Impact of feeding problems on nutritional intake and growth: Oxford Feeding Study II

The Effects of Swallowing Disorders and Oral Malformations on Nutritional Status in Children with Cerebral Palsy

Nutrition plays an important role both from a nutrition and a socio-psychological point of view; this part seems to be even more crucial in cerebral palsy where undernutrition is responsible for an increase in morbidity and mortality. The objective of this study was to evaluate the effects of swallowing disorders and oral malformations on the nutritional status of children with cerebral palsy. We evaluated 65 patients aged 2 to 17 years using a cross-sectional, descriptive and observational approach. All patients had a definite diagnosis of cerebral palsy. The measurement of anthropometric variables (weight, height, Body Mass Index (BMI) and circumferences) was performed according to recognized techniques and measurements. The Z-score was also calculated using the World Health Organization (WHO) references. The 5-level Gross Motor Function Classification System was used, providing a standardized classification of motor disability patterns for children with cerebral palsy. The population had a median age of 9.25 (4.50−16.00) and was about 53% female. Furthermore, 75% of the patients had a height inferior to 158 cm. The results of our study show that 42 (64.6%) had false routes, 17 (26.2%) had oral-facial malformations and 51 (78.5%) did not have lip prehensions during meals. The results also show that growth retardation is closely related to gross motor function with p = 0.01, as well as all nutritional indices (Z-score weight for age, Z-score height for age and Z-score BMI for age) are affected by swallowing disorders and oral malformations, with statistically significant values < 0.05. In conclusion, a preventive and curative management specific to this population of children with cerebral palsy must be implemented with an interdisciplinary concertation.

Assessment of Swallowing Disorders, Nutritional and Hydration Status, and Oral Hygiene in Students with Severe Neurological Disabilities Including Cerebral Palsy

BACKGROUND

Special needs schools (SNS) educate children and young people with major neurological disabilities who are at high risk of oropharyngeal dysphagia (OD) and malnutrition (MN). We aimed to assess the prevalence of OD, MN, dehydration (DH), and oral health (OH) in students at an SNS.

METHODS

A cross-sectional observational study was conducted at SNS L'Arboç, Catalonia, Spain. We assessed (a) demographics, health status, comorbidities, and gross motor function classification system (GMFCS), (b) swallowing function, oral-motor evaluation, masticatory capacity, and EDACS classification for eating and drinking abilities, (c) nutritional and DH status (anthropometry, bioimpedance and dietary records), and (d) OH (Oral Hygiene Index Simplified).

RESULTS

A total of 33 students (mean age 13.3 years; 39.4% level V of GMFCS) were included. Main diagnosis was cerebral palsy at 57.6%. All students presented OD, 90.6% had impaired safety, 68.7% were at levels II-III of EDACS, and 31.3% required PEG; furthermore, 89.3% had chronic MN, 21.4% had acute MN, 70% presented intracellular DH, and 83.9% presented impaired OH.

CONCLUSION

MN, DH, OD, and poor OH are highly prevalent conditions in students with cerebral palsy and other neurological disabilities and must be specifically managed through nutritional and educational strategies. The multidisciplinary team at SNS should include healthcare professionals specifically trained in these conditions.

A Case-Control Study of Essential and Toxic Trace Elements and Minerals in Hair of 0-4-Year-Old Children with Cerebral Palsy

The objective of the present study was to assess hair essential and toxic trace elements and minerals in children with cerebral palsy in relation to age of the examinees. A total of 70 children with cerebral palsy and 70 healthy controls aged 0-4 years old were enrolled in the present study. The examined children were also divided into two age groups of those younger and older than 2 years old. Hair trace element content was assessed using ICP-MS at NexION 300D (PerkinElmer, USA). The obtained data demonstrate that hair boron was more than 2-fold lower in CP children as compared with the control group. At the same time, hair Na, Se, and V levels were 21%, 12%, and 20% lower when compared with healthy controls, respectively. It is also notable that a 9% and 28% decrease in hair Fe and Li levels respectively were nearly significant. The observed alterations were more profound in a younger group of patients. No significant group difference in hair toxic metal and metalloid levels was observed between the general cohorts of children with and without CP. In regression models, only hair Al and Ca contents were significantly associated with the presence of cerebral palsy, whereas hair Mg, Na, Ni, and Se levels were characterized as significant negative predictors. The observed alteration in trace element metabolism may also provide an additional link between cerebral palsy, psychomotor delay, and certain diseases, including diabetes, epilepsy, and osteoporosis. However, further studies using other substrates (blood, urine) or biomarkers are required.

Parental Influence in Forming Preschool Children's Eating Behaviors-A Cross-Sectional Survey in Chongqing, China

Children’s eating habits are closely related to their health problems and the outlook for children’s nutritional statuses appears poor. A cross-sectional survey was conducted among parents of preschool children from December 2018 to January 2019. Sixteen representative kindergartens in 6 districts of Chongqing, China, were included in the study. We took 2200 samples and collected information by questionnaire and after screening, 1781 questionnaires were valid and finally included in the data analysis (n = 1781). Ordinal logistic regression analysis found that age, fathers’ education level, forced diet and perception of children’s body shape were factors associated with children’s eating behaviors (ordered logistic regression/three-level eating behavior; odds ratios p < 0.05). 80.24% of preschool children may have unhealthy eating behavior in this survey and 80.35% of parents had forced their children to eat. Eating behaviors of preschool children in Chongqing are closely related to family factors. This study provides important insight for parents and health care workers in China to improve preschool-aged children’s nutritional behaviors. Intervention programs should focus on parents with low income, low education levels, coercive dietary behaviors and deviated body shape perceptions to reduce children’s eating behavioral problems.

Suboptimal Nutrition and Low Physical Activity Are Observed Together with Reduced Plasma Brain-Derived Neurotrophic Factor (BDNF) Concentration in Children with Severe Cerebral Palsy (CP)

Brain-derived neurotrophic factor (BDNF) is a mediator of exercise and nutrition-induced neural plasticity. In children with cerebral palsy (CP), neuromuscular deficits and mobility impairment have a negative impact on their physical activity level and nutritional status, but whether these children have reduced BDNF concentrations is unknown. Therefore, the aim of the present study was to investigate the plasma BDNF concentration, nutritional status, and physical activity level in children with mild to severe CP. Blood sampling, dietary registration, and questionnaires were completed for children with mild CP (gross motor function classification system (GMFCS) I⁻II, n = 31, age 10.6 ± 0.6 years), severe CP (GMFCS IV⁻V, n = 14, age 10.9 ± 1.1 years) and typically developed (TD) children (n = 22, age 10.9 ± 0.6 years). Children with severe CP had ~40% lower plasma BDNF concentration than TD children (p < 0.05). Furthermore, children with severe CP had lower daily physical activity level than TD children (p < 0.01), and a daily intake of energy, n-3 fatty acids, and dietary fibers that was only ~50% of TD (p > 0.001). Reduced plasma BDNF concentrations were observed in children with severe CP. This may be of significance for optimal neural growth and plasticity. This was observed together with low physical activity levels and a suboptimal intake of energy, n-3 fatty acids, and dietary fibers.

Nutrition of Patients with Severe Neurologic Impairment

Background

Commercial enteral formulas are generally recommended for gastrostomy feeding in patients with severe neurologic impairment. However, pureed food diets are still widely used and even gaining popularity among certain groups. We tried to compare the effectiveness of gastrostomy feeding for treatment of severe malnutrition with either enteral formulas or pureed feeds.

Patients and methods

A 6-month nutritional intervention was made with 37 malnourished children, adolescents and young adults (2–26 years old) with severe neurologic impairment (Gross Motor Function Classification system [GMFCS] grade V). The individual needs were calculated. Participants were fed by gastrostomy with either enteral formulas (n = 17) or pureed food (n = 20). Measurements to assess nutritional status were made at the beginning and at the end of intervention.

Results

The Z scores for weight-for-age and for the body-mass index increased more in enteral formula than in pureed food group (2.07 vs. 0.70, p = 0.0012; and 3.75 vs. 0.63, p = 0.0014, respectively). Fat mass index increased more in enteral formula than in pureed food group (1.12 kg/m²vs. 0.38 kg/m²; p = 0.0012). Patients in the enteral formula group showed increase in lean body mass expressed as fat-free mass index (0.70 kg/m²), while those in pureed food group did not (-0.06 kg/m²) (p = 0.0487).

Conclusions

The results suggest that even professionally planned pureed food diet is less effective than commercial enteral formula for nutritional rehabilitation of malnourished patients with severe neurologic impairment. However, larger and if possible randomised clinical studies should be made to confirm our findings.

Anthropometric Parameters of Nutritional Status in Children with Cerebral Palsy

INTRODUCTION

Patients with cerebral palsy (CP), besides the basic neurological damage, are also often undernourished. Adequate nutrition for children is very important during the period of intensive growth and development, which is of particular importance in patients with CP.

GOAL

To evaluate the nutritional status of patients with CP who are treated at the Pediatric Clinic, Clinical Centre of Sarajevo University and causes of malnutrition in these patients.

MATERIALS AND METHODS

Eighty patients with CP underwent anthropometric assessment (body weight, body height, body mass index, head circumference, subscapular skinfold thickness, triceps skinfold thickness and mid upper arm muscle circumference). Severity of CP was classified based on the Gross Motor Function Classification System (GMFCS). We compared the anthropometric parameters of our patients with normal values of healthy children, as well as with degree of motor impairment, oromotor dysfunction, feeding assistance, length of meals and daily feeding time.

RESULTS

There were significant differences in all monitored parameters in relation to normal values, with 38 (47.5%) malnourished patients in the total group, out of which 29 (63.0%) with severe motor impairment and with 9 (11.3%) obese patients in the total group. The presence of oromotor dysfunction and other monitored parameters had a significant impact on the nutritional status of these patients.

CONCLUSION

In severely disabled patients with CP there is a risk of profound malnutrition. Early identification and treatment of these patients is very important for their growth, development and health.

Serum albumin levels and their correlates among individuals with motor disorders at five institutions in Japan

BACKGROUND/OBJECTIVES

The level of serum albumin is an index of nourishment care and management. However, the distribution and correlates of serum albumin levels among individuals with motor disorders have not been reported until now. Therefore, we examined the distribution and correlates of serum albumin levels among individuals with motor disorders.

SUBJECTS/METHODS

A cross-sectional study on 249 individuals with motor disabilities (144 men, mean age: 51.4 years; 105 women, mean age: 51.4 years) was conducted at five institutions in Ibaraki Prefecture, Japan in 2008. The results were compared with data from the National Health and Nutrition Survey.

RESULTS

The mean serum albumin levels were 4.0 ± 0.4 g/dL for men and 3.8 ± 0.5 g/dL for women. Overall, 17 (11.8%) men and 25 (23.8%) women had hypoalbuminemia (serum albumin level ≤ 3.5 g/dL); these proportions were greater than those among healthy Japanese adults (≤ 1%). Low serum albumin level was related with female sex, older age, low calf circumference, low relative daily energy intake, low hemoglobin (Hb), low blood platelet count, low high-density lipoprotein cholesterol (HDL-C), low HbA_1c, and high C-reactive protein (CRP) levels. The strongest correlates, based on standardized betas, were Hb (0.321), CRP (-0.279), and HDL-C (0.279) levels.

CONCLUSIONS

These results indicate that the prevalence of hypoalbuminemia is higher in individuals with motor disabilities than in healthy individuals and that inflammation is a strong negative correlate of serum albumin levels. Therefore, inflammation should be examined for the assessment of hypoalbuminemia among institutionalized individuals with motor disabilities.

The nutritional state of children and adolescents with cerebral palsy is associated with oral motor dysfunction and social conditions: a cross sectional study

BACKGROUND

Cerebral palsy (CP) is the main cause of severe physical impairment during childhood and has commonly shown oral motor association. It has been considered as the main cause of the high prevalence of problems in children's nutrition. Respiration, chewing, swallowing, speaking and facial expressionare part of the orofacial motor functions and when affected they can interfere in children's well-being. The aim of this study was to correlate two methods of orofacial motor evaluation, analyze the influence of orofacial motor functional impairment on the nutritional status of children and adolescents with CP, and the association between socioeconomic factors.

METHODS

Seventy children and adolescents with CP were selected, age range 6-16 years and following the exclusion criteria previously determined; 129 normoreactive children (control group), sex and age-matched to patients with CP. For the orofacial motor analysis two evaluation instruments were applied, the "Oral Motor Assessment Scale" (OMAS) and "Nordic Orofacial Test-Screening" (NOT-S). The anthropometric evaluation was based on the World Health Organization (WHO) and followed the criteria recommended by the Brazilian Ministry of Health.

RESULTS

There was statistically significant correlation between the oral motor methods of evaluation (r = -0.439, p < 0.0001). Concerning the nutritional status evaluation, being overweight was associated with dystonic and mixed CP forms variables (p = 0.034), mother with no partnership (p = 0.045) and mild oral motor impairment (p = 0.028).

CONCLUSION

It could be concluded that, the weight's gain by children and adolescents might be favored by a better functional oral motor performance and social factors.

Growth and nutritional risk in children with developmental delay

INTRODUCTION

Nutritional risk impacts outcome in developmental delay. The main objectives were to identify the incidence and factors contributing to growth faltering.

METHODS

Clinical data review was completed for 500 patients with developmental delay accepted to an Early Intervention service. Data was collected using the standardised parent nutrition screening checklist prior to and at time of initial dietary assessment. Data was compared to nutritional assessment data, GOSH and FSAI dietary guidelines. Weight category was determined using RCPCH growth and BMI charts. Statistical analysis was conducted using Statistical Package for the Social Sciences version 20 (IBM Statistics 20.0).

RESULTS

Nutritional risk was identified in 48.6 %. Weight categories were growth faltering (13.5 %), underweight (7.7 %), overweight (8.4 %) and obesity (4.3 %) at initial assessment. Growth faltering was correlated with age <1 year (p = 0.000) and with gestational age (p = 0.017) with highest rates identified in those born 32-36 weeks (3.6 %). Weight category was associated with introduction of solids pre 17 weeks recommendation (10.1 %), ANOVA demonstrating significance (P = 0.013). There was poor parental recognition of nutritional risk in 22.7 % of those assessed. Nutritional difficulties were common: 4.2 % were enterally fed, 7.7 % were on prescribed nutritional supplements, 29.1 % (n = 121) had feeding difficulties and 13.9 % (n = 58) had behavioural feeding difficulties. Iron intake did not meet the recommended intake in 20.9 % (n = 87), calcium in 4.5 % (n = 19). The prevalence of constipation was 21.6, 11.8 % of whom required medical management.

CONCLUSIONS

Developmental delay predisposes to nutritional deficits which influence outcome. Screening, assessment and timely interventions are warranted to prevent poorer developmental outcomes.

Bone mineral density evaluation among patients with neuromuscular scoliosis secondary to cerebral palsy

Objective

To evaluate bone mineral density among patients with neuromuscular scoliosis secondary to quadriplegic cerebral palsy.

Methods

This was a descriptive prospective study in which both bone densitometric and anthropometric data were evaluated. The inclusion criteria used were that the patients should present quadriplegic cerebral palsy, be confined to a wheelchair, be between 10 and 20 years of age and present neuromuscular scoliosis.

Results

We evaluated 31 patients (20 females) with a mean age of 14.2 years. Their mean biceps circumference, calf circumference and body mass index were 19.4 cm, 18.6 cm and 16.9 kg/m², respectively. The mean standard deviation from bone densitometry was −3.2 (z-score), which characterizes osteoporosis.

Conclusion

There is high incidence of osteoporosis in patients with neuromuscular scoliosis secondary to quadriplegic cerebral palsy.

Food pattern and nutritional status of children with cerebral palsy

OBJECTIVES

To assess the food intake pattern and the nutritional status of children with cerebral palsy.

METHODS

Cross-sectional study with 90 children from two to 12.8 years with cerebral palsy in the following forms: hemiplegia, diplegia, and tetraplegia. Nutritional status was assessed by weight, height, and age data. Food intake was verified by the 24-hour recall and food frequency questionnaire. The ability to chew and/or swallowing, intestinal habits, and physical activity were also evaluated.

RESULTS

For 2-3 year-old age group, the mean energy intake followed the recommended range; in 4-6 year-old age group with hemiplegia and tetraplegia, energy intake was below the recommended limits. All children presented low intake of carbohydrates, adequate intake of proteins and high intake of lipids. The tetraplegia group had a higher prevalence of chewing (41%) and swallowing (12.8%) difficulties compared to 14.5 and 6.6% of children with hemiplegia, respectively. Most children of all groups had a daily intestinal habit. All children presented mild physical activity, while moderate activity was not practiced by any child of the tetraplegia group, which had a significantly lower height/age Z score than those with hemiplegia (-2.14 versus -1.05; p=0.003).

CONCLUSIONS

The children with cerebral palsy presented inadequate dietary pattern and impaired nutritional status, with special compromise of height. Tetraplegia imposes difficulties regarding chewing/swallowing and moderate physical activity practice.

Growth in children with cerebral palsy during five years after selective dorsal rhizotomy: a practice-based study

BACKGROUND

Overweight is reported as a side effect of SDR. The aims were to study the development of weight, height and body mass index (BMI) during five years after SDR.

METHODS

This prospective, longitudinal and practice-based study included all 56 children with CP spastic diplegia undergoing SDR from the start in March 1993 to April 2003 in our hospital. The preoperative Gross Motor Function Classification System (GMFCS) levels were I-II in 17, III in 15, IV-V in 24 children. Median age at SDR was 4.3 years (range 2.4-7.4 years). Weight and height/recumbent length were measured. Swedish growth charts for typically developing children generated weight, height and BMI z-scores for age and gender.

RESULTS

The preoperative median z-scores were for height -1.92 and for body mass index (BMI) -0.22. Five years later, the median BMI z-score was increased by + 0.57 (p < 0.05). The occurrence of thinness (BMI < -2 SD) was decreased (n.s.) and obesity (BMI > + 2 SD) increased (p < 0.05). Baseline BMI and age at the start of follow-up influenced the BMI change during the five years (p < 0.001 and p < 0.05 respectively).The individual growth was highly variable, but a tendency towards increasing stunting with age was seen in severe gross motor dysfunction (GMFCS levels IV-V) and the opposite, a slight catch-up of height in children with walking ability (GMFCS levels I-III).

CONCLUSIONS

These are the first available subtype- and GMFCS-specific longitudinal growth data for children with CP spastic diplegia. Their growth potential according to these data should be regarded as a minimum, as some children were undernourished. It is unknown whether the spasticity reduction through SDR increased the weight gain velocity, or if the relative weight increase was part of the general "obesity epidemic".For some children the weight increase was highly desirable. In others, it resulted in overweight and obesity with risk of negative health effects. Weight and height should be monitored to enable early prevention of weight aberrations also causing problems with mobility, activity and participation.

A prospective, longitudinal study of growth, nutrition and sedentary behaviour in young children with cerebral palsy

Background

Cerebral palsy is the most common cause of physical disability in childhood, occurring in one in 500 children. It is caused by a static brain lesion in the neonatal period leading to a range of activity limitations. Oral motor and swallowing dysfunction, poor nutritional status and poor growth are reported frequently in young children with cerebral palsy and may impact detrimentally on physical and cognitive development, health care utilisation, participation and quality of life in later childhood. The impact of modifiable factors (dietary intake and physical activity) on growth, nutritional status, and body composition (taking into account motor severity) in this population is poorly understood. This study aims to investigate the relationship between a range of factors - linear growth, body composition, oral motor and feeding dysfunction, dietary intake, and time spent sedentary (adjusting for motor severity) - and health outcomes, health care utilisation, participation and quality of life in young children with cerebral palsy (from corrected age of 18 months to 5 years).

Design/Methods

This prospective, longitudinal, population-based study aims to recruit a total of 240 young children with cerebral palsy born in Queensland, Australia between 1^st September 2006 and 31^st December 2009 (80 from each birth year). Data collection will occur at three time points for each child: 17 - 25 months corrected age, 36 ± 1 months and 60 ± 1 months. Outcomes to be assessed include linear growth, body weight, body composition, dietary intake, oral motor function and feeding ability, time spent sedentary, participation, medical resource use and quality of life.

Discussion

This protocol describes a study that will provide the first longitudinal description of the relationship between functional attainment and modifiable lifestyle factors (dietary intake and habitual time spent sedentary) and their impact on the growth, body composition and nutritional status of young children with cerebral palsy across all levels of functional ability.

Mothers' voice: a qualitative study on feeding children with cerebral palsy

BACKGROUND

Around one third of children with cerebral palsy have severe difficulty eating and drinking and are at risk of undernourishment. A gastrostomy feeding tube may be offered as a way of providing nourishment as it bypasses the main physical difficulties. For the families feeding and concerns about the method of feeding affect many areas of their daily life but we know little about what the experience is actually like. This study aimed to explore mothers' experience of feeding children with cerebral palsy.

METHODS

Ten principal carers for children with cerebral palsy and severe eating difficulty were interviewed. Four of the children, one girl and three boys aged 2.5 to 4.5 years were being fed solely by mouth and six children, three girls and three boys, aged 4.5 years to 15 years and 10 months, were fed via a gastrostomy feeding tube. Long, loosely structured tape recorded interviews were transcribed and manually analysed using a phenomenological approach. This involved extracting and coding each relevant phrase that contained meaning; then through sequential stages of ordering and reduction into themes the invariant meanings were uncovered. The transcripts were analysed in two groups, oral and gastrostomy feeding, in an identical manner.

RESULTS

Phenomenological analysis resulted in two prose accounts that described in depth the essence of the experience. The accounts were mutually informative. Both groups treasured feeding by mouth suggesting that support for oral feeding should be given a higher priority. The accounts explained why some professional encounters added to families' stress and why consistency of care is so important. The study gives insight about the kinds of support families find helpful.

CONCLUSIONS

This study should help those involved to understand the families' predicament better and so make a contribution towards providing more appropriate support.

CALCIUM AND BONE MINERAL METABOLISM IN CHILDREN WITH CHRONIC ILLNESSES

Increased longevity and improved medical management of children with chronic illnesses has led to a focus on the short- and long-term consequences of these conditions on bone health. Bone loss is influenced by diet, malabsorption, and disease-related imbalances in bone turnover. It may be exacerbated by common medications, especially corticosteroids. Assessment of bone mass and quality, calcium absorption, kinetically derived rates of bone turnover, and biochemical markers of bone turnover have increased our knowledge of the pathophysiology of bone loss in these children as well as provided insights into possible therapeutic interventions. Increased intake of calcium and vitamin D, while useful, is unlikely to prevent or resolve bone loss in many chronically ill children. Emphasis on combination of nutritional interventions with exercise and newer bone-sparing therapies may be necessary.