Clinical Nutrition ESPEN 11 (2016) e67ee69
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Metabolic disturbances in patients with cerebral palsy and gastrointestinal disorders Catalina Jaramillo a, Abiodun Johnson b, Ruchi Singh c, Tetyana L. Vasylyeva d, * a
Pediatric Resident (PGY-3), Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, USA Pediatric Gastroenterology, Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, USA c Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, USA d Pediatric Nephrology, Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, USA b
a r t i c l e i n f o
s u m m a r y
Article history: Received 25 March 2015 Accepted 12 August 2015
Under nutrition and growth failure are common ﬁndings in children with cerebral palsy (CP) and neurologically impairments. Electrolyte and micronutrient abnormalities have also been documented. Gastrointestinal (GI) diseases like gastro esophageal reﬂux disease (GERD), feeding difﬁculties and constipation have been associated with increased frequency of these derangements. The goal of this study was to determine the prevalence of malnutrition, metabolic and electrolyte abnormalities in pediatric patients with cerebral palsy and gastrointestinal disorders. A retrospective review of 172 medical records was performed out of which 45 subjects did not have any GI problem, 69 patients had constipation and 58 patients either had GERD, esophagitis, gastrostomy and feeding difﬁculties. Data collected included: weight, length and body mass index, pre-albumin, albumin, vitamin D, potassium, chloride, bicarbonate, calcium, magnesium (Mg), phosphorus. The results demonstrate a signiﬁcant difference (p ¼ 0.0126) in the values of albumin in children with CP with GI disorders vs. those without. Additionally, a signiﬁcant difference (p ¼ 0.0129) was found in Mg levels between CP children with constipation vs. GERD/esophagitis/feeding issues/gastrostomy. Results suggest that children with CP and GI disorders have decreased levels of albumin, but normal pre-albumin. The mechanism for this is not completely clear and although we acknowledge importance of nutritional intake for albumin level support, other mechanisms such as low grade chronic inﬂammation and increased gut and vascular permeability may play a role. The lower levels of Mg in children with CP and constipation could be secondary to the use of laxatives. Further prospective studies looking at nutritional protein intake, gut and vascular permeability and laxative use in this patient population are important for future optimization of health care management. © 2015 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.
Keywords: Cerebral Palsy Malnutrition Gastrointestinal disorders Albumin Magnesium
1. Introduction Under nutrition and growth failure are common ﬁndings in children with cerebral palsy (CP) and neurological impairments . As a group, children with CP are smaller and poorly nourished compared with their typically developing peers . These differences between affected and non-affected children are more noticeable with increasing age and severity of motor impairment
* Corresponding author. Department of Pediatrics, Nephrology Section, Texas Tech University Health Sciences Center, 1400 South Coulter Street, Amarillo, TX 79106, USA. E-mail address: [email protected]
. The most signiﬁcant factor affecting the nutritional status of children with CP is inadequate intake to meet metabolic demands . In addition, gastrointestinal (GI) diseases like gastroesophageal reﬂux disease (GERD) and constipation have been associated with increased frequency of these derangements. Under nutrition and growth failure in neurologically impaired children seem to be related to inappropriate caloric intake, altered nutrient needs, inability to self-feed and oral motor dysfunction. Up to one-third of pediatric patients have associated growth disorder and nutritional deﬁcits . Additionally, malnutrition affects quality of life and is associated with increased health care use. Although in the past under nutrition was considered as a natural spectrum of disease of neurologically impaired children, it is now recognized that adequate nutrition in these patients is essential .
http://dx.doi.org/10.1016/j.clnesp.2015.08.003 2405-4577/© 2015 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.
C. Jaramillo et al. / Clinical Nutrition ESPEN 11 (2016) e67ee69
Electrolyte and micronutrient deﬁciencies are also documented in children with cerebral palsy. Iron, zinc, essential fatty acids and vitamins C, D and E were reported to be deﬁcient in 15e50% of these children. Dietary calcium, vitamin D and phosphorus intakes are below the Daily Reference Intake in 50e80% of these children . In a cross-sectional observational study performed to assess the adequacy of sodium, potassium, phosphorus and ﬂuid intakes in children with cerebral palsy, it was shown that 60% of children were sodium deﬁcient . There were no deﬁciencies in potassium and only one child in the study was considered to have possible inadequate phosphorus intake . The goal of this study was to determine whether GI disorders complicated CP impact children's development and metabolic status.
2. Materials and methods The charts of patients with CP followed in the specialized pediatric clinic, at Texas Tech University Health Science Center (TTUHSC, Amarillo) were retrospectively reviewed after IRB approval. TTUHSC clinic for special need children has three designated providers for CP patients, who followed standardized nutritional protocols and evaluated growth parameters with every visit. CP patients with and without GI disorder received the same or similar professional care. Patients were followed at least every three months with close attention to nutrition and growth. In general, younger children with gastrostomy tubes were on PediaSure® or if growth delay was noticed, on PediaSure® 1.5 Cal (AbbottNutrition). Older children with gastrostomy tubes were on Ensure® (AbbottNutrition), Peptamen Junior®/Peptamen Junior® Health Sciences), or Jevity®/Jevity® 1.2 Cal/Jevity® 1.5 Cal 1.5 (Nestle (AbbottNutrition). Formula preferences and caloric supplements were individually determined by clinical and social (availability, insurance coverage preferences) factors. Patients with adequate growth, who were able tolerate oral feeding were prescribed diet appropriate for age; if the growth curve plateaued or declined, they received additional caloric supplements. A total of the 268 medical records of pediatric patients under 18 years of age with diagnosis of neurologic impairments were reviewed. Ninety-six patients were excluded due to either absence of CP or insufﬁcient data. Demographic data collected included weight in percentile (%p), length (%p) and body mass index (BMI, % p) (Table 1). The most resent laboratory data from were collected: pre-albumin, albumin, sodium (Na), potassium (K), chloride (Cl), bicarbonate (HCO3), calcium (Ca), magnesium (Mg), phosphorus (Phos) and vitamin D (Table 2).
Table 1 Demographics and gastrointestinal (GI) problems in children with cerebral palsy.
Mean age (years) Weight (%p) Length/height (%p) BMI (%p) Gender (n) Male Female GI problems Constipation (n) GERD (n) Esophagitis (n) Gastrostomy (n) Feeding difﬁculties (n)
No GI disorder
9.01 ± 0.36 31 ± 2.8 25.3 ± 2.7 43.6 ± 3.1
9.51 32.9 34.9 35.6
69 24 11 43 13
e e e e e
e e e e e
± ± ± ±
0.74 4.9 4.5 4.9
p Value 0.19NS 0.60NS 0.12NS 0.19NS
Age, weight, length/height and BMI data is represented as Mean ± SEM; n ¼ total number; % p, percentile value; GI, gastrointestinal; GERD, gastro esophageal reﬂux disorder; NS, no signiﬁcant.
Table 2 Lab chemistries of patients with Cerebral Palsy. Lab chemistries
Na (mM/L) K (mM/L) Cl (mM/L) HCO3 (mM/L) Ca (mg/dL) Mg (mg/dL) Phos (mg/dL) Vit D (mg/dL) Albumin (mg/dL) Pre-albumin (mg/dL)
138.7 4 116.4 24.4 9.6 2.1 4.7 40.4 3.9 19
± ± ± ± ± ± ± ± ± ±
0.4 0.1 13.6 0.4 0.05 0.03 0.1 2.9 0.05 0.9
No GI disorder
± ± ± ± ± ± ± ± ± ±
0.85 0.34 0.2 0.98 0.66 0.15 0.79 0.09 0.0126* 0.57
138.6 4.2 105.4 23.5 9.6 2.1 5.1 33 4.1 18.4
0.5 0.1 0.5 0.4 0.1 0.06 0.2 2.7 0.06 1
Na; Sodium, K; Potassium, Cl; Chloride, HCO3; bicarbonate, Ca; calcium, Mg; magnesium, Phos; phosphorus, Vit D; Vitamin D, mM/L; millimolar/liter, mg/dL; milligram/deciliter. Data is represented as Mean ± SEM. *Statistical signiﬁcance p ¼