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Nutritional, Gastrointestinal and Endo-Metabolic Challenges in the Management of Children with Spinal Muscular Atrophy Type 1. Nutrients 2021; 13:nu13072400. [PMID: 34371910 PMCID: PMC8308588 DOI: 10.3390/nu13072400] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/08/2021] [Accepted: 07/10/2021] [Indexed: 12/18/2022] Open
Abstract
The management of patients with spinal muscular atrophy type 1 (SMA1) is constantly evolving. In just a few decades, the medical approach has switched from an exclusively palliative therapy to a targeted therapy, transforming the natural history of the disease, improving survival time and quality of life and creating new challenges and goals. Many nutritional problems, gastrointestinal disorders and metabolic and endocrine alterations are commonly identified in patients affected by SMA1 during childhood and adolescence. For this reason, a proper pediatric multidisciplinary approach is then required in the clinical care of these patients, with a specific focus on the prevention of most common complications. The purpose of this narrative review is to provide the clinician with a practical and usable tool about SMA1 patients care, through a comprehensive insight into the nutritional, gastroenterological, metabolic and endocrine management of SMA1. Considering the possible horizons opened thanks to new therapeutic frontiers, a nutritional and endo-metabolic surveillance is a crucial element to be considered for a proper clinical care of these patients.
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Stewart E, Prayle AP, Tooke A, Pasalodos S, Suri M, Bush A, Bhatt JM. Growth and nutrition in children with ataxia telangiectasia. Arch Dis Child 2016; 101:1137-1141. [PMID: 27573920 DOI: 10.1136/archdischild-2015-310373] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 08/05/2016] [Accepted: 08/09/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Ataxia telangiectasia (A-T) is a rare multisystem disease with high early mortality from lung disease and cancer. Nutritional failure adversely impacts outcomes in many respiratory diseases. Several factors influence nutrition in children with A-T. We hypothesised that children with A-T have progressive growth failure and that early gastrostomy tube feeding (percutaneous endoscopic gastrostomy, PEG) is a favourable management option with good nutritional outcomes. METHODS Data were collected prospectively on weight, height and body mass index (BMI) at the national paediatric A-T clinic. Adequacy and safety of oral intake was assessed. Nutritional advice was given at each multidisciplinary review. RESULTS 101 children (51 girls) had 222 measurements (32 once, 32 twice, 24 thrice) between 2009 and 2016. Median (IQR) age was 9.3 (6.4 to 13.1) years. Mean (SD) weight, height and BMI Z-scores were respectively -1 (1.6), -1.2 (1.2) and -0.4 (1.4). 35/101 children had weight Z-scores below -2 on at least one occasion. Weight, height and BMI Z-scores declined over time. Decline was most obvious after 8 years of age. 14/101 (14%) children had a PEG, with longitudinal data available for 12. In a nested case control study, there was a trend for improvement in weight in those with a PEG (p=0.10). CONCLUSIONS Patients with A-T decline in growth over time. There is an urgent need for new strategies, including an understanding of why growth falters. We suggest early proactive consideration of PEG from age 8 years onwards to prevent progressive growth failure.
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Affiliation(s)
- Emma Stewart
- Nottingham Children's Hospital, National Paediatric Ataxia Telangiectasia Clinic, QMC, Nottingham, UK
| | - Andrew P Prayle
- University of Nottingham, School of Clinical Science, Queens Medical Centre, Child Health, Nottingham, UK
| | - Alison Tooke
- Nottingham Children's Hospital, National Paediatric Ataxia Telangiectasia Clinic, QMC, Nottingham, UK
| | - Sara Pasalodos
- Nottingham Clinical Genetics Service, National Paediatric Ataxia Telangiectasia Clinic, Clinical Genetics Service, City Hospital Campus, Nottingham, UK
| | - Mohnish Suri
- Nottingham Clinical Genetics Service, National Paediatric Ataxia Telangiectasia Clinic, Clinical Genetics Service, City Hospital Campus, Nottingham, UK
| | - Andy Bush
- Imperial College, London, UK.,National Heart and Lung Institute, London, UK.,Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Jayesh M Bhatt
- Nottingham Children's Hospital, National Paediatric Ataxia Telangiectasia Clinic, QMC, Nottingham, UK
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Kapadia MZ, Joachim KC, Balasingham C, Cohen E, Mahant S, Nelson K, Maguire JL, Guttmann A, Offringa M. A Core Outcome Set for Children With Feeding Tubes and Neurologic Impairment: A Systematic Review. Pediatrics 2016; 138:peds.2015-3967. [PMID: 27365302 DOI: 10.1542/peds.2015-3967] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2016] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Mufiza Z Kapadia
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences,
| | - Kariym C Joachim
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences
| | - Chrinna Balasingham
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences
| | - Eyal Cohen
- Division of Paediatric Medicine, Paediatrics Outcomes Research Team, and Institute of Health Policy, Management and Evaluation, and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada; and
| | - Sanjay Mahant
- Division of Paediatric Medicine, Paediatrics Outcomes Research Team, and Institute of Health Policy, Management and Evaluation, and CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada; and
| | - Katherine Nelson
- Division of Paediatric Medicine, Institute of Health Policy, Management and Evaluation, and Paediatric Advanced Care Team, Department of Paediatrics, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Jonathon L Maguire
- Division of Paediatric Medicine, Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, and Department of Paediatrics, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Division of Paediatric Medicine, Paediatrics Outcomes Research Team, and Institute of Health Policy, Management and Evaluation, and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Martin Offringa
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences
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Describing nutrition in spinal muscular atrophy: A systematic review. Neuromuscul Disord 2016; 26:395-404. [PMID: 27241822 DOI: 10.1016/j.nmd.2016.05.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 05/06/2016] [Accepted: 05/06/2016] [Indexed: 01/27/2023]
Abstract
Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disease of variable severity. Progressive muscle wasting and impairment in functional ability in SMA have a profound influence on nutritional outcomes. This systematic review summarises the existing evidence on nutrition in SMA. The search strategy was conducted across five databases in August 2014, and updated in March 2016, using key terms relating to growth, nutrition requirements, dietary intake and nutrition management. Studies were selected for inclusion using a two pass method, and data systematically extracted using standardised forms. Thirty-nine studies met eligibility criteria. Body composition is abnormal in patients with SMA, and feeding and swallowing issues are prevalent among sufferers of SMA types I and II. Nutritional management practices vary internationally. There is a paucity of literature regarding nutrition requirements in SMA, although it appears that energy expenditure may be reduced. Children with SMA require individualised nutritional management in order to address their growth and nutrition requirements. There is an urgent need for larger, coordinated, prospective intervention studies of nutrition in SMA.
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Bhatt JM, Bush A, van Gerven M, Nissenkorn A, Renke M, Yarlett L, Taylor M, Tonia T, Warris A, Zielen S, Zinna S, Merkus PJFM. ERS statement on the multidisciplinary respiratory management of ataxia telangiectasia. Eur Respir Rev 2015; 24:565-81. [PMID: 26621971 PMCID: PMC9487625 DOI: 10.1183/16000617.0066-2015] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/08/2015] [Indexed: 11/05/2022] Open
Abstract
Ataxia telangiectasia (A-T) is a rare, progressive, multisystem disease that has a large number of complex and diverse manifestations which vary with age. Patients with A-T die prematurely with the leading causes of death being respiratory diseases and cancer. Respiratory manifestations include immune dysfunction leading to recurrent upper and lower respiratory infections; aspiration resulting from dysfunctional swallowing due to neurodegenerative deficits; inefficient cough; and interstitial lung disease/pulmonary fibrosis. Malnutrition is a significant comorbidity. The increased radiosensitivity and increased risk of cancer should be borne in mind when requesting radiological investigations. Aggressive proactive monitoring and treatment of these various aspects of lung disease under multidisciplinary expertise in the experience of national multidisciplinary clinics internationally forms the basis of this statement on the management of lung disease in A-T. Neurological management is outwith the scope of this document.
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Affiliation(s)
- Jayesh M Bhatt
- Nottingham Children's Hospital, UK Paediatric National Clinic, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Bush
- Imperial College and Royal Brompton Hospital, London, UK
| | - Marjo van Gerven
- Dept of Paediatrics, Division of Respiratory Medicine, Amalia Children's Hospital Radboud, University Medical Centre, Nijmegen, The Netherlands
| | - Andreea Nissenkorn
- Rare Diseases Service and Pediatric Neurology Unit, Edmond and Lilly Safra Pediatric Hospital, Sheba Medical Center, Tel HaShomer, Israel Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Renke
- Dept of Allergology, Pneumology and Cystic Fibrosis, Children's Hospital, Goethe-University Theodor-Stern Kai, Frankfurt/Main, Germany
| | | | - Malcolm Taylor
- School of Cancer Sciences, University of Birmingham, Birmingham, UK
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Adilia Warris
- Institute of Medical Sciences, University of Aberdeen and the Royal Aberdeen Children's Hospital, Aberdeen, UK
| | - Stefan Zielen
- Dept of Allergology, Pneumology and Cystic Fibrosis, Children's Hospital, Goethe-University Theodor-Stern Kai, Frankfurt/Main, Germany
| | - Shairbanu Zinna
- Nottingham Children's Hospital, UK Paediatric National Clinic, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Peter J F M Merkus
- Dept of Paediatrics, Division of Respiratory Medicine, Amalia Children's Hospital Radboud, University Medical Centre, Nijmegen, The Netherlands
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Chatwin M, Bush A, Macrae DJ, Clarke SA, Simonds AK. Risk management protocol for gastrostomy and jejunostomy insertion in ventilator dependent infants. Neuromuscul Disord 2013; 23:289-97. [PMID: 23465657 DOI: 10.1016/j.nmd.2013.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 01/06/2013] [Accepted: 01/09/2013] [Indexed: 12/01/2022]
Abstract
Gastrostomy, gastrojejunostomy and anti-reflux surgery in infants and children who are chronically ventilator dependent are associated with significant risk of morbidity and mortality. We report outcomes of 22 high risk children who underwent these procedures at our centre. Pre-operative investigations included: overnight oxygen and carbon dioxide monitoring and subsequent optimisation of ventilatory support, echocardiography, video fluoroscopy, and assessment of gastroesophageal reflux. We carried out 24 procedures under general anaesthesia. Twenty-one children used ventilatory support pre-operatively. Median age of first surgical procedure was 18 months (range 3-180). Supplementary feeding was commenced in 20 children prior to procedure, median age 9 months (1-31). Median PICU length of stay was 1 (1-8) days. No children died in the post-operative period. Extubation was possible within 24h in 87% of cases. Complications included; atelectasis (n=2), ileus (n=2), abdominal distension (n=4) and loose stools (n=1). We conclude that, in this high risk cohort of ventilator dependent children with predominantly neuromuscular disorders, with careful assessment, operative intervention can be carried out under general anaesthesia, with the child being extubated early back onto their routine ventilatory support and aggressive airway clearance. Additionally this protocol can minimise post-operative complications and is associated with a good outcome in the majority.
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Affiliation(s)
- M Chatwin
- Clinical and Academic Department of Sleep and Breathing, Royal Brompton & Harefield NHS Foundation Trust, United Kingdom.
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Poruk KE, Davis RH, Smart AL, Chisum BS, LaSalle BA, Chan GM, Gill G, Reyna SP, Swoboda KJ. Observational study of caloric and nutrient intake, bone density, and body composition in infants and children with spinal muscular atrophy type I. Neuromuscul Disord 2012; 22:966-73. [PMID: 22832342 PMCID: PMC3484247 DOI: 10.1016/j.nmd.2012.04.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 04/18/2012] [Accepted: 04/23/2012] [Indexed: 11/19/2022]
Abstract
Clinical experience supports a critical role for nutrition in patients with spinal muscular atrophy (SMA). Three-day dietary intake records were analyzed for 156 visits in 47 SMA type I patients, 25 males and 22 females, ages 1month to 13years (median 9.8months) and compared to dietary reference intakes for gender and age along with anthropometric measures and dual-energy X-ray absorptiometry (DEXA) data. Using standardized growth curves, twelve patients met criteria for failure to thrive (FTT) with weight for age <3rd percentile; eight met criteria based on weight for height. Percentage of body fat mass was not correlated with weight for height and weight for age across percentile categories. DEXA analysis further demonstrated that SMA type I children have higher fat mass and lower fat free mass than healthy peers (p<0.001). DEXA and dietary analysis indicates a strong correlation with magnesium intake and bone mineral density (r=0.65, p<0.001). Average caloric intake for 1-3years old was 68.8±15.8kcal/kg - 67% of peers' recommended intake. Children with SMA type I may have lower caloric requirements than healthy age-matched peers, increasing risk for over and undernourished states and deficiencies of critical nutrients. Standardized growth charts may overestimate FTT status in SMA type I.
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Affiliation(s)
- Katherine E Poruk
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Rebecca Hurst Davis
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Abby L Smart
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Benjamin S Chisum
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Bernie A LaSalle
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Gary M Chan
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Gurmail Gill
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Sandra P Reyna
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Kathryn J Swoboda
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Durkin ET, Schroth MK, Helin M, Shaaban AF. Early laparoscopic fundoplication and gastrostomy in infants with spinal muscular atrophy type I. J Pediatr Surg 2008; 43:2031-7. [PMID: 18970936 DOI: 10.1016/j.jpedsurg.2008.05.035] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Revised: 05/05/2008] [Accepted: 05/21/2008] [Indexed: 11/30/2022]
Abstract
BACKGROUND/PURPOSE Spinal muscular atrophy (SMA) in children leads to progressive muscle weakness, dysphagia, aspiration, and death. We hypothesized that early laparoscopic fundoplication and gastrostomy in infants with SMA type I could be performed safely perhaps leading to fewer aspiration events and improved nutritional status. METHODS Children diagnosed with SMA type I from 2002 through 2005 were included (n = 12). All children underwent laparoscopic Nissen fundoplication with gastrostomy shortly after diagnosis. Postoperative respiratory management and discharge criteria were standardized. RESULTS All patients were extubated immediately postoperatively. There were no significant complications. Average time to full feeding and inpatient length of stay were 42 +/- 4.9 hours (range, 30-48 hours) and 78 +/- 22.5 hours (range, 44-120 hours), respectively. Mean weight-for-length percentile was doubled at 1 year postoperatively (P = .03). The number of respiratory-related hospitalizations in the cohort decreased by almost 50% in the ensuing 12 months after surgery, although this did not reach statistical significance in this small cohort (P = .34). CONCLUSIONS Early laparoscopic fundoplication and gastrostomy is safe and is associated with improved nutritional status. A trend toward fewer significant long-term aspiration-related events was seen after fundoplication. To better assess the long-term benefits of performing an antireflux procedure in these high-risk patients, a larger prospective trial comparing current nutritional support practices is needed.
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Affiliation(s)
- Emily T Durkin
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792-7375, USA
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