Energy expenditures and dietary intakes in cerebral palsy

Nutrition support in the pediatric surgical patient

This article deals with the nutritional needs of pediatric patients. It begins by discussing the caloric requirements of different pediatric patients and moves on to a breakdown of the specific nutrients required. It then progresses to a detailed description of the enteral and parenteral modalities for delivery of nutrition to pediatric patients. The article concludes with a discussion of specific problems and disorders encountered in pediatric surgical patients.

Energy expenditure and physical activity of ambulatory children with cerebral palsy and of typically developing children

BACKGROUND

Children with cerebral palsy (CP) expend more energy when walking than do their typically developing peers. The effect this has on physical activity levels (PALs) and on total energy expenditure (TEE) will have important implications when determining energy requirements.

OBJECTIVES

This study aimed to investigate the components of TEE in children with CP in comparison with typically developing children and to determine what effect the higher energy expenditure during walking has in ambulatory children with CP on PAL and on TEE.

DESIGN

Sixteen children with mild CP and 16 typically developing children, aged 5-12 y, were recruited for the study. Resting energy expenditure (REE) and the energy expenditure during walking were measured by using indirect calorimetry. TEE was determined by using the doubly labeled water technique. PAL was calculated as the ratio of TEE to REE. Body composition was estimated by using oxygen-18.

RESULTS

TEE was lower in children with CP (7012 +/- 1268 kJ/d) than in typically developing children (8309 +/- 2088 kJ/d) because of a lower PAL (1.57 +/- 0.23 compared with 1.79 +/- 0.26). The children with CP expended significantly more energy when walking than did the typically developing children (13.8 +/- 4.9 compared with 10.3 +/- 2.3 kJ/min) while walking at a lower velocity (61 +/- 10 compared with 72 +/- 8 m/min). Correlations between energy expenditure during walking and PAL were not statistically significant for either group.

CONCLUSIONS

Children with CP expend more energy during walking and have a lower PAL and lower energy requirements than do typically developing children. This has important implications when estimating the energy requirements of children with CP.

Insights into energy requirements in disease

Accurate information about the energy needs of a range of acute and chronic diseases and morbidity is lacking and often complicated by the medication prescribed to treat the condition and also because of the presence of pre-existing malnutrition. Assessing the energy requirements of patients with acute and chronic diseases is more complex than for those in good health. These requirements not only depend on the aggressiveness of the disease and level of inactivity it causes, but also on the treatment, and the presence of prior malnutrition. It used to be generally believed that the energy requirements were increased in a number of diseases. It is now realised that this is not usually the case. Therefore, it is necessary to put these changing ideas into context by considering a wide range of acute and chronic diseases which this paper proposes to do. This paper is almost exclusively restricted to studies that have measured total energy expenditure (TEE) using tracer techniques in both hospital and the community (mostly doubly labelled water and to a lesser extent bicarbonate–urea), and continuous 24–hour indirect calorimetry in artificially ventilated patients in hospital.

Feeding the disabled child

Feeding difficulty and malnutrition are common in disabled children. Intake may be reduced because of anorexia, chewing and swallowing difficulties, or vomiting. Feeding is often time consuming, unpleasant, and may result in aspiration. Malnutrition may result in impaired growth and neurodevelopment, and impaired cardiorespiratory, gastrointestinal, and immune functions. Multidisciplinary assessment is recommended and should include a feeding history, oral-motor examination, and nutritional assessment. The energy requirements of most disabled children are less than those for a normal child of the same age but may be increased by spasticity, athetosis, convulsions, and recurrent infections. Micronutrient deficiencies may occur even in children receiving nutritionally complete feeds if the volume is reduced because of low energy requirements. Oral intake may be improved by a change of posture, special seating, feeding equipment, oral desensitization, mashing or pureeing of lumpy food, thickening of liquids, use of calorie supplements, and treatment of reflux/esophagitis. Non-oral feeding should be considered when oral feeding is unsafe, not enjoyable, inadequate, or very time consuming. Long-term support requires a gastrostomy. This is less obtrusive than a nasogastric tube, less likely to become displaced, less traumatic, and is associated with improved quality of life, but is also associated with significant morbidity. If there is symptomatic reflux a fundoplication may be required, but this is associated with significant mortality and substantial morbidity.

Are skinfold measurements suitable to compare body fat between children with spastic cerebral palsy and healthy controls?

The aim of this study was to assess whether percentage of body fat (BF) can be predicted adequately from skinfold measurements in comparative studies of children with spastic cerebral palsy (CP) and healthy control children. The deuterium dilution technique (D2O) was used as a reference method. In contrast with what was expected, %BF predicted from skinfold measurements was considerably lower than that determined by the D2O method in children with CP, whereas in the controls this was not seen. A proportionally large internal fat deposit and a different distribution of subcutaneous fat in children with CP may be responsible for this. It was concluded that skinfold measurements are not suitable for predicting %BF in comparative studies of children with CP and control children. For evaluation of diet- or exercise-related interventions in children with CP, the use of skinfold measurements seems to be justified. However, it may be more appropriate to use skinfold thicknesses without converting them to BF.

Energy expenditure and body composition in children with spastic quadriplegic cerebral palsy

OBJECTIVE

To determine the relationship between resting energy expenditure and body cell mass in a group of children with spastic quadriplegic cerebral palsy (SQCP) in comparison with a group of healthy volunteers.

SUBJECTS AND METHODS

Children with SQCP (n = 13) and healthy control subjects (n = 21) participated in the study. Resting energy expenditure (REE) by indirect calorimetry, as well as body composition measurements were obtained. Those included skinfold measurements, isotope dilution methods for total body water and extracellular water (2H2O or H2(18)O and NaBr, respectively), and bioelectrical impedance analysis. Intracellular water was calculated as total body water minus extracellular water.

RESULTS

Overall REE in children with SQCP was significantly less than in control subjects or from predicted World Health Organization equations. There was a poor correlation between REE and weight or height for children with SQCP and those for control subjects. Children with SQCP showed a higher variance and small improvement in the correlation between REE and lean body mass or intracellular water in comparison with control subjects. Nine of the thirteen children with SQCP had significantly reduced REE per unit of lean tissue or intracellular water. Furthermore, bioelectrical impedance analysis was validated against dilution methods as a suitable technique for measuring total body water (r2 = 0.90, r = 0.95) and extracellular water (r2 = 0.84, r = 0.92) in children with SQCP.

CONCLUSION

REE in children with SQCP is poorly correlated with body cell mass. We postulate that the central nervous system plays a crucial role in energy regulation. In children with SQCP, individual energy expenditure should be measured so that optimal nutritional status can be achieved. Bioelectrical impedance analysis can be used in this population to measure body water spaces.

Apparent growth hormone deficiency in children with cerebral palsy

Ten children with cerebral palsy (CP) and growth failure underwent assessment of the growth hormone (GH) axis, including spontaneous GH secretion, GH secretion in response to pharmacological stimulation, and circulating levels of insulin-like growth factor-1 (IGF-1) and IGF binding protein-3 (IGFBP-3). Six of the children had subnormal GH secretion consistent with GH deficiency. Subnormal growth velocity was the best clinical predictor of GH deficiency. The large percentage of these children with apparent GH deficiency is surprising. Possible mechanisms include anatomic abnormalities of the hypothalamic-pituitary axis, psychosocial deprivation, and an interaction between suboptimal nutritional status and an abnormal central nervous system.

Pattern of growth in children with cerebral palsy

OBJECTIVE

To provide a growth reference standard for children with quadriplegic cerebral palsy (QCP). Growth references specific to children with cerebral palsy would facilitate uniformity in clinical appraisal of their growth and nutritional status and would simplify comparative interpretation of growth data.

DESIGN

Weights and lengths were obtained according to standardized procedures. Measurements were taken at time of visit to an orthopedic clinic and from retrospective review of charts.

SUBJECTS

Three hundred sixty children with QCP. Growth data were based on 1,630 observations.

ANALYSIS

Growth curves representing the 10th, 50th, and 90th percentiles were estimated using a smoothing splines technique. Statistical bootstrapping was performed to confirm significant differences from the growth charts of the National Center for Health Statistics (NCHS).

RESULTS

Growth charts were constructed for boys and girls, aged 0 to 120 months, depicting length for age, weight for age, and weight for length. Average differences in length for age, weight for age, and weight for length between children with QCP and NCHS standards were -2.3 z, -2.4 z, -1.3 z for boys, and -2.1 z, -2.1 z, -1.1 z for girls. Children with QCP fell progressively behind in stature and weight. Compared with their NCHS counterparts, they were 5% shorter at 2 years of age and more than 10% shorter at 8 years of age.

APPLICATION

Charts representing the pattern of growth in children with QCP should be accessible to parents and health care professionals to facilitate evaluation and monitoring of nutritional status.

Athetosis increases resting metabolic rate in adults with cerebral palsy

OBJECTIVES

To determine whether resting metabolic rate (RMR) is higher or lower in adults with cerebral palsy compared with the RMR of control subjects and to further examine physical characteristics of cerebral palsy that might affect RMR.

DESIGN

Twenty-one adults with cerebral palsy (9 women, 12 men) were compared with 50 control subjects (25 men, 25 women) within the same age range (18 through 50 years). The following measurements were made: RMR by indirect calorimetry, anthropometrics, body composition, and habitual physical activity patterns. The study was conducted at the University of Vermont General Clinical Research Center and the Ball State University Human Performance Laboratory.

STATISTICAL ANALYSES

Mean values +/- standard deviations, t tests, Pearson product-moment correlation coefficients, analysis of covariance, and stepwise multiple correlation regression analysis were used to examine the relationships among variables of interest.

RESULTS

No significant differences were found in body weight, body mass index, fat mass, percentage body fat, and measured RMR between the two groups. The subjects with cerebral palsy were significantly shorter, had less fat-free mass, and expended fewer kilocalories in leisure time activities than the control subjects. After statistical adjustment for differences in fat-free mass, the subjects with cerebral palsy had a 14% (P < .001) higher adjusted RMR (1,742 kcal/day) compared with that of the control subjects (1,534 kcal/day). According to stepwise regression analysis, RMR was best predicted in the entire sample by fat-free mass and the presence or absence of athetosis (multiple R = .83, P < .001). The presence of cerebral palsy alone was not significantly correlated with RMR.

CONCLUSIONS

The increased energy requirements of adults with cerebral palsy can be partially explained by athetotic movements. In this sample, the presence of athetosis increased RMR by an average of 524 kcal/day.

Growth hormone deficiency in two children with cerebral palsy

The authors describe two children with cerebral palsy and linear growth failure secondary to growth hormone deficiency. One of the children was successfully treated with growth hormone replacement therapy. His linear growth velocity increased from 3cm/year before therapy to 8.3 cm/year during the first two years of therapy. Potential complications such as worsening orthopedic status did not occur. Psychosocial benefits were noted. The authors conclude that growth hormone deficiency may play a role in linear growth failure in some children with cerebral palsy and that some of these children may benefit from growth hormone therapy.

Daily physical activity of schoolchildren with spastic diplegia and of healthy control subjects

OBJECTIVE

To assess the differences in daily physical activity between children with spastic diplegia and healthy schoolchildren, to determine whether special physical activity programs are needed in the population with cerebral palsy.

DESIGN

Cross-sectional design.

SETTING

Children's rehabilitation center Franciscusoord (day care center) and elementary schools.

SUBJECTS

Children with spastic diplegia (5 boys; mean (+/- SD) age 8.0 +/- 1.4 years; 9 ambulant, 1 wheelchair use) and healthy children (5 boys; mean (+/- SD) age 8.4 +/- 1.0 years).

MEASUREMENTS

Total daily energy expenditure (TEE) and sleeping metabolic rate (SMR) were measured by the doubly labeled water technique and a respiration chamber. The TEE/SMR ratio was used as an index for the level of daily physical activity.

RESULTS

The TEE/SMR ratio under normal daily conditions in the children with cerebral palsy (mean +/- SD): 1.56 +/- 0.19) was significantly lower (p < 0.05) than in their healthy peers (mean +/- SD: 1.83 +/- 0.23) and was similar to the TEE/SMR ratio in a room-sized chamber.

CONCLUSION

Children with spastic diplegia are considerably less active than their healthy peers. We recommend special physical activity programs for these children.

Clinical correlates of linear growth in children with cerebral palsy

The purpose of this cross-sectional study was to determine correlates of linear growth in children with cerebral palsy (CP). 171 children with CP were measured and their charts reviewed. z scores were calculated for weight (Wz) and height (Hz). Hz correlated positively with Wz and head circumference, and negatively with age, the presence of spastic quadriplegia, non-ambulation and seizures. The correlation between Hz and age was stronger when non-ambulatory children were analysed separately. Multiple linear regression resulted in only Wz and age contributing significantly to the variance in stature as measured by Hz. These results provide preliminary evidence that nutritional status is a major correlate of growth in CP. The finding that linear growth worsens with age independent of nutrition suggests that other factors also influence growth in CP.

Feeding and nutritional problems in children with cerebral palsy and myelomeningocoele

This study was undertaken to characterize the food intake, current feeding situation and nutritional status of children with cerebral palsy and myelomeningocoele. Thirty children with cerebral palsy and 14 with myelomeningocoele were investigated. The children with cerebral palsy were subgrouped into those with diplegia (11 children), dystonia (10 children), hemiplegia (6 children) and ataxia (3 children). Information was obtained from medical records, current dietary recording and clinical and anthropometric examinations. Feeding problems, low energy intake and wasting were frequent among the children with cerebral palsy, particularly those with the dystonic form. Children with myelomeningocoele gave the impression of being overnourished, despite a seemingly relatively low energy intake. It is clear that nutritional and feeding aspects should receive particular attention in the habilitation of children with various disabilities.

Erythrocyte membrane lipid alterations in undernourished cerebral palsied children during high intakes of a soy oil-based enteral formula

Five undernourished children with severe cerebral palsy (CP) were tube-fed sufficient volumes of Isocal to allow rapid weight gain. Isocal provided, on average, 88% of their daily energy intake for at least 25 days. The purpose of our study was to correct the undernutrition and to analyze the major erythrocyte phospholipids before and after feeding periods for possible feeding and disease-related differences. The fatty acid profiles of erythrocyte membranes from CP children were compared with those from 12 healthy children and with the fatty acid composition of the formula. There were no clinical or biochemical indications of essential fatty acid deficiency. The feeding of a soy oil-based formula increased the proportions of 18:2n-6 in the phospholipids. The increases occurred predominantly in phosphatidylcholine followed by phosphatidylethanolamine. Despite such large dietary intakes of soy oil, no changes were observed in the phospholipid concentrations of 20:4n-6, 18:3n-3, 20:5n-3, or in the C22n-6 and C22n-3 fatty acids. These findings are consistent with an inhibition of the delta 6 desaturase by high dietary linoleate.

Identification of children with cerebral palsy unable to maintain a normal nutritional state

7 children aged 2-16 with severe cerebral palsy and growth failure were compared with children of the same weight in respect of their eating efficiency. Children with cerebral palsy took 2-12 times longer to chew and swallow a standard amount of puréed food and 1-15 times longer for solid food than did their weight-controls. A behaviour score of feeding characteristics was higher in children with cerebral palsy than in controls. Even long meal times do not compensate for the severity of these childrens' feeding impairment. The measurements of feeding efficiency provides the basis for early identification of children who cannot be adequately nourished without ancillary feeding by nasogastric tube or by enterostomy.

Rapid correction of wasting in children with cerebral palsy

Severe cerebral palsy is often accompanied by wasting. The authors used standard methods for the correction of primary protein energy malnutrition in children with severe cerebral palsy. A randomised controlled trial was used to compare intensive nasogastric tube-feeding with the best oral feeding that could be achieved. Nasogastric feeding led to highly significant increases in weight. The changes in skinfold thickness and mid-arm muscle circumference indicated increases in both lean and fat tissue. This study indicates that wasting associated with cerebral palsy can be quickly corrected, so there is no reason why such patients should be exposed to the increased risks associated with wasting.