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Limited effect of enteral nutrition on growth in a group of children with severe developmental disabilities
Abstract
Objectives. A group of children with severe neurological diseases, on home enteral nutrition, was evaluated to assess the modifications of growth variables during the first year of nutritional intervention. Methods. Nineteen patients were studied. The following variables were recorded at the start (T0) and after 12 months (T12) of enteral nutrition: age, weight and length (z-score), percentage of ideal weight for length, type of enteral feeding, actual and recommended energy intake for age and weight. Results. Median age at the start of enteral nutrition was 7.5 (range 0-16.6) years. At T0, mean (SD) values for weight and length z-score and percent weight for length were -5.7 (5.9), -3.2 (2) and 84% (18) respectively. No significant modifications were noted for weight and length z-score after 12 months of enteral nutrition. At the same time, percent weight for length significantly increased [mean difference (95% CI): 6.9% (0.3; 13.5); p = 0.04] in the group studied. Weight z-score was significantly related (r = -0.73, p < 0.001) with age at T0, while no relationship was observed for length z-score and percent weight for length. Mean (SD) ratio between actual energy intakes and those recommended for age was 0.77 (0.37) at T0 and 0.65 (0.37) at T12. Conclusions. In severely disabled children, enteral nutrition caused limited modifications of growth variables during the first year of nutritional support. Determinants other than malnutrition alone may have a role in growth failure in such patients. Both growth charts and recommended energy intakes for healthy children may be unreliable standards in this clinical context.
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There are few data on the optimal micronutrient composition of paediatric enteral feeds. The recent European Directive on Foods for Special Medical Purposes (1999/21/EC) did not distinguish between the composition of adult and paediatric feeds.
To evaluate, in an open, observational study, the long term nutritional biochemistry of 12 children aged 1-6 years and/or 8-20 kg.
The children were receiving at least 50% of their estimated average requirement (EAR) for energy from paediatric enteral formulae: 1.0 kcal/ml (Nutrison Paediatric Standard) or 1.5 kcal/ml (Nutrison Paediatric Energy Plus). Venous blood samples for trace elements, vitamins, and minerals were taken at study entry and six months later. Parents kept three day food and feed records every month.
Despite a median energy intake of only 75% EAR (range 52-158%), 67% (n = 8) achieved their reference nutrient intake (RNI) for all micronutrients. No significant micronutrient deficiencies were seen on blood analysis after six months. Eighty three per cent (n = 10) had vitamin B(12) and 92% (n = 11) had copper intake >150% RNI. Fifty eight per cent (n = 7) had high plasma B(12) (>733 micromol/l) and 75% (n = 9) had high serum copper (>22 micromol/l) concentrations.
Children without excess losses maintain adequate micronutrient status on long term enteral feeding. Subjects had high blood concentrations of vitamin B(12) and copper, and had high dietary intakes of these micronutrients. We suggest that the maximum nutrient guidelines for paediatric enteral feeds should be more clearly defined.
Research has shown that growth retardation among children with quadriplegic cerebral palsy (CP) is often attributed to feeding dysfunction and malnutrition. The study compared weight-for-height values and limb anthropometric composition of nasogastric and gastrostomy tube-fed children with quadriplegic CP with those of orally fed children with quadriplegic CP and normal children, to examine the plausible effects of tube feeding on weight-for-height, fat, and muscle values for children with quadriplegic CP.
Triceps, anterior mid-thigh, and medial calf skinfold thicknesses and the corresponding circumferences of the right or less affected side were measured. The subjects consisted of 119 normal children and 62 orally fed and 48 tube-fed children with quadriplegic CP. Body weight and height were recorded. For children with CP whose height could not be measured, height was estimated from the ulna length. Weight-for-height z scores, limb skinfold thicknesses, fat areas, skinfold-corrected muscle girths, and muscle areas of the children were compared.
Tube-fed children with CP had normal mean weight-for-height z scores. Weight-for-height z scores of the orally fed children with CP were significantly below those of normal children and tube-fed children with CP. For children with CP, whereas triceps skinfold thickness seemed to predict the mid-upper arm fat area correctly, leg skinfold thicknesses seemed to overestimate the corresponding fat areas. Stepwise multiple regression analysis showed that triceps skinfold thicknesses had good correlation (r = 0.86) and the presence of CP had nonsignificant correlation with mid-upper arm fat areas. Multiple regression analysis of fat areas with skinfold thicknesses and the presence of CP, however, showed that CP was correlated negatively (partial correlation of CP: thigh, -0.45; calf, -0.53) with thigh and calf fat areas. Although skinfold-corrected mid-upper arm muscle girths of children with CP were quite similar to those of normal children, leg muscle girths were much reduced for both orally fed and tube-fed children with CP. The apparent thickening of leg skinfold thicknesses among children with CP probably was attributable to disproportional leg muscle wasting, with resulting reduced internal circumference of the subcutaneous fat layer. For tube-fed children with CP, skinfold thicknesses and fat areas were increased significantly, although their leg skinfold-corrected muscle girths and areas remained reduced.
Skinfold thickness may overestimate the fat area in the affected limb with significant muscle wasting for children with CP. The condition was particularly obvious in the leg, where muscle wasting was prominent. Because leg muscles represent approximately one quarter of the normal body weight, low weight-for-height values among children with CP can be caused by leg muscle wasting attributable to disuse atrophy, which is unlikely to be correctable with tube feeding. Tube feeding may improve body weight mainly through fat deposition.
Energy and nutritional requirements of patients with severe developmental disabilities (SDDs) on home enteral nutrition (EN) are still poorly understood. Patients fed with less than the recommended dietary allowance (Italian recommended dietary allowance, LARN) for energy may also have low intakes of trace elements and/or vitamins. Clinical records of 21 children and adolescents with SDDs on home EN were reviewed, comparing their energy and micronutrientintakestoLARN.Medianenergyintakeswere64%and48%ofthoserecommended for age and weight, respectively. Calcium, iron, vitamin A, folate and niacin intakes were lower than recommended in more than 70% of patients, while inadequate intakes of B vitamins and other micronutrients were less frequently observed. We suggest that long-term administration of EN at a suboptimal caloric rate may carry the risk of reduced intakes of some micronutrients. UntilmetabolicneedsofpatientswithSDDsarebetterdefined,regularbiochemicalmonitoringof main micronutrients and individualized supplementation are probably advisable. (Nutritional Therapy&Metabolism2006;24:147-54)
Children with moderate to profound mental retardation frequently are short for their age and commonly have some type of motor dysfunction. These conditions cause their caloric requirement to differ from normal recommendations for children of their age group. Consequently, a means for expressing their caloric needs in terms of body size and motor status instead of age is desirable. In this report we show that their caloric needs can be conveniently expressed in terms of body height. Ambulatory mentally retarded children with various types of motor dysfunction required approximately the same number of calories per unit of body height as those without motor dysfunction. Children whose motor dysfunction was severe enough to cause them to be nonambulatory required approximately 75 per cent as many calories as ambulatory children of comparable height.
We measured resting metabolic rate (RMR) in 12 persons (aged 10 to 30 years) with severe impairment of the central nervous system requiring gastrostomy feedings, and compared our findings with the RMR predicted from standardized equations. The RMR was 70.6% +/- 15.7% of that predicted from the Mayo Clinic nomogram, 63.7% +/- 18% of that predicted from the Food and Agriculture Organization/World Health Organization/United Nations University equation, and 75.4% +/- 17.3% of that predicted from the Robertson and Reid equation. Energy intake was 756 +/- 225 kcal/day and RMR was 708 +/- 231 kcal/day; RMR adjusted for changes in body energy stores was 729 +/- 231 kcal/day. No significant differences were found between energy intake and RMR, or between energy intake and the sum of RMR and changes in body energy stores. These findings demonstrate that standardized equations overestimate energy needs of individuals with severe CNS impairment. Measures of energy intake adjusted for weight changes represent a valid method to determine energy requirements in a group of individuals with severe CNS impairment. Length was found to be significantly correlated with RMR (r = 0.79; p < 0.01). When the regression equation was tested on another group of subjects from the same residential facility, the equation predicted energy needs reasonably well for those individuals with similar energy intakes but not for all patients with CNS disorders.
To document catch-up growth in children in the first 18 months after gastrostomy surgery and characterize how weight and length growth differ according to medical and nutritional risks.
Repeated measures study to evaluate weight and linear growth in gastrostomy-fed children.
Seventy-five subject met the selection criteria; gastrostomy placement anytime from birth to age 6.5 years, diagnosis of failure to thrive before gastrostomy. surgery, absence of nonmedical barriers to adequate nutrition. Children were seen in specialty outpatient clinics.
Three measurements of weight and length: at the time of surgery and 12 and 18 months after surgery.
Paired t tests of z scores were used to determine catch-up growth. Analysis of variance used variables (age of placement, ambulatory status, prematurity, mode of feeding) to determine statistically significant predictors of growth.
After gastrostomy surgery, catch-up growth was observed in height and weight for children regardless of prematurity or age at the time of gastrostomy placement. Ambulatory children did not achieve catch-up growth, but nonambulatory children did. At 18 months after surgery, catch-up growth occurred in children whose sole source of nutrition was through occurred in children whose sole source of nutrition was through the gastrostomy, as well as in those who were able to receive nutrition by mouth. Children with a diagnosis of cerebral palsy experienced better growth than children with other diagnoses. CONCLUSION/APPLICATION: Failure to thrive in children up to age 6.6 years can be corrected when adequate nutrition is provided. Benefits of gastrostomy surgery observed in catch-up growth reinforce the importance of medical nutrition therapy.
We assessed the bias and precision of the Arlington Developmental Center (ADC) equations derived from our previous study and the Harris-Benedict equations for estimating resting energy expenditure in non-ambulatory, tube-fed patients with severe neurodevelopmental disabilities.
Fifteen non-ambulatory patients with neurodevelopmental disabilities referred to the nutrition consult service for evaluation of enteral tube feeding via a permanent ostomy who had a steady-state resting energy expenditure measurement performed by indirect calorimetry were included in the study. The predicted energy expenditure values were compared with the measured resting energy expenditure values and evaluated for bias and precision.
Both ADC equations were more precise (95% confidence interval [CI]: 9-22% and 10-18% error, respectively) for the total population than the Harris-Benedict equations (95% CI: 17-40% error). The ADC-2 equation was precise (95% CI: 7-15% error) and unbiased (95% CI: -5 to 139 kcal/d) in contrast to the Harris-Benedict equations (95% CI: 23-54% error; bias, +230 to 365 kcal/d) for patients with cerebral palsy and fixed upper extremity contractures. The Harris-Benedict equations were precise and unbiased (95% CI: 3-14% error; bias, -182 to 39 kcal/d) for patients with cerebral palsy with preservation of upper body movement, whereas the ADC equations were biased toward underprediction and associated with greater error (95% CI: -367 to -73 kcal/d and 7-26% error; 95% CI: -379 to -109 kcal/d and 9-27% error, respectively).
The ADC-2 equation was unbiased and more precise in non-ambulatory adult patients with severe neurodevelopmental disabilities and fixed upper extremity contractures, whereas the Harris-Benedict equations were more precise and unbiased for those with preservation of limited functional and non-functional upper extremity movement.
