Nutritional Challenges In Management of Children with Neurological Impairment. Sarah Donohoe Community Children's Dietitian

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1 Nutritional Challenges In Management of Children with Neurological Impairment Sarah Donohoe Community Children's Dietitian

2 References Feeding and Nutrition in Children with Neuro Disability Peter Sullivan 2009 A Practical Approach to the Nutritional Management of Children with Cerebral Palsy EJCN vol 67 supplement 2 Dec 2013 Practical experience - Feeding clinics in schools

3 Please can you review: This 9 year old girl with cerebral palsy and scoliosis she has drifted from the 25 th centile and is now on the 0.4 th centile for weight 19kg and appears thin Nutritional assessment - anthropometry Oral Nutritional Support Enteral Feeding feed tolerance Liquidised diet via gastrostomy

4 Assessment of Growth : Weight & Height Standing height if possible. Estimate height from tibia length or knee height In practice knee height easiest to measure and most accurate Weight and height plotted on WHO growth charts Charts based on populations of CP children not used in practice show what growth is, not necessarily ideal growth Lack of growth or deviation from growth curve short stature attributed to neurological condition or nutrition related? Care interpreting weight due to altered body composition central fat stores

5 Best Practice : Energy Balance Estimate of body fat will indicate if child in positive or negative energy balance Gurka 2009 added correction factors to Slaughters equations for % body fat increasing accuracy in children with CP More accurate indicator of nutritional status than weight To calculate need skin fold measurements - triceps and subscapular Practicality??

6 Nutritional Requirements Dietary Reference Values revised in 2011 S.A.C.N Range of kcals / kg specific for male and female 0 18 years Dietetic consensus is to estimate energy from height age if have accurate height Children with low energy expenditure a % of estimated average requirement is used In practice estimates are a starting point, need to look at in context of growth

7 Assessment of Requirements 9 years 1.22m height age of 7 years Estimated Average Requirement ( EAR ) for energy for 7 years is 67kcals / kg 67kcals / kg x 19kg = 1300kcals Reduced energy expenditure ( WHO ) 74% of EAR = 960kcals Weight gain x 120% = 1150kcals target

8 Protein, vitamin and mineral requirements No evidence to suggest that children with neurological impairment have lower nutrient requirements Practice varies aim between LRNI and RNI for age Calcium anticonvulsant therapy alters calcium and vitamin D metabolism. Increased risk of osteopenia in non weight bearing. Protein aim RNI for age

9 Assessment of Intake Detailed diet history meal patterns, routine, time spent feeding, portion sizes compared to siblings at same age, effect of illness on intake Meal time observation at school Liaison with speech therapy team Think of recall in context of food groups Carbohydrates B vitamins and some iron Fruit & Vegetables Vit C, beta carotene, vit A, folate, iron, fibre, vit K Meat, fish and pulses protein, iron, zinc and B vitamins Milk and dairy foods calcium, protein, B12, vitamins A&D

10 Diet History Breakfast : 8oz bottle of full fat cows milk, weetabix x 1 with full fat milk School snack : mashed banana few spoons of Lunch : ½ - full portion of smooth school meal, dessert cake and custard / full fat yoghurt After school bottle of milk 8oz Evening meal Blended meal eg shepherds pie / stew with mash and vegetables. Can be a few spoons only if tired after school. Occasional yoghurt / chocolate dessert Supper- bottle of milk 5oz Estimate ~ 1000kcals

11 Milk and milk based foods are providing high proportion of energy Intake of protein, calcium, phosphate will be good Diet low in meat, eggs, fortified cereals, fruit and vegetables probable low intake of iron, zinc, folate and vitamin C Energy intake below requirements as her weight is drifting

12 Nutritional Support : Food fortification 30mls double cream - 104kcals 100g mashed baked beans 98kcals and 7g protein 10g ground almonds- 80 kcals and 3g protein Boiled egg mashed 85kcals and 8g protein 30g grated cheese 125kcals and 8g protein Dessert spoon houmous 70kcals Butter 10g 75kcals Table spoon golden syrup 70kcals

13 Nutritional Supplements Energy Supplements Calogen 30mls = 135kcals Calogen Extra 30mls =120kcals and 1.5g protein Procal Shot 30mls = 100kcals and 2g protein Supersoluble Duocal powder = 12 scoops = 75kcals

14 Nutritional Supplements Fortini 1 6 years 200mls = 300kcals and 7g protein Fortisip 200mls = 300kcals and 12g protein Fortisip Compact 125mls = 300kcals, 12g protein Above are nutritionally complete

15 Case study Try food fortification and 1 x fortsip compact per day Aim to give fortisip in place of milk on cereal at bedtime Start to discuss enteral feeding Work done locally by speech therapy team about making the decision

16 Enteral Feeding Challenges : Poor feed tolerance Times of feeds in relation to transport / physio / activities Feeding regimen - bolus v continuous Type of feed used Route of feeding - increase in jejunal feeding?

17 Feeding Plans : Bolus Feeding Feed volume divided over 3 5 feeds Gravity fed or via pump bolus over 30 90mins Can supplement oral intake Simulates normal feeding physiologically normal Care with children with delayed gastric emptying Not used in jejunal feeding

18 Feeding Plans : Continuous Feeding Volume of feed is given over ~ 12 hours Child is attached to pump for prolonged time Allows higher fluid intake with reduced risk of gastric distension, reflux and aspiration Avoid overnight feeding if possible Can be split into 2 blocks of feeding eg 8am 12noon then 4pm 8pm

19 Types of Enteral Feeds Standard feeds ( available +/ - fibre ) 100kcals / 100mls Nutrini, Tentrini, Nutrison Well tolerated Energy feeds ( available +/ - fibre ) 150kcals / 100mls Nutrini Energy, Tentrini Energy,Nutrison Energy Higher fat content can delay gastric emptying

20 Peptide Feeds Nutrini Peptisorb, Peptamen Junior*, Peptamen Junior Advance*, Vital 1.5kcal *100% hydrolysed whey protein Whey based formula decrease gastric emptying time Reduce regurgitation 60% fat as MCT Well tolerated

21 Enteral Feeding Challenges :Feed not being nutritionally complete All feeds are nutritionally complete in specified volume. Some children have very low requirements and need volumes of feed below nutritionally complete volume Feed analysis done and supplementation with Paediatric Seravit Parents reluctant to change feed if child tolerating

22 Low Energy feeds Nutrini Low energy multi fibre 76 kcals / 100mls Nutrison 800 Complete 83kcals / 100mls Useful in children with low energy requirements

23 Feeding Plan Discuss options with child and family Bolus feeding regimen Tentrini Energy 360mls =540kcals 120mls after breakfast, after evening meal and bedtime =~ 500kcals Pump bolus over 30 minutes Times can be moved / feeds omitted if eaten well

24 In Summary.. Nutritional assessment concept of energy balance, review diet history in context of food groups. Oral Nutritional Supplements Choose the supplement that best fits the gap. Feed tolerance Timing of feeds, how feed is given, type of feed and route

25 Liquidised diet via Gastrostomy Reported benefits reduced vomiting and retching, improved bowel function, improvements in mood and well being. Parental preference food is love BDA does not promote blended diet- dietitians have duty of care to advise on safe practice

26 Preparation & administration Meals need to contain balance of foods from food groups eat well plate Food needs to be cooked,liquidised, fluid added so can pass through 5mm metal sieve. Frozen for no longer than one month Blends that contain precooked food need to be reheated, stirred till piping hot and allowed to cool to room temperature before being given. Drawn up in 60mls syringe. Given 20mls bursts then pause, over normal duration of meal

27 What are the risks? Nutritional risk foods diluted, Research has shown expected nutrient content often less than actual Infection food preparation, storage, reheating Mechanical tube blockage, device condition, pressure of plunging meals

28 In Practice Time consuming planning, cooking, blending, sieving, adding fluid to get correct consistency, feeding. Parents need to be nutritionally aware Research suggests that nutrient content of blended food may be lower than expected, long term effect unknown Some parents struggle to get calories in blend high enough within reasonable volume Online information First attempt in hospital, blended hospital food too thick and herbs too large.

29 South Tees Policy South Tees policy for community, Zoes Place and ward use Button devices only -Not for Freka PEGS, NGT s and jejunal tubes Bolus feeding only, pumps not licenced Standard Operating Procedure for preparation, storage, reheating and administration of liquidised diet Information sheet for parents

30 Risk assessment / disclaimer Food alerts and clinical alerts for when blended diet should not be given. Child needs spare button with them Alternative feed prescribed in case problem with blended diet