Incidence of gastroesophageal reflux with whey- and casein-based formulas in infants and in children with severe neurological impairment

Dietary and nutritional interventions in children with cerebral palsy: A systematic literature review

Background

Cerebral palsy is an extremely severe brain injury associated with multiple nutritional and clinical issues, such as underweight, gastroesophageal reflux, constipation, and nutrient deficiency. Evidence-based dietary and nutritional interventions may improve the quality of life of children with cerebral palsy.

Aim

Systematically review randomized clinical trials evaluating nutritional and dietary interventions in the clinical, nutritional, and neurodevelopmental aspects of children with cerebral palsy.

Methods

A search was performed in electronic databases (LILACS, Medline, Web of Science, Embase, Scopus, Cochrane Library, ClinicalTrials.gov, Brazilian Digital Library of Theses and Dissertations, ProQuest Dissertations and Theses Database, OpenGrey) using keywords. The search was firstly performed in May 2020 and updated on June 18th, 2021. Eligible studies were randomized clinical trials, that included children between 2 and 12 years old, and evaluated the effect of nutritional or dietetic interventions on clinical, nutritional or neurodevelopmental outcomes. Risk of bias was investigated using the RoB-2 tool. The study was registered on PROSPERO (CRD42020181284).

Results

Fifteen studies were selected. Positive results included the use of whey-based or pectin-enriched enteral formulas for gastroesophageal reflux (n = 6); 25-hydroxy-vitamin D supplementation for hypovitaminosis D (n = 2); supplementation with lipid mixture or diet with high-density energy for improvements in anthropometric measures (n = 2); supplementation with probiotics, prebiotics, symbiotics or magnesium for constipation (n = 2); nutritional support system for gross motor function (n = 1); lactoferrin and iron hydroxide polymaltose for iron deficiency anemia (n = 1); and educational intervention to improve feeding skills (n = 1). The overall risk of bias was high for 60% of the studies, and some concerns were raised for the remaining 40%.

Conclusion

Some promising dietary and nutritional interventions may promote important clinical improvements for patients with cerebral palsy. However, evidence is weak, as few clinical trials have been published with many methodological errors, leading to a high risk of bias.

Semi-Elemental and Elemental Formulas for Enteral Nutrition in Infants and Children with Medical Complexity-Thinking about Cow's Milk Allergy and Beyond

Children with medical complexities, such as multi-system disorders and/or neurological impairments, often experience feeding difficulties and need enteral nutrition. They frequently have impaired motility and digestive-absorbing functions related to their underlying condition. If a cow's milk allergy (CMA) occurs as a comorbidity, it is often misdiagnosed, due to the symptoms' overlap. Many of the commercialized mixtures intended for enteral nutrition are composed of partially hydrolyzed cow's milk proteins, which are not suitable for the treatment of CMA; thus, the exclusion of a concomitant CMA is mandatory in these patients for obtaining symptoms relief. In this review, we focus on the use of elemental and semi-elemental formulas in children with neurological diseases and in preterm infants as clinical "models" of medical complexity. In children with neurodisabilities, when gastrointestinal symptoms persist despite the use of specific enteral formula, or in cases of respiratory and/or dermatological symptoms, CMA should always be considered. If diagnosis is confirmed, only an extensively hydrolyzed or amino-acid based formula, or, as an alternative, extensively hydrolyzed nutritionally adequate formulas derived from rice or soy, should be used. Currently, enteral formulas tailored to the specific needs of preterm infants and children with neurological impairment presenting concomitant CMA have not been marketed yet. For the proper monitoring of the health status of patients with medical complexity, multidisciplinary evaluation and involvement of the nutritional team should be promoted.

Severe neurological impairment: a review of the definition

Severe neurological impairment (SNI) is a term commonly used in the medical literature, though there is no agreed definition. This limits opportunities for research into healthcare needs, treatment opportunities, resource planning, and outcome. We reviewed the literature to establish consistency of use of the term and to place it in the context of other commonly employed terms used to describe children with severe, complex medical needs. Forty-two articles were included for full-text analysis, with 23 including a definition of SNI. Motor impairment, intellectual disability, communication difficulties, and increased care needs were included in the definition in 80%, 70%, 30%, and 13% of papers respectively. Dependence on others for decision-making, chronicity, and distinction between disorders of the central nervous system and peripheral nervous system were less frequently included. There is wide variation in the use of the term SNI. A consensus-based definition of this term would be useful to facilitate future research. WHAT THIS PAPER ADDS: There is inconsistency in use of the term severe neurological impairment (SNI), limiting research efforts. In defining SNI, considerations are mobility, intellectual disability, communication difficulties, and increased care needs. Distinction between acute and chronic, central and peripheral nervous system disorders, and dependence on others for decision-making were less significant.

Evaluation and Management of Respiratory Illness in Children With Cerebral Palsy

Cerebral palsy (CP) is the most common cause of disability in childhood. Respiratory illness is the most common cause of mortality, morbidity, and poor quality of life in the most severely affected children. Respiratory illness is caused by multiple and combined factors. This review describes these factors and discusses assessments and treatments. Oropharyngeal dysphagia causes pulmonary aspiration of food, drink, and saliva. Speech pathology assessments evaluate safety and adequacy of nutritional intake. Management is holistic and may include dental care, and interventions to improve nutritional intake, and ease, and efficiency of feeding. Behavioral, medical, and surgical approaches to drooling aim to reduce salivary aspiration. Gastrointestinal dysfunction, leading to aspiration from reflux, should be assessed objectively, and may be managed by lifestyle changes, medications, or surgical interventions. The motor disorder that defines cerebral palsy may impair fitness, breathing mechanics, effective coughing, and cause scoliosis in individuals with severe impairments; therefore, interventions should maximize physical, musculoskeletal functions. Airway clearance techniques help to clear secretions. Upper airway obstruction may be treated with medications and/or surgery. Malnutrition leads to poor general health and susceptibility to infection, and improved nutritional intake may improve not only respiratory health but also constipation, gastroesophageal reflux, and participation in activities. There is some evidence that children with CP carry pathogenic bacteria. Prophylactic antibiotics may be considered for children with recurrent exacerbations. Uncontrolled seizures place children with CP at risk of respiratory illness by increasing their risk of salivary aspiration; therefore optimal control of epilepsy may reduce respiratory illness. Respiratory illnesses in children with CP are sometimes diagnosed as asthma; a short trial of asthma medications may be considered, but should be discontinued if ineffective. Overall, management of respiratory illness in children with CP is complex and needs well-coordinated multidisciplinary teams who communicate clearly with families. Regular immunizations, including annual influenza vaccination, should be encouraged, as well as good oral hygiene. Treatments should aim to improve quality of life for children and families and reduce burden of care for carers.

Evaluation and Treatment of Malnutrition and Associated Gastrointestinal Complications in Children with Cerebral Palsy

The majority of children with cerebral palsy (CP) have feeding difficulties and are especially prone to malnutrition. The early involvement of a multidisciplinary team should aim to prevent malnutrition and provide adequate nutritional support. Thorough nutritional assessment, including body composition, should be a prerequisite for the nutritional intervention. As in typically-developed children nutritional support should start with dietary advice and the modification of oral feeding, if safe and acceptable. However, for prolonged feeding, in the presence of unsafe swallowing and inadequate oral intake, enteral nutrition should be promptly initiated and early gastrostomy placement should be evaluated and discussed with parents/caregivers. Gastrointestinal problems (oropharyngeal dysfunction, gastroesophageal disease, and constipation) in children with CP are frequent and should be actively detected and adequately treated as they can further worsen the feeding process and nutritional status.

European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Neurological Impairment

OBJECTIVES

Feeding difficulties are frequent in children with neurological impairments and can be associated with undernutrition, growth failure, micronutrients deficiencies, osteopenia, and nutritional comorbidities. Gastrointestinal problems including gastroesophageal reflux disease, constipation, and dysphagia are also frequent in this population and affect quality of life and nutritional status. There is currently a lack of a systematic approach to the care of these patients. With this report, European Society of Gastroenterology, Hepatology and Nutrition aims to develop uniform guidelines for the management of the gastroenterological and nutritional problems in children with neurological impairment.

METHODS

Thirty-one clinical questions addressing the diagnosis, treatment, and prognosis of common gastrointestinal and nutritional problems in neurological impaired children were formulated. Questions aimed to assess the nutritional management including nutritional status, identifying undernutrition, monitoring nutritional status, and defining nutritional requirements; to classify gastrointestinal issues including oropharyngeal dysfunctions, motor and sensory function, gastroesophageal reflux disease, and constipation; to evaluate the indications for nutritional rehabilitation including enteral feeding and percutaneous gastrostomy/jejunostomy; to define indications for surgical interventions (eg, Nissen Fundoplication, esophagogastric disconnection); and finally to consider ethical issues related to digestive and nutritional problems in the severely neurologically impaired children. A systematic literature search was performed from 1980 to October 2015 using MEDLINE. The approach of the Grading of Recommendations Assessment, Development, and Evaluation was applied to evaluate the outcomes. During 2 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation using the nominal voting technique. Expert opinion was applied to support the recommendations where no randomized controlled trials were available.

Whey- vs casein-based enteral formula and gastrointestinal function in children with cerebral palsy

OBJECTIVES

Children with severe cerebral palsy (CP) commonly have gastrointestinal (GI) dysfunction. Whey-based enteral formulas have been postulated to reduce gastroesophageal reflux (GOR) and accelerate gastric emptying (GE). The authors investigated whether whey-based (vs casein-based) enteral formulas reduce GOR and accelerate GE in children who have severe CP with a gastrostomy and fundoplication.

METHODS

Thirteen children received a casein-based formula for 1 week and either a 50% whey whole protein (50% WWP) or a 100% whey partially hydrolyzed protein (100% WPHP) formula for 1 week. Reflux episodes, gastric half-emptying time (GE t(1/2)), and reported pain and GI symptoms were measured.

RESULTS

Whey formulas emptied significantly faster than casein (median [interquartile range (IQR)] GE t(1/2), 33.9 [25.3-166.2] min vs 56.6 [46-191] min; P = .033). Reflux parameters were unchanged. GI symptoms were lower in children who received 50% WWP (visual analog symptom score, median [IQR], 0 [0-11.8]) vs 100% WPHP (13.0 [2.5-24.8]) (P = .035).

CONCLUSION

This pilot study shows that in children who have severe CP with a gastrostomy and fundoplication, GE of the whey-based enteral formula is significantly faster than casein. The acceleration in GE does not alter GOR frequency, and there appears to be no effect of whey vs casein in reducing acid, nonacid, and total reflux episodes. The results indicate that enteral formula selection may be particularly important for children with severe CP and delayed GE.

Tolerance of an enteral formula with insoluble and prebiotic fiber in children with compromised gastrointestinal function

The effects of adding fiber to the tolerance of a peptide-based formula have not been studied. The objective of this study was to evaluate the tolerance of a peptide-based formula with insoluble and prebiotic fiber in children with compromised gut function. During January 2005 to June 2006, a 6-week randomized, double-blind, cross-over clinical study was conducted to compare stool frequency, stool consistency, and tolerance (abdominal pain, abdominal distension, vomiting, weight gain, and intake) between a formula with or without 3.5 g fructo-oligosaccharides and 3.8 g insoluble fiber/L. Fourteen children with gastrointestinal dysmotility (n=9), Crohn's disease (n=3), or mild short bowel syndrome (n=2) were randomized to receive one of two formulas for 2 weeks followed by a 5-day washout period and then the second diet for another 2 weeks. Means and standard deviations of daily stool frequency and consistency were calculated and compared using intent-to-treat analysis. Linear mixed models were applied to each outcome variable. Stool frequency did not differ by formula. Stool consistency did differ with more soft "mushy" stools (less hard stools) occurring with use of fiber (P<0.001) and more watery stools occurring with control formula (P<0.01). The extremes of stool consistency were normalized with the fiber formula. No significant differences were observed in vomiting, abdominal pain, feeding intakes, or weight gain between the two formulas. This study showed that a peptide-based formula containing fiber was as well-tolerated as a fiber-free formula in a small population of children with gastrointestinal impairments. Longer-term effects of the fiber formula need to be studied.

Compared with casein or total milk protein, digestion of milk soluble proteins is too rapid to sustain the anabolic postprandial amino acid requirement

BACKGROUND

The in vivo quality of milk protein fractions has seldom been studied in humans.

OBJECTIVE

Our objective was to compare the postprandial utilization of dietary nitrogen from 3 [(15)N]-labeled milk products: micellar caseins (MC), milk soluble protein isolate (MSPI), and total milk protein (TMP).

DESIGN

The macronutrient intakes of 23 healthy volunteers were standardized for 1 wk, after which time the subjects ingested a meal containing MC (n = 8), MSPI (n = 7), or TMP (n = 8). [(15)N] was measured for an 8-h period in plasma amino acids, proteins, and urea and in urinary urea.

RESULTS

The transfer of dietary nitrogen to urea occurred earlier after MSPI ingestion than after MC and TMP ingestion, and concentrations remained high for 8 h, concomitantly with higher but transient hyperaminoacidemia and a higher incorporation of dietary nitrogen into plasma amino acids. In contrast, deamination, postprandial hyperaminoacidemia, and the incorporation of dietary nitrogen into plasma amino acids were lower in the MC and TMP groups. Finally, total postprandial deamination values were 18.5 +/- 2.9%, 21.1 +/- 2.8%, and 28.2 +/- 2.9% of ingested nitrogen in the TMP, MC, and MSPI groups, respectively.

CONCLUSIONS

Our results confirm the major role of kinetics in dietary nitrogen postprandial utilization and highlight the paradox of MSPI, which, despite its high Protein Digestibility Corrected Amino Acid Score, ensures a rate of amino acid delivery that is too rapid to sustain the anabolic requirement during the postprandial period. Milk proteins had the best nutritional quality, which suggested a synergistic effect between soluble proteins and caseins.

Gastric emptying of two whey-based formulas of different energy density and its clinical implication in children with volume intolerance

OBJECTIVE

Whey-based formulas have faster gastric emptying than casein-based formulas. Isoenergetic, isovolumic, whey-based formulas of different osmolarity and fat content empty in a similar manner. Will the gastric emptying of high and low energy density whey-based formulas be similar?

DESIGN

We studied the gastric emptying rate of equal volumes of two whey-based formulas of different energy density (4.18 kJ/ml and 6.27 kJ/ml) and osmolality (270 and 450 mOsm/kg, respectively) in 10 children (4.5-12 y) with volume intolerance and resultant inability to gain weight.

RESULTS

The two formulas had comparable gastric emptying rates at 30, 60, 90 and 120 min. Over a one month clinical trial, substitution of the lower energy density whey-based formula (no weight gain over 2 months) with an equal volume of the high energy density formula produced a mean weight gain of 1.17+/-0.5 kg per patient without change in tolerance.

CONCLUSION

The higher density whey-based formula can safely substitute an equal volume of a lower energy density formula to produce weight gain without affecting tolerance.

IMPLICATION

This provides an important intervention for increasing energy intake in children with volume intolerance or fluid restriction.

Nutrition and swallowing in pediatric neuromuscular patients

The management of the patient with neuromuscular disease is complex. Every child should be seen as a distinct individual and therefore merits patient-specific assessment and intervention. This article reviews nutritional management using spinal muscular atrophy and Duchenne's muscular dystrophy as representative models. The history of nutritional intake, nutritional needs, and underlying medical problems with physical examination, anthropometric, body composition, and biochemical markers are all important parts of the assessment and should be done at regular intervals. Intervention may include calorie restriction or calorie supplementation. Treatment strategies that follow diagnosis of dysphagia include positioning, increased sensory input, or direct maneuvers, such as volume changes or thickening liquid. Percutaneous endoscopic gastrostomy can be safely placed in almost all situations with minimal risk. Patients benefit most from a multidisciplinary and systematic management program.