Feeding disorders in the Child with Cerebral Palsy Dr Owen Hensey Central Remedial Clinic Dublin
Environment Behaviour Physical Factors influencing feeding
Normal swallow Trachea Epiglottis Pharynx Bolus Epiglottis
Normal swallow Trachea Epiglottis Pharynx Bolus Epiglottis
Neurological coordination
Normal Gastrointestinal Tract Anatomy
Growth and Health in Children with Moderate to Severe Cerebral Palsy <ul><li>GMFCS III, IV and V </li></ul>Richard D S...
Weight Centiles
Cause of Inadequate Nutritional Intake <ul><li>Inability to self feed </li></ul><ul><li>Increased length of time taken to ...
Clinical consequences of nutritional deficiencies <ul><li>Mild to severe undernutrition </li></ul><ul><li>Poor growth </li...
Osteoporosis/rickets <ul><li>Risk factors: </li></ul><ul><li>Low vitamin D </li></ul><ul><li>Immobility (GMFC level) </li>...
Longer Term Consequences of Feeding Disorders <ul><li>Gastrooesophageal reflux </li></ul><ul><li>Aspiration </li></ul><ul...
Normal Stomach
Gastro-oesophageal reflux acid reflux diaphragm oesophagus lower oesophageal sphincter stomach
Reflux in Cerebral Palsy <ul><li>Chronic recumbent posture </li></ul><ul><li>Increased muscle tone </li></ul><ul><li>Oral ...
Symptoms of Gastrooesophageal Reflux <ul><li>Vomiting </li></ul><ul><li>Abdominal pain/colic </li></ul><ul><li>Reluctance ...
Effects of Gastrooesophageal Reflux <ul><li>Anaemia due to bleeding </li></ul><ul><li>Food refusal </li></ul><ul><li>Failu...
Aspiration Pneumonia
Bronchiectasis
Clinical suspicion of aspiration: <ul><li>Recurrent respiratory infections </li></ul><ul><li>Coughing during feeds </li></...
Diagnosis of feeding disorders <ul><li>Clinical history </li></ul><ul><li>Barium swallow </li></ul><ul><li>pH studies </li...
Barium Swallow
Effects of Gastrooesophageal Reflux on Oesophagus <ul><li>Oesophagitis </li></ul><ul><li>Stricture </li></ul><ul><li>Her...
Oesophageal Stricture
pH studies Normal Severe reflux (pH<4)
Indications for a feeding study <ul><li>Clinical suspicion of aspiration </li></ul><ul><li>Prolonged feeding time </li></u...
Abnormal findings <ul><li>Preoral - extensor spasm as food approaches mouth </li></ul><ul><li>Oral - abnormalities of...
Aspiration <ul><li>Before during or after swallow ? </li></ul><ul><li>Cough ? </li></ul><ul><li>Cleared ? </li></ul><ul><l...
Useful Findings <ul><ul><li>Aspiration excluded: </li></ul></ul><ul><ul><li>allows resumption / continuation of feeding <...
Other Useful Findings <ul><li>No suck ability – needs tube/PEG feed </li></ul><ul><li>Swallows best when food put further...
Medical management of feeding disorders
Management of Gastrooesophageal Reflux <ul><li>Conservative: </li></ul><ul><li>Eliminate constipation </li></ul><ul><li>Po...
Management of Gastrooesophageal Reflux <ul><li>Medical: </li></ul><ul><li>Thickening agents </li></ul><ul><li>Gaviscon </l...
Management of Gastrooesophageal Reflux/ Aspiration <ul><li>Medical: </li></ul><ul><li>Nasogastric tube </li></ul><ul><li>...
NG tube feeding <ul><li>Sucking partly a learned response </li></ul><ul><li>NG tube further reduces function </li></ul><ul...
PEG tube
Mickey button
Mickey button
Nissan fundoplication
Nissen fundoplication <ul><li>Efficacy: </li></ul><ul><li>90% success in stopping GOR </li></ul><ul><li>? stops respirator...
Nissen fundoplication <ul><li>Complications: </li></ul><ul><li>15% perioperative or surgery failure </li></ul><ul><li>Post...
Jejunal Feeding Naso-Jejunal Tube Gastro-Jejunal Tube
Gastrostomy tube feeding in children with cerebral palsy: a prospective, constitutional study <ul><li>Sullivan P. et al, D...
<ul><li>Oxford/Manchester/Watford </li></ul><ul><li>57 children with CP </li></ul><ul><li>Median age 4.33yrs </li></ul><u...
Results <ul><li>Weight and subcutaneous fat deposition increased significantly over study period </li></ul><ul><li>Almost ...
Complications <ul><li>Complication % </li></ul><ul><li>Minor site infection 59 </li></ul><ul><li>Granulation tissue 42 </l...
Quality of life of carers <ul><li>6 months: </li></ul><ul><li>Mental health </li></ul><ul><li>Role limitation due to emoti...
Improved survival Respiratory care Gastrostomy feeding Epilepsy control Improved nutrition Immunization Improved social an...
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Ponència Owen Hensey - Desordres a l'alimentació del pc

Published on: Mar 4, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Ponència Owen Hensey - Desordres a l'alimentació del pc

  • 1. Feeding disorders in the Child with Cerebral Palsy Dr Owen Hensey Central Remedial Clinic Dublin
  • 2. Environment Behaviour Physical Factors influencing feeding
  • 3. Normal swallow Trachea Epiglottis Pharynx Bolus Epiglottis
  • 4. Normal swallow Trachea Epiglottis Pharynx Bolus Epiglottis
  • 5. Neurological coordination
  • 6. Normal Gastrointestinal Tract Anatomy
  • 7. Growth and Health in Children with Moderate to Severe Cerebral Palsy <ul><li>GMFCS III, IV and V </li></ul>Richard D Stevenson et al, Pediatrics 2006;118:1010
  • 8. Weight Centiles
  • 9. Cause of Inadequate Nutritional Intake <ul><li>Inability to self feed </li></ul><ul><li>Increased length of time taken to feed </li></ul><ul><li>Poor fluid intake </li></ul><ul><li>Inability to communicate </li></ul><ul><li>Inability to forage </li></ul><ul><li>Increased calorie use in dyskinetic cerebral palsy </li></ul>
  • 10. Clinical consequences of nutritional deficiencies <ul><li>Mild to severe undernutrition </li></ul><ul><li>Poor growth </li></ul><ul><li>Functional immune deficiency </li></ul><ul><li>Behavioural/learning effects </li></ul><ul><li>Quality of life </li></ul><ul><li>Survival </li></ul><ul><li>Osteoporosis/ rickets </li></ul>
  • 11. Osteoporosis/rickets <ul><li>Risk factors: </li></ul><ul><li>Low vitamin D </li></ul><ul><li>Immobility (GMFC level) </li></ul><ul><li>Altered muscle tone </li></ul><ul><li>Low sun exposure </li></ul><ul><li>Anti convulsants </li></ul>
  • 12. Longer Term Consequences of Feeding Disorders <ul><li>Gastrooesophageal reflux </li></ul><ul><li>Aspiration </li></ul><ul><li>Unsafe to orally feed </li></ul>
  • 13. Normal Stomach
  • 14. Gastro-oesophageal reflux acid reflux diaphragm oesophagus lower oesophageal sphincter stomach
  • 15. Reflux in Cerebral Palsy <ul><li>Chronic recumbent posture </li></ul><ul><li>Increased muscle tone </li></ul><ul><li>Oral motor dysfunction </li></ul><ul><li>Delayed gastric emptying </li></ul><ul><li>Musculoskeletal deformity </li></ul><ul><li>Constipation </li></ul><ul><li>Behavioural </li></ul><ul><li>20-30% of developmentally disabled children have reflux </li></ul>
  • 16. Symptoms of Gastrooesophageal Reflux <ul><li>Vomiting </li></ul><ul><li>Abdominal pain/colic </li></ul><ul><li>Reluctance to feed </li></ul><ul><li>Poor sleeping habits </li></ul><ul><li>Respiratory complaints </li></ul>
  • 17. Effects of Gastrooesophageal Reflux <ul><li>Anaemia due to bleeding </li></ul><ul><li>Food refusal </li></ul><ul><li>Failure to thrive </li></ul><ul><li>Poor sleep pattern </li></ul><ul><li>Abnormal posturing </li></ul><ul><li>(Sandifer syndrome) </li></ul><ul><li>Parental anxiety </li></ul><ul><li>Aspiration with respiratory infection </li></ul>
  • 18. Aspiration Pneumonia
  • 19. Bronchiectasis
  • 20. Clinical suspicion of aspiration: <ul><li>Recurrent respiratory infections </li></ul><ul><li>Coughing during feeds </li></ul><ul><li>Apnoeic spells during feeds </li></ul>
  • 21. Diagnosis of feeding disorders <ul><li>Clinical history </li></ul><ul><li>Barium swallow </li></ul><ul><li>pH studies </li></ul><ul><li>Endoscopy and biopsy </li></ul><ul><li>Feeding studies </li></ul>
  • 22. Barium Swallow
  • 23. Effects of Gastrooesophageal Reflux on Oesophagus <ul><li>Oesophagitis </li></ul><ul><li>Stricture </li></ul><ul><li>Hernia </li></ul>
  • 24. Oesophageal Stricture
  • 25. pH studies Normal Severe reflux (pH<4)
  • 26. Indications for a feeding study <ul><li>Clinical suspicion of aspiration </li></ul><ul><li>Prolonged feeding time </li></ul><ul><li>Inability to cope with solids or lumpy foods </li></ul><ul><li>Difficulties with bottle feeding </li></ul>
  • 27. Abnormal findings <ul><li>Preoral - extensor spasm as food approaches mouth </li></ul><ul><li>Oral - abnormalities of lip closure </li></ul><ul><li>Tongue - abnormal tongue movement </li></ul><ul><li>Pharyngeal - abnormalities of swallow </li></ul><ul><li>Focus on findings that affect management </li></ul>
  • 28. Aspiration <ul><li>Before during or after swallow ? </li></ul><ul><li>Cough ? </li></ul><ul><li>Cleared ? </li></ul><ul><li>Silent ? </li></ul>
  • 29. Useful Findings <ul><ul><li>Aspiration excluded: </li></ul></ul><ul><ul><li>allows resumption / continuation of feeding </li></ul></ul><ul><ul><li>improves confidence of parents/carers </li></ul></ul><ul><ul><li>Aspiration present: </li></ul></ul><ul><ul><li>consider gastrostomy </li></ul></ul>
  • 30. Other Useful Findings <ul><li>No suck ability – needs tube/PEG feed </li></ul><ul><li>Swallows best when food put further in mouth – adjust feeding style </li></ul><ul><li>Can only swallow with neck extension </li></ul><ul><li>– adjust feeding posture </li></ul>
  • 31. Medical management of feeding disorders
  • 32. Management of Gastrooesophageal Reflux <ul><li>Conservative: </li></ul><ul><li>Eliminate constipation </li></ul><ul><li>Positioning </li></ul><ul><li>Solid foods </li></ul><ul><li>Thickened fluids </li></ul>
  • 33. Management of Gastrooesophageal Reflux <ul><li>Medical: </li></ul><ul><li>Thickening agents </li></ul><ul><li>Gaviscon </li></ul><ul><li>Erythromycin </li></ul><ul><li>Antacids – Cimetidine(Tagamet) </li></ul><ul><li>Ranitidine(Zantac) </li></ul><ul><li>Omeprazole(Losec) </li></ul><ul><li>Lansoprazole(Zoton) </li></ul><ul><li> </li></ul>
  • 34. Management of Gastrooesophageal Reflux/ Aspiration <ul><li>Medical: </li></ul><ul><li>Nasogastric tube </li></ul><ul><li>Surgical: </li></ul><ul><li>PEG feeding </li></ul><ul><li>Fundoplication </li></ul>
  • 35. NG tube feeding <ul><li>Sucking partly a learned response </li></ul><ul><li>NG tube further reduces function </li></ul><ul><li>Inevitable reflux ± aspiration </li></ul><ul><li>? no longer that 2 months </li></ul>
  • 36. PEG tube
  • 37. Mickey button
  • 38. Mickey button
  • 39. Nissan fundoplication
  • 40. Nissen fundoplication <ul><li>Efficacy: </li></ul><ul><li>90% success in stopping GOR </li></ul><ul><li>? stops respiratory symptoms </li></ul>
  • 41. Nissen fundoplication <ul><li>Complications: </li></ul><ul><li>15% perioperative or surgery failure </li></ul><ul><li>Postoperative retching/burping </li></ul><ul><li>Dumping syndrome (10 – 15%) </li></ul><ul><ul><li>Failure to thrive </li></ul></ul><ul><ul><li>Frequent loose stools </li></ul></ul><ul><ul><li>Postprandial pallor, sweating and lethargy </li></ul></ul><ul><ul><li>Feeding difficulties </li></ul></ul><ul><ul><li>Absolute refusal to feed </li></ul></ul>
  • 42. Jejunal Feeding Naso-Jejunal Tube Gastro-Jejunal Tube
  • 43. Gastrostomy tube feeding in children with cerebral palsy: a prospective, constitutional study <ul><li>Sullivan P. et al, DMCN 2005, 47: 77-85 </li></ul>
  • 44. <ul><li>Oxford/Manchester/Watford </li></ul><ul><li>57 children with CP </li></ul><ul><li>Median age 4.33yrs </li></ul><ul><li>(Range 5mths-17.25yrs) </li></ul><ul><li>Outcome measures: </li></ul><ul><ul><li>Nutritional intake </li></ul></ul><ul><ul><li>General health </li></ul></ul><ul><ul><li>Complications </li></ul></ul><ul><ul><li>Growth/anthropometry </li></ul></ul>
  • 45. Results <ul><li>Weight and subcutaneous fat deposition increased significantly over study period </li></ul><ul><li>Almost all parents reported a significant improvement in their child’s health </li></ul><ul><li>Decreased incidence of respiratory tract infection and hospital admissions </li></ul><ul><li>Decreased feeding time </li></ul><ul><li>Serious complications rare </li></ul>
  • 46. Complications <ul><li>Complication % </li></ul><ul><li>Minor site infection 59 </li></ul><ul><li>Granulation tissue 42 </li></ul><ul><li>Leakage 30 </li></ul><ul><li>Tube blockage 19 </li></ul><ul><li>Tube migration 7 </li></ul><ul><li>Child pulled tube out 4 </li></ul><ul><li>Peritonitis 2 </li></ul>
  • 47. Quality of life of carers <ul><li>6 months: </li></ul><ul><li>Mental health </li></ul><ul><li>Role limitation due to emotional problems </li></ul><ul><li>Physical and social functioning </li></ul><ul><li>Energy/vitality </li></ul><ul><li>12 months: </li></ul><ul><li>Further statistically significant increase in all parameters </li></ul><ul><li>Reduction in feeding time </li></ul><ul><li>Ease of drug administration </li></ul><ul><li>Reduced concern re nutritional status </li></ul>
  • 48. Improved survival Respiratory care Gastrostomy feeding Epilepsy control Improved nutrition Immunization Improved social and living standards

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