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CONCLUSION How to Manage Gastroenterological and
• Nutritional evaluation and management should be • Enteral tube feeding is recommended in cases of Nutritional Problems in Children with
performed by a MDT unsafe or inefficient oral feeding, preferably before Neurological Impairment
• Accurate nutritional assessments should be carried the development of undernutrition
out to monitor nutritional status • Follow-up anthropometry is important and A short guide based on the 2017 European Society for Paediatric Gastroenterology,
• Oral feeding is the preferred option in children micronutrient markers should be checked annually Hepatology and Nutrition (ESPGHAN) Consensus Guidelines
with NI if it is nutritionally sufficient, safe, stress- • Parents and/or caregivers should be involved in
free and feeding time is not prolonged decision making, especially around gastrostomy THE NEED FOR THE ESPGHAN CONSENSUS
feeding
Children with neurological impairment (NI) frequently have feeding and swallowing problems which can
be associated with undernutrition, growth failure, micro-nutrient deficiencies, osteopenia, and nutritional
Multidisciplinary nutritional assessment of the neurologically impaired child: comorbidities.
• weight, length, triceps skinfold Prior to this ESPGHAN consensus, there was a lack of systematic approach to the care of children with NI.
• dietary history (e.g., meal duration)
• evaluation of oral motor function ASSESSING NUTRITIONAL STATUS
A multidisciplinary team (MDT) is recommended to perform nutritional evaluation and management. An ideal MDT
Adequate nutrition Inadequate nutrition includes a physician, dietitian, nurse, speech therapist, physical therapist, psychologist, and occupational therapist.
Safe Unsafe HOW TO ASSESS NUTRITIONAL STATUS
Safe Unsafe* Routine nutritional assessments by MDT
Optimize intake
Systematic re-evaluation Ensure consistency,
(yearly or on indication) positioning Inadequate nutrition
Weight and height Knee height or tibial Measurement of fat mass Anthropometry should
measurements should not length should be by skinfold thickness be checked at least every
Tube feeding be solely relied on measured to assess linear should be a routine 6 months
Unsafe (supplementary vs. growth when height component of the
exclusive) cannot be measured nutritional assessment
GORD Laboratory assessments
• Assess micronutrient status (e.g., vitamin D, iron status, calcium, phosphorus) as part of nutritional assessment
No Yes • Micronutrients should be checked annually
Gastrostomy Controlled Not controlled HOW TO IDENTIFY UNDERNUTRITION
(PPI, diet) (PPI, diet) Undernutrition should be assessed based on the interpretation of anthropometric data.
Standard growth charts are not helpful as growth patterns vary from the general pediatric population.
• Gastrostomy with fundoplication Cerebral palsy specific growth charts may not be recommended to identify undernutrition.
• Jejunostomy
FIGURE 1. *Unsafe swallow is defined as occurring in a child who has both a history of aspiration pneumonia (antibiotics RED FLAG WARNING SIGNS TO IDENTIFY UNDERNUTRITION:
or hospital admission for chest infection) and objective evidence of aspiration or penetration on contrast video fluoroscopy.
GORD: gastroesophageal reflux; PPI: proton pump inhibitor. • Physical signs of undernutrition such as decubitus skin problems and poor peripheral circulation
• Weight for age z score <-2
• Triceps skinfold thickness <10th centile for age and sex
Reference Disclaimer • Mid-upper arm fat or muscle area <10th percentile
Romano C et al. European Society for Paediatric Gastroenterology, Hepatology This guide has been reproduced for Healthcare professional use only from the ESPGHAN • Faltering weight and/or failure to thrive
and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Consensus Guidelines for the Evaluation and Treatment of Gastrointestinal and
Nutritional Complications in Children with Neurological Impairment. Journal of Nutritional Complications in Children with Neurological Impairment. The development
Pediatric Gastroenterology and Nutrition 2017; 65: 242–264 was supported by Nutricia Advanced Medical Nutrition.
NUTRITIONAL REQUIREMENTS DIETETIC MANAGEMENT AND MONITORING
WHICH TYPE OF DIET?
Requirements How to assess requirements
1st choice: Consider switching to enteral tube
• Energy requirements are diffi cult to defi ne in • Energy needs can be feeding if:
children with NI estimated using Dietary • Oral feeding is preferred in all children when it
• Energy requirements must be individualised to take Reference Intake (DRI) for is nutritionally suffi cient, safe, stress-free, and • Severe OPD (dysphagia, unsafe swallow) has
into account mobility, muscle tone, activity level, basal energy expenditure for feeding time is not prolonged associated repeated pulmonary aspirations,
altered metabolism, and growth normally developing children • Follow-up period of 1–3 months when trialling pneumonias, dehydration, and/or life-threatening
• Immobile patients dependent on a wheelchair oral feeding, but more frequently in infants events
Energy and severely malnourished patients
require only 60–70% of the energy of typically • Total oral feeding time exceeds 3 hours per day
developing children • Where inadequate oral intake manifests as insuffi cient
• Children with NI who can walk or have athetosis weight gain or a decrease in height velocity
have higher energy requirements
• Problems with protein intake may arise when calorie • Dietary reference intakes • Ethical consideration:
needs are low (DRIs) can be used, as Parents and/or caregivers should always be involved in decision making including about gastrostomy feeding
• Only use supplementary protein in specifi c clinical protein requirements are
Protein situations, such as decubitus ulcers, or in children similar to healthy children ENTERAL FEEDING – WHICH TYPE OF ENTERAL PRODUCT?
with low energy requirements Children <1 year old: Human milk, standard infant milk formula or nutrient dense formula
• High risk of dehydration caused by inability to • Monitor hydration (1.0 kcal/mL) if clinically indicated
communicate thirst, drooling or unsafe swallowing status closely Children >1 year old: Standard (1.0 kcal/mL) polymeric age-appropriate
Fluid • Excessive salivary secretion is a clinical symptom of formula including fi ber
children with NI Children with increased energy High-energy density formula (1.5 kcal/mL) containing fi ber.
• Micronutrient defi ciency is common, particularly • DRI for micronutrients in requirements or poor volume tolerance: Must monitor hydration carefully
where nutritional supplements are not being received typically developing children Children with low energy needs: Low-fat, low-calorie (0.75 kcal/mL), high fi ber and
• Children who are tube-fed may develop nutritional can be used to estimate the micronutrient-replete formula
Micronutrients defi ciencies as nutritional formulas provide adequate appropriate micronutrient
micronutrients only when suffi cient volumes are intake for children with NI Children with GORD or Whey-based formula
consumed • Vitamin D supplements gagging and retching:
may be required
CAUTION: There are nutritional adequacy and safety concerns around pureed food for enteral tube feeding
GASTROINTESTINAL ISSUES
BOLUS OR CONTINUOUS?
Consider using a combination of nocturnal
OROPHARYNGEAL DYSFUNCTION GASTROESOPHAGEAL REFLUX continuous feeds with day time bolus
(OPD) >90% PREVALENCE DISEASE (GORD) 70% INCIDENCE feeds in children with high-caloric needs
• Feeding history taken from early infancy • Consider modifying enteral nutrition or poor tolerance to volume
and direct visual assessment of feeding (thickening of liquid enteral formulas)
by appropriately trained professionals and the use of whey-based formulas as
is recommended options for the management of GORD
• Consider OPD in all patients even with
no obvious clinical signs or symptoms
• OPD is a risk factor for undernutrition CONSTIPATION WHICH TYPE OF TUBE?
• Growth and nutritional status should • Consider increasing fl uid and fi ber Consider using a gastrostomy to provide intragastric access for
be monitored regularly intake in addition to other therapeutic long-term tube feeding
options for constipation Consider using jejunal feeding in cases of aspiration due to GORD,
refractory vomiting, retching and bloating
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