Patología gastrointestinal en niños con parálisis cerebral infantil y otras discapacidades neurológicas

Nutritional status and prevalence of dysphagia in cerebral palsy: usefulness of the Eating and Drinking Ability Classification System scale and correlation with the degree of motor impairment according to the Gross Motor Function Classification System

INTRODUCTION AND OBJECTIVES

Digestive disorders are one of the most common comorbidities among children with cerebral palsy (CP). The aim of this study is to examine the nutritional status of patients with CP, the prevalence of dysphagia by degree of motor impairment, and the impact of digestive disorders on quality of life.

MATERIAL AND METHODS

We conducted a descriptive, cross-sectional, open-label study of out-patients with CP from a tertiary hospital in the Region of Madrid using a structured interview, classifying dysphagia using the Eating and Drinking Ability Classification System (EDACS). We gathered demographical and anthropometric data, and analysed the correlation between severity of dysphagia and functional status as measured with the Gross Motor Function Classification System (GMFCS).

RESULTS

Our sample included 44 patients (65.9% boys), with a mean (standard deviation) age of 9.34 (5) years and a mean BMI of 18.5 (4.9). Forty-three percent presented safety and efficiency limitations (EDACS level > II). Safety and efficiency limitations were associated with more extensive motor involvement (60% had tetraparesis), more varied clinical manifestations (87% had mixed forms) and poorer functional capacity (100% on GMFCS V). The impact on nutritional status increased with higher EDACS and GMFCS scores.

CONCLUSIONS

This is the first study into the usefulness of the EDACS scale in a representative sample of Spanish children and adolescents with CP. Our findings underscore the importance of screening for dysphagia in these patients, regardless of the level of motor impairment, and the need for early treatment to prevent the potential consequences: malnutrition (impaired growth, micronutrient deficiencies, osteopaenia, etc.), microaspiration, or recurrent infections that may worsen patients' neurological status.

Effects of a Modern Kefir on Conditions Associated with Moderate Severe Spastic Quadriparesis Cerebral Palsy

Cerebral palsy (CP) in children constitutes a set of movement and body posture disorders caused by brain injury, which in turn is associated with a series of intestinal, respiratory, and malnutrition conditions. Twenty-four children were selected and included for the present study and subdivided into two groups: (1) children who included modern kefir (containing 12 probiotic species) in their diet; and (2) control group (not including kefir in their diet). The group supplemented with modern kefir received a beverage with multi probiotic species and the control group received commercial yogurt (which included the 2 typical lactic acid bacteria) for 7 weeks. Anthropometric variables, resting energy expenditure, presence, and diagnosis of functional digestive disorders (FDD), frequency of respiratory problems, presence of elevated C-reactive protein, differential count of leukocytes were evaluated. A significant increase in weight and height was found in the kefir group at the final time point. In addition, kefir intake promoted a significant reduction in functional constipation and stool hardness and increased the absolute value of blood lymphocytes. Since the fermented milk beverage modern kefir improves constipation, which is the most important FDD in children with CP and the nutritional and immune status, it could be considered an important strategy to improve health in these children.

Factors associated with the stool characteristics of children with cerebral palsy and chronic constipation

BACKGROUND

chronic constipation is a common gastrointestinal problem in children with cerebral palsy and several factors can influence the stool frequency, consistency and pH in these cases.

AIM

to identify the association of dietary factors, use of anticonvulsants and family history of constipation with the stool characteristics of children with cerebral palsy and chronic constipation.

METHODS

an analytical cross-sectional study was performed of 45 children with cerebral palsy and chronic constipation that included 19 females and 26 males, aged 37 ± 13 months. Dietary factors, the use of anticonvulsants and family history were analyzed. Stool frequency, consistency (Bristol Stool Form Scale) and pH (using a pH-meter) were also determined.

RESULTS

there was a positive correlation between stool frequency and the consumption of oilseeds (r = 0.339, p = 0.023). There was a negative correlation between hard stools and fluid intake (r = -0.336, p = 0.042) and between stool pH and the consumption of cereals rich in insoluble fiber, high soluble fiber vegetables, carrots and potatoes (r = -0.339, p = 0.030; r = -0.308, p = 0.044; r = -0.336, p = 0.027; r = -0.307, p = 0.045, respectively). An association was also identified between the use of anticonvulsant polytherapy and hard stools (OR = 14.2 [95% CI 1.16-174], p = 0.038). There was no association between family history and constipation.

CONCLUSIONS

rich-fiber food consumption, fluids intake and anticonvulsant polytherapy were associated with the stool characteristics of children with cerebral palsy and chronic constipation.

Bone health impairment in patients with cerebral palsy

Bone health problems may be related to the nutritional deficit in pediatric patients with cerebral palsy. It is common to find asymptomatic vertebral fractures when they have low bone mineral density. Fat mass deficit could be related to a lower bone mineral density and a higher risk of vertebral fractures.

OBJECTIVES

To study the bone health of patients with CP and its relationship with neurological and nutritional status.

PURPOSE

Cerebral palsy (CP) is the most common cause of motor disability in pediatric age.

METHODS

Cross-sectional, observational, descriptive, and analytical study in which patients with CP between 4 and 5 years with Gross Motor Function Classification System (GMFCS) grades III-IV-V were included. It was carried out: survey, anthropometric study, bioimpedanciometry (BIA), and bone densitometry. Patients with low bone mineral density (BMD Z score less than - 2.0) underwent lumbar radiography looking for vertebral fractures to be diagnosed with osteoporosis.

RESULTS

Total sample: 51 patients (51.0% women). Mean age: 11.0 ± 0.5 years. BMD Z score average: - 2.1 (95% CI - 2.5, - 1.7). BMD Z score according to GMFCS: grade III - 1.6 (- 2.2; - 1.), grade IV - 1.6 (- 2.4; - 0.9), grade V - 3.1 (- 3.9, - 2.2) (p = 0.013). Bone health classification according to the International Society for Clinical Densitometry was: 47.1% normal, 52.9% low BMD. Relationship between low BMD and low fat mass (p = 0.030) and low cell mass (p = 0.040) was found. Prevalence of vertebral fractures in lumbar radiography: 25.9%, increasing as the degree of neurological involvement. Vertebral fractures were found in 5/13 GMFCS grade V, 2/6 GMFCS grade IV, and 0/10 GMFCS grade III.

CONCLUSIONS

Bone health in the pediatric population with CP is compromised in relation to the degree of neurological involvement and nutritional status. Those patients with moderate-severe cerebral palsy and low BMD seem to present an increased risk of fracture.

Nutritional status and prevalence of dysphagia in cerebral palsy: Usefulness of the Eating and Drinking Ability Classification System scale and correlation with the degree of motor impairment according to the Gross Motor Function Classification System

INTRODUCTION AND OBJECTIVES

Digestive disorders are one of the most common comorbidities among children with cerebral palsy (CP). The aim of this study is to examine the nutritional status of patients with CP, the prevalence of dysphagia by degree of motor impairment, and the impact of digestive disorders on quality of life.

MATERIAL AND METHODS

We conducted a descriptive, cross-sectional, open-label study of outpatients with CP from a tertiary hospital in the Region of Madrid using a structured interview, classifying dysphagia using the Eating and Drinking Ability Classification System (EDACS). We gathered demographical and anthropometric data, and analysed the correlation between severity of dysphagia and functional status as measured with the Gross Motor Function Classification System (GMFCS).

RESULTS

Our sample included 44 patients (65.9% boys), with a mean (standard deviation) age of 9.34 (5) years and a mean BMI of 18.5 (4.9). Forty-three percent presented safety and efficiency limitations (EDACS level>II). Safety and efficiency limitations were associated with more extensive motor involvement (60% had tetraparesis), more varied clinical manifestations (87% had mixed forms) and poorer functional capacity (100% on GMFCS V). The impact on nutritional status increased with higher EDACS and GMFCS scores.

CONCLUSIONS

This is the first study into the usefulness of the EDACS scale in a representative sample of Spanish children and adolescents with CP. Our findings underscore the importance of screening for dysphagia in these patients, regardless of the level of motor impairment, and the need for early treatment to prevent the potential consequences: malnutrition (impaired growth, micronutrient deficiencies, osteopaenia, etc.), microaspiration, or recurrent infections that may worsen patients' neurological status.

Total Oesophagogastric Dissociation in Neurologically Impaired Children: 18 Years' Experience and Long-term Follow-up

OBJECTIVES

Total oesophagogastric dissociation (TOGD) is an alternative antireflux surgery for neurologically impaired children because of a 16% to 38% fundoplication failure rate. This study evaluates TOGD's feasibility and its long-term efficacy both as a Primary and as a "Rescue" procedure after failed fundoplication.

METHODS

Thirty patients (18 boys) who underwent TOGD between 2000 and 2018 in 2 Italian Centres were retrospectively reviewed. Twenty-three were Primary procedures and 7 were "Rescue" ones. Inclusion criteria were severe neurodisability, intractable gastroesophageal reflux, and dysphagia.

RESULTS

Preoperatively, all children had regurgitation, vomiting or retching, and 93% had unsafe swallowing and aspiration, with recurrent chest infections/aspiration pneumonia. Median relative weight was 77% (48%--118%). All patients were taking antireflux medication before surgery. Median age at TOGD was 6.48 years (0.69--22.18). Median follow-up was 3.5 years (0.6-17.7). No recurrence of gastroesophageal reflux (GER) and vomiting was recorded. The number of chest infections and length of hospital stay showed a significative decrease (P value <0.0001 for both), whereas median relative weight reached 101% (P value 0.002). Parents'/caregivers' perception of outcome showed a significative improvement. Six patients (20%) experienced early complications and 3 required surgical intervention. Three late complications (10%) also required surgery. There was no surgery-related mortality.

CONCLUSION

TOGD is an effective procedure with an acceptably low complication rate for children with severe neurological impairment and is followed by a major improvement in general health and quality of life for children and families. There was no substantial difference in outcome between Primary and "Rescue" procedures.

The lethal twist - a story of unspoken pain: small intestinal volvulus in cerebral palsy

Small intestinal volvulus (SBV) is the abnormal twisting of bowel around the axis of its mesentery, leading to obstruction and vascular compromise, resulting in bowel ischemia and necrosis which are life-threatening. Risk factors include malformation, malrotation, and adhesions. Its rare incidence and vague clinical presentation make it a difficult diagnosis, more so in a nonverbal patient who cannot express his pain, which is the first and most prominent symptom. Studies suggest an increased frequency of intestinal obstruction in cerebral palsy patients. There are no reported cases of small intestinal volvulus in association with cerebral palsy.

We present a case of a 21-year-old man with severe cerebral palsy and kyphoscoliosis. The patient presented to the emergency room with respiratory distress and abdominal distension. An acute abdomen was noted. Abdominal X-rays revealed gas patterns suggestive of small intestinal obstruction. The patient rapidly deteriorated, and resuscitation attempts were unsuccessful.

Autopsy revealed peritoneal cavity filled with extensively dilated and thin-walled loops of small intestine. Twisting of the small intestine, showing 360° rotation around the mesenteric root in a clockwise manner at two separate sites, was noted. On bowel dissection, mucosal folds were absent, and mucosa was green with patchy areas of hemorrhage consistent with ischemic necrosis. There was no evidence of any malformation, malrotation or adhesions.

Small intestinal volvulus is a rare entity with a nonspecific clinical presentation that poses a diagnostic challenge. This autopsy highlights the need to maintain a high index of suspicion for small intestinal volvulus in cases of bowel obstruction in cerebral palsy patients to expedite surgery and prevent mortality. The primary caregivers of non-verbal cerebral palsy patients living outside of healthcare facilities need to be trained in recognition of life-threatening medical emergencies such as gastrointestinal obstruction and seek emergent attention at the earliest to prevent treatment delays.

Bone mineral density and nutritional status in children with quadriplegic cerebral palsy

This study demonstrated the relationship of low bone mineral density (BMD) with the degree of motor impairment, method of feeding, anthropometric indicators, and malnutrition in children with quadriplegic cerebral palsy (CP). The control of these factors could optimize adequate bone mineralization, avoid the risk of osteoporosis, and would improve the quality of life.

PURPOSE

The purpose of the study is to explore the relationship between low BMD and nutritional status in children with quadriplegic CP.

METHODOLOGY

A cross-sectional analytical study included 59 participants aged 6 to 18 years with quadriplegic CP. Weight and height were obtained with alternative measurements, and weight/age, height/age, and BMI/age indexes were estimated. The BMD measurement obtained from the lumbar spine was expressed in grams per square centimeter and Z score (Z). Unpaired Student's t tests, chi-square tests, odds ratios, Pearson's correlations, and linear regressions were performed.

RESULTS

The mean of BMD Z score was lower in adolescents than in school-aged children (p = 0.002). Patients with low BMD were at the most affected levels of the Gross Motor Function Classification System (GMFCS). Participants at level V of the GMFCS were more likely to have low BMD than levels III and IV [odds ratio (OR) = 5.8 (confidence interval [CI] 95% 1.4, 24.8), p = 0.010]. There was a higher probability of low BMD in tube-feeding patients [OR = 8.6 (CI 95% 1.0, 73.4), p = 0.023]. The probability of low BMD was higher in malnourished children with weight/age and BMI indices [OR = 11.4 (1.3, 94), p = 0.009] and [OR = 9.4 (CI 95% 1.1, 79.7), p = 0.017], respectively.

CONCLUSION

There was a significant relationship between low BMD, degree of motor impairment, method of feeding, and malnutrition. Optimizing these factors could reduce the risk of osteopenia and osteoporosis and attain a significant improvement of quality of life in children with quadriplegic CP.

Esophageal eosinophilia in pediatric patients with cerebral palsy

Objective:

To describe the clinical picture, test results, and clinical evolution of patients with cerebral palsy associated with diagnosis of eosinophilic esophagitis, monitored at tertiary centre.

Methods:

Cross-sectional, retrospective and descriptive study that evaluated the medical records data of pediatric patients with diagnosis of cerebral palsy and eosinophilic esophagitis in a tertiary center of pediatric gastroenterology between August 2005 and August 2013.

Results:

Seven out of 131 patients with cerebral palsy had the diagnosis of eosinophilic esophagitis. The mean age at diagnosis of eosinophilic esophagitis was 52.3 months and the mean number of eosinophils in esophagus was 35 per high-power field. Symptoms more frequent were recurrent vomiting and disphagia. Endoscopic alterations found were mucosal thickening, vertical lines, mucosal opacificacion and white plaques.

Conclusion:

The frequency of eosinophilic esophagitis found was higher than in general pediatric population. The investigation of eosinophilic esophagitis should be done regularly in those patients, once this entity could overlap other gastrointestinal diseases.