessary to help provide adequate nutrition. They are rich in micro- and macronutrients, which enhance a child’s diet without the need to consume large amounts of food. Usually, the first recommendation would be to take ONS in addition to regular food. ONS come in different formats, such as powders, milky drinks or pudding-like textures, and can also come in various flavours. To improve compliance, ONS can be added to recipes.

A dietitian can help identify the desired quantity and type of ONS the child needs to take to complete the overall diet.

An initial follow-up after one to three months is usually advised, except in infants and children with a very poor nutritional status who need to have more regular short-term follow-up.

If weight gain is still inadequate, despite the introduction of ONS, tube feeding may need to be considered.1

References:

  1. Bell KL and Samson-Fang L. Nutritional management of children with cerebral palsy. Eur J Clin Nutr. 2013;67 Suppl 2:S13-6.
Nestlé Health Science

Tube feeding is indicated in children with cerebral palsy (CP) who have a functional gastrointestinal tract, and it should be considered if the following factors are present:1

  • Lengthy mealtimes that are limiting the child’s participation in school and community activities
  • Child and their caregivers are experiencing stress when it comes to oral feeding
  • Aspiration during feeding is contributing to recurrent respiratory illnesses and/or interfering with the enjoyment of meals
  • Child continues to show poor weight gain and growth despite the use of oral nutrition supplements

The method of formula administration can be through continuous drip, intermittent bolus, or a combined continuous nighttime and intermittent daytime bolus. Together with other healthcare professionals, you will recommend the most appropriate method based on the child’s needs.

Even if a child is not fed orally, it is still important to make sure that they are being included in family mealtimes.2

We encourage you to communicate with and support your patient’s caregiver, because the decision to initiate tube feeding can be very difficult for both the carers and the patient.

Your help and guidance will help them overcome obstacles. Remember that feeding and eating have a deeper meaning beyond just providing adequate nutrition.1

A child should also be given opportunities to practice oral sensory responses.2 Working closely with speech language pathologists and occupational therapists may minimize risks associated with dysphagia.

The decision to place a feeding tube and start tube feeding is a difficult one for caregivers. It is therefore important to have the conversation early and allow time for discussion and questions to be answered.1

Your help and guidance will help them overcome obstacles. Remember that feeding and eating have a deeper meaning beyond just providing adequate nutrition.1

Tube feeding can be a temporary solution until the child’s eating improves and weight increases, or it can be a permanent solution. The choice of access depends on two factors:

  • The expected duration of the feeding
  • The clinical status of the child

NG and NJ tube feeding

Nasogastric (NG) and Nasojejunal (NJ) tube feeding

These forms of feeding are favoured for short-term use due to tubes being easily dislodged, blocked, and causing nasopharyngeal irritations.1

In some cases, NG feeding can be used before the insertion of a gastrostomy to allow for both nutritional rehabilitation and tolerance assessment.1

On the other hand, NJ tube feeding is indicated for children with severe GERD, vomiting, and an increased risk of aspiration.

G-tube and J-tube feeding

G-tube

This route of feeding is the preferred route when long-term tube feeding is required.

J-tube

This route of feeding may be reserved for children with severe GERD and vomiting.

There is a wide range of formulas for tube feeding to choose from.

Each formula is adapted to a child’s specific needs (e.g., caloric content, fibre content, protein content), and some are even based on real food.

→CLICK HERE TO SEE THE DIFFERENT TYPES OF FORMULAS AVAILABLE FOR FEEDING

References:

  1. Rempel G. The Importance of Good Nutrition in Children with Cerebral Palsy. Phys Med Rehabil Clin N Am. 2015 Feb;26(1):39-56.
  2. Arvedson JC. Feeding children with cerebral palsy and swallowing difficulties. Eur J Clin Nutr. 2013;67 Suppl 2:S9-12.

 

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There is a wide range of tube feeding formulae available for children with cerebral palsy (CP). All types of formulae promote normal growth and development; however, the choice of formula depends on the status of the child’s GI tract.

Formulae differ in calorie content, protein quantity and source, as well as in fibre content. For example, polymeric feeds are usually the first choice to be used, as they provide a complete nutrition that mimics a normal diet, while whey peptide based formulae are specific for children with emesis (vomiting) and may help in reducing episodes of diarrhoea in GI-compromised children.

This is usually because whey peptide based formulae may be easier to digest, offer an improved feeding tolerance and are suggested by the ESPGHAN for children with CP who suffer from GORD.1

Here are examples of different types of formulae:2

Standard formula:

What is it?

A standard tube feeding formula is a formula that is designed for children who have a functional GI tract and normal digestion.

What are the advantages?

  • They contain intact nutrients and mimic a typical diet.
  • Some standard formulae can be used for both tube feeding and oral feeding, and some contain added ingredients, such as fibre, to promote regular bowel movements.

Peptide based formula

What is it?

A peptide based formula contains proteins that ‘have been broken down’ into peptides to facilitate absorption and digestion in children with impaired GI function (GORD, vomiting or tolerance issues)

What are the advantages?

  • Whey* peptide based formulae are specifically designed for those who have an abnormal functioning of the GI tract. These types of formulae facilitate gastric emptying, nutrient absorption, for an enhanced energy and protein delivery, and gut function preservation, and they also ensure gastrointestinal tolerance.3
  • They may reduce the number of vomiting, regurgitation and diarrhoea episodes, while supporting optimal nutrient absorption and digestion.4

*The whey is the watery part of milk that separated from the curds. The protein in cow’s milk is 20% whey protein and 80% casein protein.5

We believe that hearing the stories of how families coped with CP can help you gain a deeper understanding of what they go through.

→Click here to watch the real stories we have compiled from caregivers

 

References:

  1. Romano C et al. European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Neurological Impairment. J Pediatr Gastroenterol Nutr. 2017;65(2):242-264.
  2. NHS, Learning About Nutrition. Available at: https://www.nestlehealthscience.us/mytubefeedingkid/learning-about-nutrition
  3. Alexander D et al. Nutritional and health benefits of semi-elemental diets: A comprehensive summary of the literature. World J Gastrointest Pharmacol Ther. 2016;7(2):306-19.
  4. Minor G et al. Formula Switch Leads to Enteral Feeding Tolerance Improvements in Children With Developmental Delays. Glob Pediatr Health. 2016;3:2333794X16681887.
  5. Savino P. Knowledge of constituent ingredients in enteral nutrition formulas can make a difference in patient response to enteral feeding. Nutr Clin Pract 2017:884533617724759
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