Cerebral palsy (CP) is a non-progressive disorder of posture, tone, and/or movement that results from a static insult to the developing brain. It is a disorder of posture and movement, typically associated with epilepsy, speech, vision, and cognitive dysfunction. CP is caused by brain damage that occurs before birth or during a baby’s birth or up until the age of five years. Damage to the brain by lack of oxygen, trauma, or infection are etiological factors associated with CP.
We need to understand the physiological classification of CP to understand the energy needs of the patient. There are four types of CP:
- Spastic CP: The most common type of CP and accounts for 70–80% of cases. It causes muscle tightness and movement difficulties.
- Athetoid CP: This type of CP accounts for 10% of the cases. It mainly involves purposeless and uncontrolled movements that increase energy expenditure.
- Ataxic CP: It results in loss of muscle coordination and accounts for 5–10% of the cases.
- Mixed CP: It results in muscle stiffness and involuntary movements (5–10%).
Medical problems associated with CP
The nutritional status of a neurologically impaired (NI) child is influenced by medical problems associated with the disorder. Nutritional therapy must be modified to reduce the complications associated with these medical problems.
- Gastroesophageal reflux disorder (GERD). This refers to the backflow of contents of the stomach towards the mouth. It is a common problem that affects 50-70% of neurologically impaired children. It is mainly caused by low muscle tone and abdominal spasticity. Reflux is also caused by the improper positioning of the child during feeding, as most of them cannot sit upright. Aspiration, difficulty swallowing, food refusal, and malnutrition, are the complications of GERD. Irritability in these children is one of the symptoms used for the determination of reflux after feeding. Decreasing food volume and using a high-calorie formula to fulfil the nutritional requirement must be the part of nutritional therapy to prevent refluxes.
- Constipation. This develops when the stool becomes hard and difficult to pass. Immobility, weak muscle tone, excessive fluid loss from reflux or drooling, or medications, are causal factors of constipation. Gradually increasing insoluble fibre in the diet will relieve constipation. Insoluble fibre forms bulk and results in large stools, which will be difficult to push due to poor muscle tone. Loading with fibres delays gastric emptying and could result in severe refluxes. These things must be kept in mind while introducing fibre to this population.
- Spasticity. This is caused by damage to the part of the brain and spinal cord that controls muscle movement. Spasticity increases energy expenditure, which causes malnutrition in neurologically impaired children.
- Sialorrhea. This is referred to as excessive salivation or drooling. It is mainly caused by poor oral muscular control. This causes dehydration in children.
Nutritional problems in children with CP
Malnutrition. There are a number of factors are responsible for malnutrition in NI children.
- Inadequate food intake due to oral-motor dysfunction, poor hand-mouth coordination, poor lip closure, and reliance on the caregiver for feeding.
- Increased energy expenditure in case of spastic and athetoid CP.
- Digestive issues such as reflux and constipation.
Short stature. Epilepsy medication affects vitamin D and calcium metabolism. This affects bone growth and the linear growth of the child. Resolving malnutrition does not necessarily improve linear growth in these kids. More severe the disease, the more severe will be growth problem.
Dehydration. Drooling causes excessive loss of water and electrolytes from the body and results in dehydration. This is one of the causal factors for constipation in these children.
Osteopenia. Osteopenia is referred to as low bone density. Poor nutritional status; medications; various endocrine factors such as hypothalamic dysfunction, growth hormone or thyroid issues; ineffective metabolism of calcium and vitamin D; inadequate sun exposure; prolonged immobilization; and prematurity, are the risk factors for osteopenia.
Overnutrition. Overnutrition is also one of the nutritional problems in children with CP. Decreased physical activity, lower caloric requirements, and lack of nutrition monitoring, are some of the factors responsible for overnutrition.
Nutrient requirements of children with CP
- Energy. Energy requirements in children with CP depends on energy expenditure. Factors that affect energy expenditure include age, brain activity, body composition, physical activity, and muscle tone. There are various equations available to calculate the energy requirements in these children, however, these equations tend to overestimate the energy expenditure of children with CP.
- Protein. Protein is essential for the proper growth and development of the child. The protein requirement in children with CP is the same as normal children.
- Fat. Fats that are easily digested must be included in the feed. Essential fatty acids must be supplemented to ensure proper growth and maintenance of body functions.
- Fluid. The intake of fluid needs to be monitored in the children with CP. Both excess and less fluid intake are harmful to the child. Excess intake may result in refluxes and lower intake may cause dehydration.
- Micronutrients. The vitamin and mineral requirement of the children with CP is the same as normal children. It is important to look at the symptoms of micronutrient deficiency in the child. Multivitamin supplementation with minerals should be administered to complement the dietary intake.
It is important to develop a nutrition plan to optimise the growth and development of a child with CP. Monitoring the effectiveness of the developed plan is equally important for adequate nutritional support for children. There are ways to make eating a more pleasant experience for children with CP a more pleasant experience.
Image credit: Freepik
Nidhi Joshi is a PhD student in Human Nutrition within the Department of Food and Nutrition at G.B. Pant University of Agriculture & Technology in India.