Nutrition in the neurologically impaired Flashcards
What are the positive benefits of nutrimental rehabilitation?
improved peripheral circulation improved healing of decubitus ulcers decreased spasticity decreased irritability improved GERD improved overall health
What are some factors about the kid and their disease that makes the risks of malnutrition greater?
quadriplegia > diplegia oromoto dysfunction Lack of hand-mouth coordination Slower eating GERD Reflux esophagitis
What is the resting metabolism of children with CP as compared to age control matches?
lower in the hypotonic and non-ambulatory population
higher in the children with increased tone and athetoid forms of CP
equal in the children who are ambulatory with no atheroid
What percentage of children with CP have oromotor dysfunction?
List some examples of dysfunctions
90%
Drooling - poor lip closure Dysfunctional swallowing Persistent extrusion reflex Inadequate sucking Reduced ability to chew
Are there other factors that affect nutrition?
Yes . Linear growth is affected, especially in non ambulatory cases. Linear growth correlates to the severity of cognitive defect
Other: endocrine dysfunction, ethnicity, genetic potential, pubertal status
What should you take in a nutritional history?
Type of food: liquids, puree, solids Amount of food Degree of dependency on caregiver Length of a typical meal Amount of spillage, is self-feeding Signs of promoter dysfunction: drooling, persistent extrusion reflex, choking, coughing, delayed swallowing Family stressors at mealtime
Apart from history, are there any investigations that can help detect aspiration?
Observing a feed
Oxygen saturation during a feed
swallowing study - caution making decisions sole based on this because reproducibility is sometimes questioned.
What is important on ROS for considering feeding problems in a kid with CP?
Reflux
Chronic respiratory problems - suggestive of aspiration
Progressive fatigue toward the end of a meal suggestive of desaturation
Ulcers
Constipation
Recurrent infections
What is pertinent on exam?
Heigh/weight
Triceps skin fold thickness
Mid arm circumference
Other signs of malnutrition: decubitus ulcers, peripheral oedema
Causes of difficulty with feeding: gingival hyperplasia and poor oral health
Clubbing - chronic desaturation.
Is there any blood work that would be helpful in this population?
Extensive blood work is unnecessary
CBC: to look for iron deficiency anaemia.
Albumin: unreliable in this population
electrolytes: not necessary because are almost always normal
Ca, O4, Vit D: if suspicious of osteoporosis, so do it with a bone scan
What are kids with scoliosis prone to, with regards to feeding difficulties? And how do you diagnose it?
Superior mesenteric artery syndrome, especially if rapid weight loss
Upper GI series
If a kid probably has chronic aspiration, apart from a swallowing study, what other investigations can you consider?
24 hour PH probe - to determine if the aspiration is secondary to reflux
Gastric emptying study - any decreased motility
Upper GI series - any anatomical abnormality
What are some of the consequences of GERD?
Food refusal
Erosive esophagitis
aspiration
Caloric loss
What are the two types of aspiration?
Aspiration of saliva and aspiration of gastric contents
What re some risk factors for osteopenia?
Reduced ambulation and weight bearing activity
Malnutrition
Limited sun exposure
The use of anti convulsants - which alter vitamin D metabolism
What is the gold standard for determining the bone minimal density of these kids?
Bone densitometry
Bone quantitative ultrasonography may be easier to perform in these children
What are some methods to determine caloric needs in this population?
- Krick method: (BMR x muscle tone factor x activity factor) + growth factor
BMR = body surface area x standard metabolic rate x 24 hours
Muscle tone factor 0.9 if decreased, 1.0 if normal and 1.1 if increased
Activity factor: 1.15 if bedridden, 1.2 if dependent, 1.25 if crawling 1.3 if ambulatory
Growth factor: 5 kcal/g of desired weight gain - Height-based method:
- 7 cal/cm in children without motor dysfunction
- 9 cal/cm in ambulatory patients with motor dysfunction
- 1 cal/cm in non-ambulatory patients
- REE based method
- 1 x measured resting energy expenditure
- monitoring growth and adjusting
What are some complications of NG? when would you consider an NG?
sinusitis
congestion
otitis
skin irritation
consider if needed for less than 3 months
Is there are role for prophylactic Anti Reflux Procedure (surgery such as a nissen)?
no
At what age do you change the formula from an infant formula to a childhood formula? What is the caloric density?
At 12 months of age.
1 or 1.5 kcal/ml
Can you use an adult formula?
No because of inadequate calorie-to-nutrient ratio
Their use may result in calcium, phosphorus and vitamin deficiency
What type of feeding regime should you use in children with dumping syndrome?
Continuous feeds
How do you assess weight/height in children with contractures?
Alternate measures such as lower leg length or arm length should be used
