Weight gain and triceps skinfolds fat mass after gastrostomy placement in children with developmental disabilities

Clinical characteristics of children with severe neurologic impairment: A scoping review

OBJECTIVE

The aim of this study is to extrapolate the clinical features of children with severe neurologic impairment (SNI) based on the functional characteristics and comorbidities described in published studies.

METHODS

Four databases were searched. We included studies that describe clinical features of a group of children with SNI (≥20 subjects <19 years of age with >1 neurologic diagnosis and severe functional limitation) using data from caregivers, medical charts, or prospective collection. Studies that were not written in English were excluded. We extracted data about functional characteristics, comorbidities, and study topics.

RESULTS

We included 102 studies, spanning 5 continents over 43 years, using 41 distinct terms for SNI. The terms SNI and neurologic impairment (NI) were used in 59 studies (58%). Most studies (n = 81, 79%) described ≥3 types of functional characteristics, such as technology assistance and motor impairment. Studies noted 59 comorbidities and surgeries across 10 categories. The most common comorbidities were related to feeding, nutrition, and the gastrointestinal system, which were described in 79 studies (77%). Most comorbidities (76%) were noted in <10 studies. Studies investigated seven clinical topics, with "Gastrointestinal reflux and feeding tubes" as the most common research focus (n = 57, 56%). The next most common topic, "Aspiration and respiratory issues," included 13 studies (13%). Most studies (n = 54, 53%) were retrospective cohorts or case series; there were no clinical trials.

CONCLUSIONS

Despite the breadth of described comorbidities, studies focused on a narrow set of clinical topics. Further research is required to understand the prevalence, clinical impact, and interaction of the multiple comorbidities that are common in children with SNI.

Quality of Life Issues for Families who Make the Decision to Use a Feeding Tube for Their Child with Disabilities

Qualitative research methods were used to study families who had made or were in the process of making the decision to use a feeding tube to meet the nutrition needs of their child with a disability. Data were gathered over a 2-year period through interviews with eight families. Family decision making in the context of quality of life was examined using a theoretical family systems model. Descriptive themes and issues emerged from the data that led to a greater understanding of what families face in making this decision for their child. The data can help families and professionals work in partnership before a child becomes severely malnourished or medically compromised as a result of inadequate nutrition. The themes and issues are discussed and implications for future interventions and research are presented.

A Core Outcome Set for Children With Feeding Tubes and Neurologic Impairment: A Systematic Review

CONTEXT

Uncertainty exists about the impacts of feeding tubes on neurologically impaired children. Core outcome sets (COS) standardize outcome selection, definition, measurement, and reporting.

OBJECTIVE

To synthesize an evidence base of qualitative data on all outcomes selected and/or reported for neurologically impaired children 0 to 18 years living with gastrostomy/gastrojejunostomy tubes.

DATA SOURCES

Medline, Embase, and Cochrane Register databases searched from inception to March 2014.

STUDY SELECTION

Articles examining health outcomes of neurologically impaired children living with feeding tubes.

DATA EXTRACTION

Outcomes were extracted and assigned to modified Outcome Measures in Rheumatology 2.0 Filter core areas; death, life impact, resource use, pathophysiological manifestations, growth and development.

RESULTS

We identified 120 unique outcomes with substantial heterogeneity in definition, measurement, and frequency of selection and/or reporting: "pathophysiological manifestation" outcomes (n = 83) in 79% of articles; "growth and development" outcomes (n = 13) in 55% of articles; "death" outcomes (n = 3) and "life impact" outcomes (n = 17) in 39% and 37% of articles, respectively; "resource use" outcomes (n = 4) in 14%. Weight (50%), gastroesophageal reflux (35%), and site infection (25%) were the most frequently reported outcomes.

LIMITATIONS

We were unable to investigate effect size of outcomes because quantitative data were not collected.

CONCLUSIONS

The paucity of outcomes assessed for life impact, resource use and death hinders meaningful evidence synthesis. A COS could help overcome the current wide heterogeneity in selection and definition. These results will form the basis of a consensus process to produce a final COS.

Radiologically Guided Placement of Mushroom-retained Gastrostomy Catheters: Long-term Outcomes of Use in 300 Patients at a Single Center

PURPOSE

To assess long-term outcomes including risk of complications and nutritional benefits of mushroom-retained (pull-type) gastrostomy catheters placed in patients by interventional radiologists.

MATERIALS AND METHODS

All patients who received pull-type gastrostomy tubes between 2010 and 2013 were retrospectively reviewed, including 142 men (average weight, 169.6 lb [76.32 kg]; mean age, 65.2 years; range, 22-92 years) and 158 women (average weight, 150.4 lb [67.68 kg]; mean age, 65.2 years; range, 18-98 years). Indications for placement were cerebrovascular accident (n = 80), failure to thrive (n = 71), other central nervous system disorder (n = 51), head and neck cancer (n = 47), and other malignancy (n = 51). Complications were recorded per Society of Interventional Radiology practice guidelines. Patient weight was documented at specific follow-up intervals. Statistical analysis was performed by using the Student t test and one-way analysis of variance for the effects of sex and indication for placement, respectively, on average weight change.

RESULTS

The technical success rate was 98.4% (300 of 305 patients). Major and minor complications occurred at a rate of 3.7% (n = 11) and 13% (n = 39), respectively. Follow-up weight during the early (≤45 days), intermediate (≤180 days), and long-term (>180 days) periods was available for 71% (n = 214), 36% (n = 108), and 15% (n = 44) of the 300 patients, respectively. Weight gain occurred in 77% (160 of 214), 60% (65 of 108), and 73% (32 of 44) of the patients, respectively. Patients who gained weight gained 6.7, 10.6, and 16.3 lb (3.02, 4.77, and 7.34 kg) during each follow-up period, respectively. Average weight gain at follow-up in all patients was 4.2, 0.6, and 5.4 lb (1.89, 0.27, and 2.43 kg), respectively. No significant differences in average weight change were seen among groups when they were classified according to sex or indication for placement.

CONCLUSION

Placement of mushroom-retained gastrostomy catheters is a viable long-term treatment option for enteral nutrition, with complication rates similar to those reported for other gastrostomy techniques. Improvement in nutrition status measured as weight gain was seen in most patients in both early and long-term periods.

Methylation capacity in children with severe cerebral palsy

BACKGROUND

  Methylation cycle and folate-mediated one-carbon metabolism maintenance is important for many physiological processes including neurotransmitter regulation, nerve myelination and DNA synthesis. These processes play an indispensible role in growth and development, as well as in cognitive function and neuromuscular stability, which are key issues in children with severe cerebral palsy (CP).

METHODS

  Blood samples were collected from children with severe CP (n = 24) and age-matched typically developing healthy controls (n = 24), as an exploratory study. The CP group was divided into orally (O) or enterally fed via percutaneous endoscopic gastrostomy (E). Concentrations of red cell folate (RCF), methylmalonic acid (MMA), mean cell volume (MCV), homocysteine (Hcy), cystathionine, choline, betaine and urate were assayed.

RESULTS

  Homocysteine was increased in both O mean (±SD) = 6·28 (±1·81 μM) and E = 6·03 (±1·28), vs. controls = 5·07 (±0·98) P = 0·02. Higher MMA was found in controls = 157 (±54) and O = 141 (±101), vs. E = 88(±21) P = 0·05. RCF was higher in E = 1422 (±70 nM) vs. O = 843 (±80) and controls = 820 (±43) P < 0·001. MCV z-scores were elevated in E = 3·1 (±1·8) and O = 1·1 (±1·1) compared with controls = -0·2 (±1·1) P < 0·001. Urate was significantly reduced in O = -0·64 (±1·38) and E = -0·87 (±0·71), vs. controls = 0·18 (±0·62) P = 0·006.

CONCLUSIONS

  Raised MCV in the presence of elevated red cell folate, adequate B12 status and low plasma urate suggest potential methyltetrahydrofolate trapping and impaired purine synthesis. Well-documented malnutrition issues in O may explain differences between CP groups. These data support the hypothesis of possible dysregulation in methylation capacity and/or folate one-carbon metabolism, although more research is needed to elucidate a precise mechanism.

Protein levels in enteral feeds: do these meet requirements in children with severe cerebral palsy?

Children with cerebral palsy (CP) have been documented to have feeding difficulties, which increase in line with condition severity and result in lowered growth potential. Much nutrition literature surrounds energy intake and expenditure in these children, with less information available on other parameters such as protein and micronutrients, which are also important for growth and development. We examined differences in protein intake and a variety of protein metabolism indices in children with CP compared with controls. A total of twenty-four children aged 4–12 years with marked CP fed orally (O, n 15) or enterally (E, n 9) were recruited, including age-matched typically developing children (C, n 24). Fasting blood samples were analysed for levels of albumin, creatinine, urea and urate. Parents collected an exact food replica for three consecutive days of their child's actual intake, which were directly analysed for protein content. Significant differences were found in protein intakes between the groups (mean percentage minimum requirements: E = 178 (sd 47); O = 208 (sd 95); C = 311 (sd 119), P = 0·005). Despite all children consuming over recommended levels, children with CP had significantly reduced levels of the protein metabolic indices compared with controls. These include as z-scores: albumin mean C = 0·71 (sd 1·04) and CP = − 0·17 (sd 1·60), P = 0·03; creatinine C = − 2·06 (sd 0·46) and CP = − 3·11 (sd 0·98), P < 0·001; urate C = 0·18 (sd 0·62) and CP = − 0·58 (sd 0·93), P = 0·002. Post hoc analysis, the present data show potentially greater protein metabolism issues in enterally fed children, compared with the other groups. This may also support recent literature that suggests shortfalls in current recommendations.

The effect of gastrostomy tube feeding on body protein and bone mineralization in children with quadriplegic cerebral palsy

AIM

The aim of this study was to investigate the effect of gastrostomy tube feeding on body protein and bone mineralization in malnourished children with cerebral palsy (CP).

METHOD

Children aged between 4 and 18 years with spastic quadriplegic CP (Gross Motor Function Classification System level V) were recruited from the Children's Hospital at Westmead to participate in this prospective cohort study. The children had measurements of anthropometry (weight, height, and skinfold), bone mineral content (BMC) by dual-energy X-ray absorptiometry, and total body protein (TBP) by neutron activation analysis before and after gastrostomy tube feeding. Comparison data were collected prospectively from age-matched healthy children and extracted from databases for this study.

RESULTS

A total of 21 children (nine females, 12 males) participated in the study (median age 8 y 5 mo; interquartile range [IQR] 6 y 9 mo-11 y 10 mo). The median length of time of gastrostomy feeding was 19.4 months (IQR 7.7-29.9 mo). Significant (p<0.05) improvements were found in the median values for weight (15.4-23.3 kg), weight standard deviation scores (SDS; -4.8 to -3.0), height (105.4-118.3 cm), per cent body fat (10.7-16.3), TBP (2.4-3.4 kg), TBP per cent predicted for height (83.4-99.0), and BMC (469-626 g). No significant increases were found in height SDS, TBP per cent predicted for age, or BMC SDS for age or height.

INTERPRETATION

Malnourished children with quadriplegic CP showed significant increases in body fat and protein with gastrostomy tube feeding. No significant change in bone mineralization predicted for age or height was observed.

Reduced body protein in children with spastic quadriplegic cerebral palsy

BACKGROUND

No studies have directly measured body protein or validated skinfold-thickness anthropometry and dual-energy X-ray absorptiometry (DXA) to assess body protein in children with spastic quadriplegic cerebral palsy (SQCP).

OBJECTIVE

We aimed to measure and evaluate body protein and to determine whether skinfold-thickness anthropometry and DXA can predict body protein in children with SQCP.

DESIGN

This was a cross-sectional study of 59 children (22 girls, 37 boys) aged 3.9-19.5 y with SQCP. The children underwent measurements of anthropometric indexes, lean tissue mass by DXA (LTM(DXA)), and total body protein by neutron activation analysis (TBP(NAA)). In addition, TBP was estimated from both skinfold-thickness anthropometry (TBP(SKIN)) and DXA (TBP(DXA)). The agreement of TBP(SKIN) and TBP(DXA) was tested against TBP(NAA) by using Bland and Altman plot analysis.

RESULTS

Height and weight SD scores (x +/- SD: -3.1 +/- 1.6 and -4.8 +/- 5.3, respectively) were significantly lower than reference data in the children with SQCP (P < 0.001). TBP(NAA) for age and height was low in the children with SQCP (P < 0.001): 56.1 +/- 17.3% and 81.5 +/- 15.7%, respectively, of the values predicted from control data. TBP(SKIN) and TBP(DXA) were both highly correlated with TBP(NAA): r = 0.90, P < 0.001, and r = 0.91, P < 0.001, respectively. Despite these significant correlations, agreement analyses showed wide variation of up to 33.3% of the mean for both methods.

CONCLUSIONS

Body protein in children with SQCP is significantly reduced for age and height. Skinfold anthropometry and DXA show wide variation in estimation of body protein compared with NAA in this group of children.

Effect of Gastrostomy on Growth in Children with Neurodevelopmental Disabilities

Chronic malnutrition and growth failure are frequent consequences of feeding difficulties in neurodevelopmentally disabled children. Gastrostomy feeding has been used successfully to alleviate chronic malnutrition as well as distress and frustration associated with feeding. Unfortunately, caregivers are often resistant to gastrostomy placement. In order to determine the impact of gastrostomies in 20 children with neurodevelopmental disability (NDD), a questionnaire was used to collect caregivers’ perceptions both before and after gastrostomy. The questionnaire assessed caregivers’ retrospective perceptions of quality of life, feeding difficulties, and the burdens and benefits of gastrostomies. To determine impact on growth, height and weight were measured once before and three times after gastrostomy (at six, 12, and 24 months). The number of times a child was fed and the amount of time spent feeding decreased significantly following gastrostomy (p<0.001 and p<0.05, respectively). Growth for all children improved following gastrostomy (p<0.001). Pregastrostomy problems improved significantly following gastrostomy, as did caregivers’ perceptions of quality of life for both themselves and their child (p<0.001). These results indicate that gastrostomy has a positive impact on growth for neurodevelopmentally disabled children, and on quality of life for both children and caregivers. Caregivers may find these results encouraging if they are faced with a decision about gastrostomy placement for their child.

Current practice in the management of children with cerebral palsy: a national survey of paediatric dietitians

BACKGROUND

Dietitians play a key role in the clinical management of children with cerebral palsy. This survey was conducted with the aim of establishing an overview of current dietetic practice in the management of these children.

METHOD

A questionnaire which asked for information on aspects of dietetic practice relating to children with cerebral palsy was circulated to members of the British Dietetic Association during May to October 2000.

RESULTS

Many respondents had a small caseload size. However, a larger caseload was linked to membership of a multi-disciplinary team, a greater proportion of severely disabled children and use of a wider range of anthropometric measurements. Dietitians who were members of a multi-disciplinary team were more likely to visit children at home.

CONCLUSIONS

This survey provides an overview of current dietetic practice in the UK regarding the management of children with cerebral palsy. There is a potential shortfall in specialist dietitians and this survey highlights some of the gaps in service provision. Children with cerebral palsy benefit from dietetic input and there is an increasing need for specialist dietitians to be involved in their management. It will be necessary to continue to identify any gaps and find ways to overcome them.

Substitute decision-making: measuring individually mediated sources of uncertainty

One aspect of O'Connor's Decisional Conflict Scale [O'Connor, A.M., Validation of a decisional conflict scale, Med. Decis. Making 15 (1995) 25-30] is the assessment of selected factors (perceived lack of information, undue social pressure, lack of support from others, and lack of clarity about personal values) that are believed to contribute to decisional uncertainty. This study explored the appropriateness of this uncertainty measure in the substitute decision-making context. Forty-nine mothers deciding on gastrostomy tube insertion for their children completed the scale, and also provided verbal reports about the contributory factors. For each of the four factors, relatively high-, moderate-, and low-scoring sub-groups were identified; then the associated verbal reports were examined for across-sub-group differences. Differences in verbal reports about information (chi 2 = 6.990, P = 0.0082), perceived pressure (chi 2 = 8.377, P = 0.0038), social support (chi 2 = 5.573, P = 0.0182), and perceived gains and losses (chi 2 = 3.85, P = 0.0499; chi 2 = 5.76, P = 0.0164) were observed, implying consistency between quantitative scores and verbal reports. This quantitative/qualitative hybrid approach may be clinically useful for assessing individually mediated factors contributing to decision uncertainty, and for evaluating therapeutic interventions in other substitute decision-making contexts.

Specialized Nutrition Support in Patients with Severe Neurodevelopmental Disabilities

Nutrition Support Consultant features issues pertinent to the clinical aspects of pharmacy nutritional support practice.

Measured energy expenditure of tube-fed patients with severe neurodevelopmental disabilities

OBJECTIVE

To determine measured resting energy expenditure (REE) of nonambulatory tube-fed patients with severe neurological neurodevelopmental disabilities.

METHODS

Twenty patients were prospectively studied. Only steady state indirect calorimetry measurements were taken. All measurements were conducted using a canopy system. Nutritional needs were met entirely by enteral feedings via a permanent ostomy.

RESULTS

REE was widely distributed from 16 kcals/kg/day to 39 kcals/kg/day. The mean REE (888+/-176 kcals/day) of the patients was significantly (p<0.01) lower than predicted as estimated by the Harris-Benedict equations (1081+/-155 kcals/day) and World Health Organization equations (1194+/-167 kcals/day). Fat-free mass (FFM) was the best parameter for predicting REE. Two predictive equations were developed that are not significantly biased and more precise (< or =15% error) than conventional predictive formulas.

CONCLUSION

Conventional formulas for estimating energy expenditure are inaccurate and generally overestimate measured energy expenditure of nonambulatory patients with severe developmental disabilities.

Mothers' experiences caring for children with disabilities who require a gastrostomy tube

In this qualitative study, mothers' experiences of feeding children with severe disabilities by a gastrostomy tube are described. Twelve mothers each participated in one, open-ended, home interview. Mothers gave detailed accounts of their activities and the tremendous stress involved in feeding the children. They described spending enormous time and energy seeking confirmation of the feeding problem and devising extraordinary practices to ensure the child's survival before "giving in" to the gastrostomy tube. Following gastrostomy tube insertion, they initially felt relief and disappointment, before customizing feeding and moving on. Mothers' suggestions for improving professional services are discussed along with implication for practice and research.

Nutrition management of patients with epidermolysis bullosa

Epidermolysis bullosa (EB), a heterogeneous group of rare, inherited disorders, is manifested by recurrent blistering of the skin induced by the slightest trauma. Little information exists regarding the nutrition management of patients with EB. This study presents information on growth, identifies potential nutrition problems, and provides guidelines for nutrition management of persons with EB. Eighty patients attending a dermatology clinic for EB patients are described. Severity of disease ranged from mild blistering of the knees, elbows, and feet to extensive blistering and scarring of the skin and entire gastrointestinal tract. Of the 18 children with EB simplex, which is a mild form of the disease, 4 (22%) were at nutritional risk. None of the 13 adults with EB simplex were underweight and 8 (62%) were overweight. Of the patients with the more severe forms of EB, 27 of the 35 (77%) children with dystrophic EB and 4 of the 7 (57%) children with junctional EB were at risk for malnutrition. Of the 7 adults with dystrophic EB, 6 (86%) were underweight. Common nutrition problems included protein-energy malnutrition, chewing and swallowing problems, constipation, anemia, and vitamin/mineral deficiencies. When nutrition care protocols address these problems, growth, development, and nutritional status can improve. For those with severe nutrition problems, gastrostomy feeding or similar nutrition therapies should be considered.