Development of equations and software for estimating weight in children with cerebral palsy

Nutritional aspects in patients with cerebral palsy: A multicenter observational study in Spain

INTRODUCTION

Cerebral palsy (CP) encompasses a group of motor disorders that can result in swallowing difficulties, affecting food intake and contributing to poor nutritional status. The goal of the study was to describe the clinical and nutritional characteristics of Spanish children with CP.

METHODS

Multicenter observational study conducted in children aged 4-14 years with a diagnosis of CP. For every patient, we collected data on sociodemographic and clinical characteristics as well as anthropometric measurements, schooling modality, nutrition received at school, nutritional support and gastrointestinal comorbidities.

RESULTS

The sample included a total of 112 patients with a mean age of 9.2 years old. The majority (70.5%) had been classified as Gross Motor Function Classification System (GMFCS) level IV or V. Compared to children classified as GMFCS level I, II or III, the group of children with GMFCS level IV/V had significantly lower mean z scores in body weight, height, weight-to-height ratio, body mass index and upper arm circumference and a significant lower mean arm area. A higher proportion of patients with GMFCS level IV/V attended special education schools compared to patients classified as level I to III (68.4% vs. 12.1%; P < .0001). A higher proportion of children classified as level IV/V compared to children classified as levels I to III presented dysphagia (62.0% vs. 15.2%; P < .0001), constipation (51.9% vs. 27.3%, P = .0218) and gastroesophageal reflux (31.6% vs. 3.0%; P = .0005).

CONCLUSIONS

Our study shows that Spanish children with CP, especially those with severe motor impairment, are at risk of malnutrition, present gastrointestinal comorbidities and require nutritional support.

Use of a specialized peptide-based enteral formula containing medium-chain triglycerides for enteral tube feeding in children with cerebral palsy and previous tube feeding intolerance on standard enteral formula: a prospective observational TolerUP study

Objective

Use of peptide-based formulas supplemented with medium chain triglycerides (MCTs) is considered a beneficial strategy to decrease the tube-feeding associated gastrointestinal tolerance. In children with cerebral palsy (CP), overall effects of enteral tube feeding as well as the utility of peptide-based specialized enteral formulas in those with gastrointestinal intolerance have not been extensively studied. This study aimed to evaluate the utility of enteral tube feeding via specialized peptide-based formula containing MCTs in children with CP in terms of gastrointestinal intolerance, anthropometrics, defecation characteristics and parental satisfaction with enteral formula.

Methods

Children with CP who received enteral tube feeding via specialized peptide-based formula containing MCTs were included in this prospective observational study. Anthropometrics (z scores for weight for age [WFA], weight for height [WFH], triceps skinfold thickness [TSFT] and mid-upper arm circumference [MUAC]), gastrointestinal intolerance symptoms, defecation frequency and stool patterns and formula satisfaction were recorded at baseline and during 6-month follow up.

Results

A total of 96 children with CP (mean ± SD age: 5.6 ± 3.2 years, 56.3% were boys) were included. Significant improvements were noted in MUAC, TSFT and WFH z scores at the 6th month visit. The rate of "severe symptoms" and the likelihood of Type-1/Type-2 (constipation) stool pattern were significantly decreased. Majority of parents were satisfied with the study formula.

Conclusion

Our findings revealed favorable efficacy and safety of using a specialized peptide-based formula containing MCT in provision of enteral tube feeding among children with CP in terms of improved anthropometrics, amelioration of gastrointestinal intolerance symptoms and normalization of bowel movements along with a high parental satisfaction.

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.

Utility of mid-upper arm circumference in pediatric malnutrition: An Australasian Society of Parenteral and Enteral Nutrition consensus statement using the Delphi method

BACKGROUND

Mid-upper arm circumference (MUAC) is a simple anthropometric tool used to screen for childhood undernutrition in humanitarian settings or low-income and middle-income countries. However, there is conflicting evidence and a lack of consensus with regard to its diagnostic use in clinical settings or population groups beyond this context. In 2023, a project officer was appointed by the Australasian Society of Parenteral and Enteral Nutrition (AuSPEN) to lead the development of a consensus review into the use of MUAC in the pediatric clinical setting.

METHODS

An AuSPEN appointed multidisciplinary group of informed clinicians used the Delphi method to critically appraise the evidence and develop a series of consensus statements. Delphi surveys were anonymous and distributed electronically. Members were asked to rate their level of agreement with each consensus statement using a 5-point Likert scale. A priori definition of consensus was established as ≥80% responses "agree" or "strongly agree."

RESULTS

Three Delphi rounds were required to reach consensus. A total of 18 consensus statements, including rationale, were developed across the topics 'assessment and diagnosis', 'screening and monitoring' and 'clinical settings'.

CONCLUSION

An evidence-based, region-specific consensus approach to the use of MUAC in pediatric malnutrition is a valuable tool for clinicians. MUAC is a straightforward, non-invasive and cost-effective tool, and may provide an advantage over traditional anthropometric tools in some clinical settings. There are limitations to the utility of MUAC and this consensus paper provides an empirical summary of advantages and limitations as they apply to the screening, assessment, diagnosis, and monitoring of pediatric malnutrition.

Measurement of mid-upper arm circumference to screen for childhood malnutrition: General applicability and use in special populations

Since the development of consensus-recommended indicators for pediatric malnutrition in 2014, screening and diagnosis of pediatric malnutrition have improved, but the indicators are not always used; malnutrition continues to be underdiagnosed in some community and healthcare settings. In particular, mid-upper arm circumference (MUAC) is underused as a screening indicator for pediatric malnutrition, despite its unique advantages and usefulness in several clinical situations. In December 2022, a scientific roundtable was held to bring together several experts in pediatric malnutrition. One of the goals of the scientific roundtable was to discuss the clinical use of anthropometric measures as screening tools for pediatric malnutrition status, with a focus on the use of MUAC. This article arose from that event and is intended as an educational tool to aid clinicians in implementing MUAC measurements. In addition to describing the use of MUAC as a screening tool, the article discusses several clinical situations in which MUAC is especially useful. Additionally, the article reviews practical aspects of measuring and interpreting MUAC values, provides links to additional educational resources, and briefly reviews areas in which further research is needed regarding the use of MUAC for screening of nutrition status in children.

Mid-upper arm circumference as a screening tool for identifying underweight adolescents

Background

Mid-upper arm circumference (MUAC) is a potentially credible alternative method for body mass index (BMI) to assess nutritional status. We aimed to assess the correlation between MUAC and BMI- Z-score and to identify a reliable MUAC cut-off point to detect underweight (BMI- Z-score of < -2 standard deviation) Sudanese adolescents.

Methods

A cross-sectional study was conducted in eastern Sudan. After obtaining adolescents' age and sex, their weight, height, and MUAC were measured using the standard procedures. The MUAC (cm) cut-off corresponding to underweight was calculated using receiver operating characteristic (ROC) curve analysis.

Results

In total, 390 adolescents were enrolled in the study and 205 (52.6%) of them were females. The median (interquartile range, IQR) age was 15.1 (14.0-16.3) years. The medians (IQR) of MUAC and BMI- Z-score were 22.0 (20.0-24.0) cm and - 0.62 (-1.5-0.3), respectively. MUAC was positively correlated with BMI Z-score in all participants (r = 0.534, p < 0.001), in females (r = 0.715, p < 0.001), and in males (r = 0.404, p < 0.001). Of the 390 enrolled adolescents, 61(15.6%) were underweight. The MUAC cut-off for underweight was ≤21.2 cm in all participants (Youden's Index, YI = 0.50; sensitivity = 82.0%; specificity = 68.0%, AUROCC = 0.78), in females (YI = 0.66, sensitivity = 86.0%, specificity = 80.0%, AUROCC = 0.87), and in males (YI = 0.32, sensitivity = 80.0%, specificity = 52.0%, AUROCC = 0.69).

Conclusion

MUAC has good accuracy results and can be adopted for community-based screening of underweight adolescents.

Nutritional status and dietary intake of children and adolescents with cerebral palsy

OBJECTIVE

To analyze the association between energy and nutrient intake, nutritional status and motor compromise in children and adolescents aged 2-19 years with cerebral palsy (CP) attending rehabilitation centers in the Province of Cordoba, Argentina.

METHODS

Cross sectional study. Data from 105 children and adolescents of both sexes aged 2-19 years with CP (67 boys [63.8% 53.84-72.95]) were collected. Motor compromise was assessed with GMFCS. 24 h records were collected and analyzed. The results were compared with the recommended by FAO/UNU/WHO for age and sex. Normal data were presented with mean and SD, while those of non-normal distribution were described as medians with their ranges. The relationship between variables was analyzed using Fisher, t, or Mann-Whitney tests, with a p value < 0.05.

RESULTS

The mean age was 11 years 6 months (SD 4 years 4 months). Fifteen [14.3% 8.23-22.48] children failed to meet at least 80% of the recommended energy. Children with GMFCS IV-V consume fewer daily calories and carbohydrate calories than their peers (I-III). The median protein intake of children GMFCS IV-V group was significantly lower than that of their peers (47.37 g vs. 71.56 g, p = 0.0057). Those who did not reach 80% of the recommended energy intake had lower intakes of macro and micronutrients.

CONCLUSION

The greater the motor compromise in children with CP, the greater the compromise in the adequacy of nutrient intake. The intake of macro and micronutrients was different according to whether or not they were able to cover at least 80% of the recommended energy for their age.

Early Tube Feeding Improves Nutritional Outcomes in Children with Neurological Disabilities: A Retrospective Cohort Study

Tube feeding is a life-saving treatment for children with neurological disabilities (ND), who often suffer from malnutrition and feeding disorders. Nonetheless, it is still not widely used. Our aim was to evaluate the outcomes of exclusive tube feeding in a cohort of ND children. All consecutive ND children who started tube feeding at our center within the last 5 years were included in this retrospective study. Weight-for-age, body mass index (BMI), mid-upper arm circumference (MUAC) Z-scores, and symptoms were collected at baseline (V0), 6 (V1), and 12 months (V2) after gastrostomy placement. Fifty children (62% males) were included. The ND-underlying disease was genetic (n = 29, 58%), hypoxic-ischemic encephalopathy (n = 17, 34%), or metabolic (n = 4, 8%). Indications for tube feeding were malnutrition (n = 35, 70%), recurrent respiratory infections (n = 11, 22%), or both (n = 4, 8%). Enteral formulae were polymeric (n = 29, 58%), semi-elemental (n = 17, 34%), hypercaloric (n = 3, 6%), or elemental (n = 1, 2%). Homemade blended feed was offered to three children (6%) in addition to the formula. Weight and BMI increased over the study period. Except for constipation, all symptoms (cough, vomiting, and diarrhea) improved at 6 and 12 months (p < 0.05). Non-serious complications (n = 8; track disruption, granuloma, and skin infection) were observed. Longer disease duration (p < 0.001) at the start of tube feeding was associated with the absence of normalization of nutritional status (BMI Z-score > 2 SD) at 12 months. Tube feeding with commercially available enteral formulae should be started as early as possible for better outcomes.

The significance of MUAC z-scores in diagnosing pediatric malnutrition: A scoping review with special emphasis on neurologically disabled children

This review by a panel of pediatric gastroenterology-hepatology-nutrition and pediatric neurology experts aimed to address the significance of mid-upper arm circumference (MUAC) assessment in diagnosis of pediatric malnutrition. Specifically, the potential utility of recently developed MUAC z-score tape in clinical practice for larger patient populations was addressed including the neurologically disabled children. In accordance with the evidence-based data, four statements were identified by the participating experts on the utility of MUAC z-score tape, including (1) MUAC z-scores correlate with body mass index (BMI) and weight for height/length (WFH/l) z-scores in diagnosing malnutrition; (2) MUAC z-score tape offers a higher sensitivity to diagnose the mild and moderate malnutrition and better ability to track the changes in nutritional status over time than the other single datapoint measurements; (3) Using single-step MUAC z-score tape in children with cerebral palsy (CP) seems to provide more reliable data on anthropometry; and (4) The clinical value of the tool in classifying secondary malnutrition in CP should be investigated in large-scale populations. In conclusion, enabling single-step estimation of nutritional status in a large-scale pediatric population regardless of age and within a wide range of weight, without formal training or the need for ancillary reference charts and calculators, MUAC z-tape offers a favorable tool for easier and earlier diagnosis of pediatric malnutrition. Nonetheless, further implementation of MUAC z-score screening in larger-scale and/or special populations is necessary to justify its utility in relation to other primary anthropometric indicators in diagnosis of malnutrition as well as in treatment monitoring in the community and hospital setting.

Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy

Cerebral palsy (CP) is the most common motor disorder of childhood, with prevalence estimates ranging from 1.5 to 4 in 1000 live births. This clinical report seeks to provide primary care physicians with guidance to detect children with CP; collaborate with specialists in treating the patient; manage associated medical, developmental, and behavioral problems; and provide general medical care to their patients with CP.

Effect of Hospital-Family Rehabilitation Intervention on Walking Function and Lower Limb Surface Electromyography in Children with Cerebral Palsy

Objective

To explore the effect of hospital-family rehabilitation intervention on walking function and lower limb surface electromyography in children with cerebral palsy (CP).

Methods

About 100 children with CP treated in our hospital from February 2019 to April 2021 were enrolled. The patients were randomly assigned into control group and study group. The control group received routine intervention, and the study group received hospital-family rehabilitation intervention. The intervention effect, GMFM88 scale score, IMMG value, CR value, lower limb surface EMG value, and compliance of gastrocnemius muscle and tibialis anterior muscle were compared.

Results

First of all, we compared the intervention effects. In the study group, 43 cases were markedly effective, 5 cases were effective, 1 case was improved, 1 case was ineffective, and the effective rate was 98.00%. In the control group, 22 cases were markedly effective, 14 cases were effective, 7 cases were improved, 7 cases were ineffective, and the effective rate of 86.00%. The intervention effect of the study group was better compared to the control group (P < 0.05). Secondly, we compared the scores of the GMFM88 scale. The scores of D area and E area and total score of the study group were higher compared to the control group (P < 0.05). The IEMG values of gastrocnemius muscle and tibialis anterior muscle were compared, and the IMMG values of passive and active gastrocnemius muscle and tibialis anterior muscle in the study group were higher compared to the control group (P < 0.05). There exhibited no significant difference in CR value before intervention (P > 0.05). After intervention, the CR values of gastrocnemius muscle and tibialis anterior muscle in the study group were significantly lower compared to the control group (P < 0.05). In terms of the surface EMG of lower limbs, the EMG value of passive activity (gastrocnemius muscle, tibialis anterior muscle) in the study group was higher compared to the control group, and the EMG value of active activity was significantly lower compared to the control group (P < 0.05). Finally, we compared the compliance. In the study group, there were 43 cases of complete compliance, 7 cases of compliance, and 0 cases of noncompliance, with a compliance rate of 100.00%. In the control group, there were 32 cases of complete compliance, 11 cases of compliance, and 7 cases of noncompliance with a compliance rate of 86.00%. The compliance rate of the study group was better compared to the control group (P < 0.05).

Conclusion

The intervention of hospital-family rehabilitation model is helpful to improve the self-care ability, cognitive function, and daily activities of children with CP, enhance the walking function and lower limb surface electromyography of children with SCP, and strengthen their qualities of life.

Embracing the Nutritional Assessment in Cerebral Palsy: A Toolkit for Healthcare Professionals for Daily Practice

Background: Nutritional status assessment (NSA) can be challenging in children with cerebral palsy (CP). There are high omission rates in national surveillance reports of weight and height information. Alternative methods are used to assess nutritional status that may be unknown to the healthcare professionals (HCP) who report these children. Caregivers experience challenges when dealing with feeding problems (FP) common in CP. Our aim was to assess the difficulties in NSA which are causing this underreport and to create solutions for registers and caregivers. Methods: An online questionnaire was created for registers. Three meetings with HCP and caregivers were held to discuss problems and solutions regarding NSA and intervention. Results: HCP mentioned difficulty in NSA due to a lack of time, collaboration with others, equipment, and childrens’ motor impairment. Caregivers experienced difficulty in preparing nutritious meals with adapted textures. The creation of educational tools and other strategies were suggested. A toolkit for HCP was created with the weight and height assessment methods described and other for caregivers to deal with common FP. Conclusions: There are several difficulties experienced by HCP that might be overcome with educational tools, such as a toolkit. This will facilitate nutritional assessment and intervention and hopefully reduce underreporting.