Development and validation of a screening tool for feeding/swallowing difficulties and undernutrition in children with cerebral palsy

Pediatric Dysphagia Risk Screening Instrument (PDRSI) in Children With Cerebral Palsy

This study aimed to evaluate whether the Pediatric Dysphagia Risk Screening Instrument (PDRSI) was a suitable test for children with cerebral palsy (CP) and assess the instrument's Turkish validity and reliability. One-hundred twenty-six children with CP participated in this study. "Cronbach's alpha (ɑ)," "Cronbach's ɑ when one item is deleted," "inter-item correlation," and "corrected item-to-total correlation" were used to assess internal consistency. In addition, inter-rater agreement tests (Cohen's kappa coefficient) were conducted for reliability. Construct validity was used to assess the validity. Moreover, flexible fiberoptic endoscopic evaluation of the swallowing method was used to describe the receiver operating characteristic curve analysis and calculate the sensitivity and specificity of T-PDRSI. It was found that the PDRSI had adequate validity and reliability. The PDRSI can be used in children with CP as a valid and reliable instrument with high sensitivity and specificity.

The evolution of nutrition management in children with severe neurological impairment with a focus on cerebral palsy

Nutritional management of children with severe neurological impairment (SNI) is highly complex, and the profile of this population is changing. The aim of this narrative review was to give the reader a broad description of evolution of the nutritional management of children with SNI in a high resource setting. In the last decade, there has been an emphasis on using multiple anthropometric measures to monitor nutritional status in children with SNI, and several attempts at standardising the approach have been made. Tools such as the Feeding and Nutrition Screening Tool, the Subjective Global Nutrition Assessment, the Eating and Drinking Ability Classification System and the Focus on Early Eating and Drinking Swallowing (FEEDS) toolkit have become available. There has been an increased understanding of how the gut microbiome influences gastrointestinal symptoms common in children with SNI, and the use of fibre in the management of these has received attention. A new diagnosis, 'gastrointestinal dystonia', has been defined. The increased use and acceptance of blended food tube feeds has been a major development in the nutritional management of children with SNI, with reported benefits in managing gastrointestinal symptoms. New interventions to support eating and drinking skill development in children with SNI show promise. In conclusion, as the life expectancy of people with SNI increases due to advances in medical and nutrition care, our approach necessitates a view to long-term health and quality of life. This involves balancing adequate nutrition to support growth, development and well-being while avoiding overnutrition and its associated detrimental long-term effects.

Nutritional Management in Children and Adolescents with Severe Neurological Impairment-Who Cares? A Web-Based Survey Among Pediatric Specialists in Germany

BACKGROUND

Nutritional management of children and adolescents with severe neurological impairment (SNI) is challenging. A web-based survey was distributed to identify the present situation and the knowledge of the involved medical professionals in Germany.

METHODS

The survey was created with LimeSurvey, and access data were distributed by several medical societies. Eighty-three questions covered four topics: "general information," "gastro- and jejunostomy procedure," "handling of gastrostomies and feeding tubes," and "nutritional management and follow-up of children and adolescents with SNI." A descriptive analysis was performed with Microsoft Excel.

RESULTS

A total of 156 participated (65 completed and 91 partially), 27% being pediatric gastroenterologists, 23% pediatric neurologists, and 10% pediatric surgeons. The most common indications for gastrostomy and tube feeding were oropharyngeal dysfunction and failure to thrive. Many patients were still underweight after some months of enteral feeding. The procedure of gastrostomy and handling recommendations varied broadly. Frequently, standard operating procedures (SOPs) and written local guidelines did not exist, and there was a considerable request for training. Only 53% of participants were aware of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition position paper published in 2017, even fewer (38%) followed the guidelines. The recommended measures to assess a nutritional status were often not respected.

CONCLUSION

Nutritional management of children and adolescents with SNI in Germany is still strongly deficient. Despite the international guideline of 2017, few colleagues are aware of and adhere to the recommendations. This could be improved by interdisciplinary teaching and evaluation of the reasons for noncompliance. The procedure of gastrostomy and the patients' follow-up vary widely. Therefore, modified SOPs should be developed.

Properties of Australian thickened formulae for infants and children: Influence of preparation and nutritional content on IDDSI properties

Between 30% and 50% of infants and children with pediatric feeding disorders demonstrate oropharyngeal aspiration. Thickening fluids are a compensatory strategy that is commonly recommended by speech pathologists for the management of oropharyngeal aspiration. Ongoing variability in the preparation of thickened fluids across infant formulas and healthcare facilities continue to limit the standardization of the preparation of thickened infant and pediatric formulas. No studies exist which examine the influence of nutritional properties of different infant formula types on IDDSI thickness levels. Our study aimed to describe the impact of standardized resting times; and understand the influence of nutritional properties on a variety of ready-to-feed liquid and powder-based Australian thickened formulae. A total of 27 ready-to-feed liquid and powder-based formulas were tested for viscosity level at baseline and when thickener was added on at least two trials. Frequency counts and percentages were used to describe categorical data. Logistic regression was used to model the binary outcome and calculate the odds ratios and their 95% confidence intervals. A total of 18 formulas proceeded to IDDSI flow testing of at least two trials because 7 formulae tested as slightly or mildly thick at baseline; while 2 formulae only had one trial of IDDSI flow testing completed. Of the 18 formulae tested, 72.22% (13/18) of commonly used powder-based and ready-to-feed formulas in Australia thickened to IDDSI slightly thick (level 1) were prepared in a standardized manner and allowed to rest for 5 min. Formulas with higher protein totals were more likely to thicken sufficiently (AOR: 7.45; 95% CI: 2.06-26.89), while formulas with higher sugar totals or those used for enteral feeds were less likely to thicken sufficiently (AOR: 0.02; 95% CI: 0.01-0.29). There was good test-retest reliability (ICC: 0.76; 95% CI: 0.22-0.97), indicating that standardizing the preparation of thickened fluids was consistently achievable. Given that not all formulae were observed to thicken to the intended consistency using standardized preparation and resting time, this study highlights the importance of using the IDDSI Flow Testing Method regularly in practice when recommending thickened infant formula recipes for managing aspiration in infants and children.

Eating and Drinking Ability Classification System to detect aspiration risk in children with cerebral palsy: a validation study

This prospective study has two aims. The first aim is to assess the concurrent validity of the Eating and Drinking Ability Classification System (EDACS) as a means of identifying aspiration risk in children with cerebral palsy by using the Pediatric version of the Eating Assessment Tool (PEDI-EAT-10) as the reference test. The second aim is to investigate the relationship between the aspiration and non-aspiration groups using both the EDACS and the PEDI-EAT-10. Data were collected and analyzed from the EDACS and PEDI-EAT-10 using a convenience sample of 131 children with cerebral palsy and feeding problems (77 males, 54 females; median age 4.4 years [IQR 2.5 years]). Risk of aspiration was identified in 118 individuals using the PEDI-EAT-10 scores of ≥ 5 points. The EDACS proved to be a valid tool in identifying aspiration risk in children who are classified in EDACS levels III-V. There was a significant correlation between the EDACS and PEDI-EAT-10 (r_s = 0.597, p < 0.001). The EDACS had 78% (95% CI = 71-86%) sensitivity and 92% (95% CI = 88-97%) specificity in identifying aspiration risk a positive predictive value of 0.99, a negative predictive value of 0.32, a positive likelihood ratio of 9.75, and a negative likelihood ratio of 0.24.   Conclusion: The EDACS is a useful clinical tool to identify aspiration risk in children with cerebral palsy. Children in EDACS levels III to V are at risk of aspiration. As time permits, we recommend the use of both tools, the EDACS and the PEDI-EAT-10, when making decisions regarding referral for an instrumented swallowing study. What is Known: • Approximately 50% of children with cerebral palsy have dysphagia. • The Eating and Drinking Ability Classification System (EDACS) can be used to classify eating and drinking efficiency and safety in children with cerebral palsy. What is New: • Based on ROC analysis, EDACS demonstrates sensitivity of 78% and specificity of 92% in clinical identification of aspiration risk. • The combined use of the EDACS and the Pediatric version of the Eating Assessment Tool is recommended to make decisions about referral for an instrumented swallow study.

Generating Items for a Novel Bedside Dysphagia Screening Tool Post Acute Pediatric Stroke

Bedside dysphagia assessment protocols are not well developed in acute pediatric stroke unlike adults. The objective of this study was to identify items deemed relevant and feasible by expert consensus to inform the development of a bedside dysphagia screening tool for acute pediatric stroke. A two-phase study was conducted: (1) literature review and expert consultation generated a comprehensive list of dysphagia assessment items; (2) items were formatted in an online survey asking respondents opinion of relevance to acute pediatric stroke and feasibility for bedside administration by a trained health professional. The Dillman Tailored Design approach optimized response rate. Respondents were identified using the snowball method. Speech-language pathologists with > 2 years in pediatric dysphagia were invited to complete the survey. Demographic and practice variables were compared using univariate statistics. Item relevance and feasibility were made using binary or ordinal responses, combined to derive item-content validity indices (I-CVI) to guide item reduction. Items with I-CVI > 0.78 (excellent content validity) were moved forward to tool development. Of the 71 invited respondents, 57(80.3%) responded, of which 34(59.6%) were from North America. Sixty-one items were generated of which 4(6.6%) items were rated 'to keep'. These were face symmetry (I-CVI:0.89), salivary control (I-CVI:0.95), alertness (I-CVI:0.89) and choking (I-CVI:0.84). Of all respondents, 31(54.4%) endorsed swallowing trials, of which 25(80.6%) endorsed thin liquid by teaspoon (n = 17, 68%) or open cup (n = 20, 80%). We identified candidate items for bedside dysphagia screening with excellent content validity for acute pediatric stroke patients. Next steps include assessment of the psychometric value of each item in identifying dysphagia in children in the acute stage of recovery from stroke.

The PURPLE N study: objective and perceived nutritional status in children and adolescents with cerebral palsy

PURPOSE

To obtain information on characteristics, management, current objective nutritional status and perception of nutritional status of children with cerebral palsy (CP) from healthcare professionals (HCPs) and caregivers.

MATERIALS AND METHODS

A detailed survey of several items on eight main topics (general characteristics, motor function, comorbidities, therapies, anthropometry, feeding mode and problems and perceived nutritional status) was developed and tested for the study. Correlation between nutritional status and Gross Motor Function Classification System (GMFCS) levels was assessed using continuous variables (Z-scores for weight-for-age, height-for-age, weight-for-height, and body mass index-for-age), and categorical variables (being malnourished, stunted, or wasted). HCP and caregiver perceptions of the child's nutritional status as well as agreement between perceived and objective nutritional status and agreement between perceived nutritional status and concerns about the nutritional status were analyzed.

RESULTS

Data were available for 497 participants from eight European countries. Poorer nutritional status was associated with higher (more severe) GMFCS levels. There was minimal agreement between perceived and objective nutritional status, both for HCPs and caregivers. Agreement between HCP and caregiver perceptions of the child's nutritional status was weak (weighted kappa 0.56). However, the concerns about the nutritional status of the child were in line with the perceived nutritional status.

CONCLUSIONS

The risk of poor nutritional status is associated with more severe disability in children and adolescents with CP. There is a mismatch between HCP and caregiver perceptions of participants' nutritional status as well as between subjective and objective nutritional status. Our data warrant the use of a simple and objective screening tool in daily practice to determine nutritional status in children and adolescents with CP. Clinical trial registration: ClinicalTrials.gov Identifier: NCT03499288 (https://clinicaltrials.gov/ct2/show/NCT03499288). IMPLICATIONS FOR REHABILITATIONUse of the ESPGHAN recommendations and simple screening tools in daily practice is needed to improve nutritional care for individuals with CP.Attention should be paid to the differences in the perception of nutritional status of individuals with CP between professionals and caregivers to improve appropriate referral for nutritional support.Objective measures rather than the professional's perception need to be used to define the nutritional status of individuals with CP.

A cross-sectional study determining the relationship between eating and drinking skills and functional independence levels of patients with cerebral palsy

Background/Aim: In cerebral palsy (CP), drinking/eating disorders are considered common. To evaluate these disorders, a very detailed and lengthy evaluation is required. Few tools are available to identify children who need to be evaluated. This study determined whether the functional independence level of children with CP is sufficient to predict their drinking/eating skills and to determine the relationship between this functional level and these skills. Methods: A total of 105 children with CP aged 4–8 years participated in a cross-sectional study in our outpatient clinic. Functional classification was assigned using the Gross Motor Function Classification System and Manuel Ability Classification System (GMFCS and MACS, respectively). For a functional assessment of daily life, the Pediatric Evaluation of Disability Inventory (PEDI) was performed by asking a relative of the child. The Eating and Drinking Abilities Classification System (EDACS) level was added to the study after asking the caregivers of the patients for eating/drinking evaluations. Results: According to the current results, we found a negative correlation between EDACS and PEDI scores. As the EDACS grade increased, the PEDI subscale and total scores decreased in a statistically significant manner (P < 0.001), while the GMFCS and MACS scale increased statistically (P < 0.001). As the PEDI subscale and total scores increased, the levels of GMFCS and MACS decreased statistically significantly (P < 0.001). Conclusions: The performances of children with CP in terms of activities of daily living are closely related to their performance in eating/drinking activities. If children are independent in their mobility, social functions, and daily self-care, they are also more independent in terms of eating/drinking.

Mini-EDACS: Development of the Eating and Drinking Ability Classification System for young children with cerebral palsy

AIM

To develop and test Mini-EDACS to describe developing eating and drinking abilities of children with cerebral palsy (CP) aged between 18 and 36 months.

METHOD

The existing Eating and Drinking Ability Classification System (EDACS) was modified to define Mini-EDACS content. Mini-EDACS was developed in three stages: (1) EDACS was modified after application to videos of standardized feeding evaluations of children with CP aged 18 to 36 months (n = 130); (2) refined content and validity of Mini-EDACS was established through an international Delphi survey; (3) interobserver reliability was assessed by comparing Mini-EDACS levels assigned by speech and language therapists (SaLTs) from video data and parent report.

RESULTS

Mini-EDACS provides age-appropriate descriptions for children aged 18 to 36 months with CP. Eighty-nine stakeholders participated in the Delphi survey; required levels of agreement were met after one round (i.e. >80% agreement). Thirteen SaLTs completed paired ratings from 43 video recordings: absolute agreement was 58% (kappa 0.43; intraclass correlation coefficient 0.78; 95% confidence interval 0.63-0.87).

INTERPRETATION

Mini-EDACS provides a valid system for classifying eating and drinking performance of children with CP under 3 years old. Results suggest moderate agreement and good reliability when rating Mini-EDACS levels from video recordings of young children with CP.

Pain burden in children with cerebral palsy (CPPain) survey: Study protocol

Pain is a significant health concern for children living with cerebral palsy (CP). There are no population‐level or large‐scale multi‐national datasets using common measures characterizing pain experience and interference (ie, pain burden) and management practices for children with CP. The aim of the CPPain survey is to generate a comprehensive understanding of pain burden and current management of pain to change clinical practice in CP. The CPPain survey is a comprehensive cross‐sectional study. Researchers plan to recruit approximately 1400 children with CP (primary participants) across several countries over 6‐12 months using multimodal recruitment strategies. Data will be collected from parents or guardians of children with CP (0‐17 years) and from children with CP (8‐17 years) who are able to self‐report. Siblings (12‐17 years) will be invited to participate as controls. The CPPain survey consists of previously validated and study‐specific questionnaires addressing demographic and diagnostic information, pain experience, pain management, pain interference, pain coping, activity and participation in everyday life, nutritional status, mental health, health‐related quality of life, and the effect of the COVID‐19 pandemic on pain and access to pain care. The survey will be distributed primarily online. Data will be analyzed using appropriate statistical methods for comparing groups. Stratification will be used to investigate subgroups, and analyses will be adjusted for appropriate sociodemographic variables. The Norwegian Regional Committee for Medical and Health Research Ethics and the Research Ethics Board at the University of Minnesota in USA have approved the study. Ethics approval in Canada, Sweden, and Finland is pending. In addition to dissemination through peer‐reviewed journals and conferences, findings will be communicated through the CPPain Web site (www.sthf.no/cppain), Web sites directed toward users or clinicians, social media, special interest groups, stakeholder engagement activities, articles in user organization journals, and presentations in public media.

Using an Automated Speech Recognition Approach to Differentiate Between Normal and Aspirating Swallowing Sounds Recorded from Digital Cervical Auscultation in Children

Use of machine learning to accurately detect aspirating swallowing sounds in children is an evolving field. Previously reported classifiers for the detection of aspirating swallowing sounds in children have reported sensitivities between 79 and 89%. This study aimed to investigate the accuracy of using an automatic speaker recognition approach to differentiate between normal and aspirating swallowing sounds recorded from digital cervical auscultation in children. We analysed 106 normal swallows from 23 healthy children (median 13 months; 52.1% male) and 18 aspirating swallows from 18 children (median 10.5 months; 61.1% male) who underwent concurrent videofluoroscopic swallow studies with digital cervical auscultation. All swallowing sounds were on thin fluids. A support vector machine classifier with a polynomial kernel was trained on feature vectors that comprised the mean and standard deviation of spectral subband centroids extracted from each swallowing sound in the training set. The trained support vector machine was then used to classify swallowing sounds in the test set. We found high accuracy in the differentiation of aspirating and normal swallowing sounds with 98% overall accuracy. Sensitivity for the detection of aspiration and normal swallowing sounds were 89% and 100%, respectively. There were consistent differences in time, power spectral density and spectral subband centroid features between aspirating and normal swallowing sounds in children. This study provides preliminary research evidence that aspirating and normal swallowing sounds in children can be differentiated accurately using machine learning techniques.

Nutritional screening of children and adolescents with cerebral palsy: a scoping review

AIM

To examine nutritional screening methods for children and adolescents with cerebral palsy.

METHOD

A scoping review was performed using established methodologies. In June 2020 we searched PubMed, Embase, CINAHL Complete, and the Cochrane Central Register of Controlled Trials to identify articles on tools/methods for nutritional screening of our target groups.

RESULTS

Thirty studies were included, containing various tools/methods used to identify under- and/or overnutrition by weight/height, circumferences, skinfolds, questionnaires, and/or technically advanced or invasive methods. Questionnaires, weight/height, circumferences, and skinfolds were considered feasible based on clinical utility, whereas bioelectrical impedance analysis and blood samples were not.

INTERPRETATION

We identified two screening tools for undernutrition that include no physical measurements, but did not find any screening tools for overweight and obesity. Most of the studies recommended one or more methods, indicating that determining nutritional status most likely includes a combination of methods, not all of which may be feasible in clinical practice. What this paper adds No nutritional screening tool using anthropometry or body composition was discovered. Heterogenous methods to identify under- and/or overnutrition are recommended. Preferable methods for nutritional screening include assessment of body composition. A validated nutritional screening tool for identification of overweight is warranted.

Reliability and validity of the Eating and Drinking Ability Classification System (EDACS) for children with cerebral palsy in Taiwan

PURPOSE

The study was to assess the inter- and intra-rater reliability, construct validity and utility of the Eating and Drinking Ability Classification System (EDACS).

METHODS

EDACS was translated into in Taiwan using an interactive process. Agreement between health professionals and teachers when using EDACS was assessed using Kappa and the Intraclass Correlation Co-efficient.

RESULTS

Paired ratings of 4 (13%) health professionals (either speech or occupational therapists) and 26 (87%) teachers were obtained for 53 children with CP aged 6.7 years (SD 4.1 years), who worked in six education institutions. The raters used EDACS independently to classify children's eating and drinking ability and re-classified children's eating and drinking abilities after one month. Pairs of raters showed substantial agreement for the EDACS level at the first assessment (k = 0.75; absolute agreement = 81%; ICC = 0.94) and the second assessment (k = 0.70; absolute agreement = 77%; ICC = 0.95). The intra-rater reliability of EDACS level showed almost perfect agreement at rater 1 (k = 0.87; absolute agreement = 91%) and rater 2 (k = 0.87; absolute agreement = 91%).

CONCLUSIONS

We conclude that the Chinese version of EDACS is valid and reliable to be easily used by health professionals and teachers to classify functional eating and drinking abilities in children with cerebral palsy.IMPLICATIONS FOR REHABILITATIONThe Chinese version of EDACS is valid and reliable to be easily used.EDACS can be used by health professionals and teachers to classify functional eating and drinking abilities in children with cerebral palsy.The EDACS is analogous to other functional classification systems (i.e., GMFCS, MACS and CFCS) and specifically represents eating and drinking ability.

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.

Efforts targeted malnutrition among children with cerebral palsy in care homes and hospitals: A qualitative exploration study

INTRODUCTION

Children with cerebral palsy (CP) are at risk of becoming malnourished. Malnutrition risk increases with increased gross motor function classification. The present study aimed to investigate and explore existing nutritional efforts and practice among staff in Danish hospitals and care homes working with children with CP.

METHODS

Ten qualitative interviews were generated with multidisciplinary staff working in hospital wards, care homes and Neuro Pediatric Team (NPT). Analysis was inspired by Braun and Clarke's thematic analysis.

RESULTS

The analysis generated the following six themes: Weighing and anthropometric measurements; Existing nutritional evaluation and intervention in practice; Cross-sectoral communication and interdisciplinarity; Involvement of the children's parents; Knowledge and professional intuition; and Time and priority. Weighing is the most common nutritional evaluation, supplemented by weight/height curves in the NPT. No actual screening is performed. In care homes without healthcare staff, the nutritional focus primarily regards the meal and how the children are able to eat. In care homes with health staff, as well as hospital departments, the focus is primarily on weight. Written communication is a necessity for the nutritional collaboration around the child to work, but collaboration between IT-systems are lacking. Interdisciplinarity and parental involvement are key components for managing nutrition issues among children with CP. The specialist dietitian was much required, but difficult to reach.

CONCLUSIONS

Despite the great focus on nutrition and nutritional status among children with CP in all of the inquired contexts, existing efforts for assessment reveal primarily on weight and intuition. No actual screening is performed. Collaboration between sectors and professionals is challenged by lacking IT-systems and systematic procedures.

[Clinical effectiveness of Subjective Global Nutritional Assessment in hospitalized children with cerebral palsy]

OBJECTIVE

To investigate the nutritional status of children with cerebral palsy (CP) and the clinical effectiveness of Subjective Global Nutritional Assessment (SGNA) in nutritional assessment of hospitalized children with CP.

METHODS

A total of 208 children with CP, aged 1-5 years, who were hospitalized from April to October 2019 were enrolled as subjects. SGNA was used to investigate nutritional status, and the Z-score method recommended by the World Health Organization was used as a reference standard to validate the clinical effectiveness of SGNA.

RESULTS

The detection rate of malnutrition in children with CP was 42.3% by SGNA and 39.4% by the Z-score method (P>0.05). The application of SGNA showed high consistency between different evaluators (κ=0.621, P<0.001). With the Z-score method as the reference standard, SGNA had a sensitivity of 80.5%, a specificity of 82.5%, a positive predictive value of 75.0%, and a negative predictive value of 86.7%, and high consistency was observed between the two evaluation methods (κ=0.622, P<0.001). SGNA was moderately consistent with weight-for-age Z-score and height-for-age Z-score (κ=0.495 and 0.478 respectively, P<0.001) and was poorly consistent with weight-for-height Z-score (κ=0.197, P<0.05).

CONCLUSIONS

There is a relatively high incidence rate of malnutrition in children with CP. SGNA can be used as a tool to assess the nutritional status of children with CP.

Top-ten tips for managing nutritional issues and gastrointestinal symptoms in children with neurological impairment

The prevalence of children with neurological impairment (NI) presenting feeding difficulties and gastrointestinal symptoms is rising. The most recent guidelines recommend early nutritional assessment and intervention in order to prevent undernutrition and growth failure, along with the proper diagnosis and treatment of some frequent gastrointestinal symptoms, such as gastroesophageal reflux disease (GERD) and constipation, which can further worsen the feeding process and nutritional status. Nonetheless, the nutritional issues and growth deficits of children with NI are often considered to be of low priority or under recognised by healthcare providers. The present article proposes ten top tips that highlight the major points along the nutritional management pathway of NI children. The implementation of these tips in all healthcare settings could potentially improve patient outcomes and reduce morbidity and mortality.

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.