Management of acute malnutrition

in children with cerebral palsy

Endy P. Prawirohartono
Department of Child Health
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada
Dr. Sardjito General Hospital
Yogyakarta

Cirebon Pediatric Update, 16-17 November 2019

 Curriculum vitae

dr. Endy P. Prawirohartono, SpAK, MPH

Birth: Magetan, 12 Agustus 1953

Education
1979 – General physician (Faculty of Medicine, Public Health and Nursing,
UGM)
1987 – Pediatrician (Faculty of Postgraduate, UGM)
2000 – Master of Public Health (Umeå University, Sweden)
2002 – Consultant in Pediatric Nutrition and Metabolic Disease (SpAK)
(Collegium of the Indonesian Pediatrician Society)
2012 – Doctoral degree: Licentiate of Medicine (Umeå University, Sweden)

Occupation
Dokter Mitra of the Dr. Sardjito General Hospital and Faculty of Medicine
Public Helath and Nursing, UGM, Yogyakarta
Topic 1
INTRODUCTION
 Cerebral palsy (CP)
• CP is a group of disorders that affect movement
and muscle tone and posture.
• It’s caused by damage that occurs to the
immature brain as it develops, most often before
birth.
• Sign and symptoms appear during infancy or
preschool years.
• It causes impaired movement associated with
abnormal reflexes, floppiness or rigidity of the
limb and trunk, abnormal posture, involuntary
movements, unsteady walking, and swallowing
 The oral and pharyngeal problems in CP

• Reduced lip closure

• Poor tongue function
• Tongue thrust
• Exaggerated bite reflex
• Tactile hypersensitivity FEEDING
• Delayed swallow initiation PROBLEMS
• Reduced pharyngeal motility
• Drooling
• Dysphagia
MALNUTRITION
Arvedson JC. Eur J Clin Nutr 2013;67:S9-S12
Kuperminch MN et al., Eur J Clin Nutr 2013; 67:S21-S23.
Red flags of feeding problems in CP

Feeding more than 30

Meal time is stressful
minutes on any regular
to child or parents
basis

Respiratory problems:
Lack of weight gain
increase congestion at
over 2-3 months
meal time, gurgly voice

Arvedson JC. Eur J Clin Nutr 2013;67:S9-S12

Kuperminch MN et al., Eur J Clin Nutr 2013; 67:S21-S23.
 Comprehensive management of CP
Child heath care
Medical
doctor and
nurse

Anxiety Psychologis
t Patient Dietician Diet

Physioth
erapist
Feeding skills
Speech and language therapy
Topic 2
COMPONENT OF PEDIATRIC
NUTRITIONAL CARE
Pediatric Nutritional Care Process
Assessment of nutritional status

Estimating nutritional requirements

Determining mode of feeding

Determining formula selection

Monitor and evaluation process

Topic 3
ASSESSMENT OF NUTRITIONAL
STATUS: ACUTE MALNUTRITION
Moderate acute malnutrition (MAM)
Severe acute malnutrition (SAM)
 MAM vs SAM
Indeks MAM SAM
WHZ*, or - 2 SD to – 3 SD < - 3 SD
MUAC** 11.5-12.5 cm < 11.5 cm
* Reference: WHO Child Growth Standard 2006
** 6-59 months
Normal > 12.5 cm
 Measurement techniques

Weight
• Without cloths
• Is calculated as the difference
between caregiver’s with and
without the child
Akhter et al., 2018
Toopchizadeh et al., 2017
 Measurement techniques

Height
• Standing position: without major skeletal deformities
• Height estimation using knee height: with major
skeletal deformities (Stevenson formula)

Height (cm) = [(2.69 x knee height) + 24.2] ± 1.1

• Reference: WHO Child Growth Standard 2006

(Toopchizadeh et al., 2017; Lopez et al., 2013)
Knee height measurement
 Measurement techniques
Height
• Arm span
Height (cm) = 6.4 + 0.93 Arm span
• Arm length
Height (cm) = 27.4 + 1.73 Arm length
• Arm span, arm length, tibia length
Height (cm) = 6.8 + 0.6 Arm span + 0.52 Arm length +
0.54 Tibia length
Yousafzai et al., 2003
 Arm span, arm length, tibia length

Tip of middle finger of one arm

to the tip of middle finger of the
other arm with arms outstreched
Knee joint to the ankle
Tip of humerus bone joint of left leg
to the tip of middle
finger of left arm

Yousafzai et al., 2003

Topic 3
ESTIMATING NUTRITIONAL
REQUIREMENTS
 Estimating nutritional requirements
ACCURATE ESTIMATION IS DIFFICULT DUE TO:

• Heterogeneity of the groups

• Altered body composition and reduced basal
metabolic rate: reduced lean body mass,
adaptation to chronic poor nutrition
• Reduced physical activity levels

Bell KL & Samson-Fang L. Eur J Clin Nutr 2013;67:S13-S16.

ENERGY AND NUTRIENTS
REQUIREMENT FOR CP WITH MAM
 Nutritional requirements: Energy
• Children with CP have decreased
energy requirements (needs
correction) i.e. severe CP (utilize
wheel chair): 60-70% of those
healthy typically developing children.
• Other situation should be considered
when estimating energy needs
Bell KL & Samson-Fang L. Eur J Clin Nutr 2013;67:S13-S16.
 Nutritional requirements: Energy
Principle: based on ideal W/H and age
Calculating energy needs:
• Plot W/H according to sex (WHO Standard 2006)
• Set ideal height by connecting the point of height to
the left until median line
• Set the age according to ideal height using height-for
age of WHO Standard 2006
• Decide energy needs based on actual weight and age
based on ideal height (above)
Case: a boy wih severe CP:
Weight = 11.5 kg, height = 95.0 cm
 B A

A is for height = 95.0 cm and weight = 11.5 kg

B = 85.0 cm is ideal height for weight = 11.5 kg
(green line indicates median)
 C

C indicates height = 85.0 cm (ideal for 1 year 9 months old)

 Energy requirements per kg body weight
for age group (years)

1 kg = 100 kcal
 Nutritional requirements: Energy
Energy requirement for child 1y 9mo old:
= 11,5 x 100 kcal = 1150 kcal/hari
Corrected energy requirements for CP:
60-70% of those healthy typically developing
children.
= 0,6-0,7 x 1150 kcal/day
= 690-805 kcal/day
 Nutritional requirements: Protein
Protein requirements = 2 g/kg/day
Case: boy, with severe CP:
Weight = 11.5 kg, height = 95.0 cm
• Determine ideal weight for height 
ideal weight for height = 14.1 kg
• Protein requirements = 14.1 x 2 g/day =
28.2 g/day

Bell KL & Samson-Fang L. Eur J Clin Nutr 2013;67:S13-S16.

Weight-for-height BOYS
2 to 5 years (z-scores)
Z-scores (weight in kg)
Height (cm) L M S -3 SD -2 SD -1 SD Median 1 SD 2 SD 3 SD
89.0 -0.3521 12.6495 0.08045 10.0 10.8 11.7 12.6 13.7 14.9 16.3
89.5 -0.3521 12.7683 0.08038 10.1 10.9 11.8 12.8 13.9 15.1 16.4
90.0 -0.3521 12.8864 0.08032 10.2 11.0 11.9 12.9 14.0 15.2 16.6
90.5 -0.3521 13.0038 0.08028 10.3 11.1 12.0 13.0 14.1 15.3 16.7
91.0 -0.3521 13.1209 0.08025 10.4 11.2 12.1 13.1 14.2 15.5 16.9
91.5 -0.3521 13.2376 0.08024 10.5 11.3 12.2 13.2 14.4 15.6 17.0
92.0 -0.3521 13.3541 0.08025 10.6 11.4 12.3 13.4 14.5 15.8 17.2
92.5 -0.3521 13.4705 0.08027 10.7 11.5 12.4 13.5 14.6 15.9 17.3
93.0 -0.3521 13.5870 0.08031 10.8 11.6 12.6 13.6 14.7 16.0 17.5
93.5 -0.3521 13.7041 0.08036 10.9 11.7 12.7 13.7 14.9 16.2 17.6
94.0 -0.3521 13.8217 0.08043 11.0 11.8 12.8 13.8 15.0 16.3 17.8
94.5 -0.3521 13.9403 0.08051 11.1 11.9 12.9 13.9 15.1 16.5 17.9
95.0 -0.3521 14.0600 0.08060 11.1 12.0 13.0 14.1 15.3 16.6 18.1
95.5 -0.3521 14.1811 0.08071 11.2 12.1 13.1 14.2 15.4 16.7 18.3
96.0 -0.3521 14.3037 0.08083 11.3 12.2 13.2 14.3 15.5 16.9 18.4
96.5 -0.3521 14.4282 0.08097 11.4 12.3 13.3 14.4 15.7 17.0 18.6
97.0 -0.3521 14.5547 0.08112 11.5 12.4 13.4 14.6 15.8 17.2 18.8
97.5 -0.3521 14.6832 0.08129 11.6 12.5 13.6 14.7 15.9 17.4 18.9
98.0 -0.3521 14.8140 0.08146 11.7 12.6 13.7 14.8 16.1 17.5 19.1
98.5 -0.3521 14.9468 0.08165 11.8 12.8 13.8 14.9 16.2 17.7 19.3
99.0 -0.3521 15.0818 0.08185 11.9 12.9 13.9 15.1 16.4 17.9 19.5
99.5 -0.3521 15.2187 0.08206 12.0 13.0 14.0 15.2 16.5 18.0 19.7
100.0 -0.3521 15.3576 0.08229 12.1 13.1 14.2 15.4 16.7 18.2 19.9
100.5 -0.3521 15.4985 0.08252 12.2 13.2 14.3 15.5 16.9 18.4 20.1

WHO Child Growth Standards

Height = 95.0 cm  ideal weight (median) = 14.1 kg

 Nutritional requirements: micronutrients

In the absence of specific recommendations for

use in the individuals with CP, standard
recommendations for individual for dietary
intakes of vitamins, minerals and trace elements
should be utilized.

Guideline for children with SAM of Ministry of

Health RI can be used.
Bell KL & Samson-Fang L. Eur J Clin Nutr 2013;67:S13-S16.
WHO, 2013
 Nutritional requirements:
micronutrients

Give daily for at least two weeks:

• a multivitamin supplement
• folic acid 5 mg on day 1, then 1 mg/day
• zinc 2 mg Zn/kg/day
• copper 0.3 mg/kg/day
• once gaining weight, ferrous sulfate 3 mg/kg/day
• vitamin A orally (aged < 6 mo: 50000 IU, aged 6 mo – 12 months:
100.000 IU, older children 200.000 UI 20,.000 daily) – on day 1
ENERGY AND NUTRIENTS
REQUIREMENT FOR CP WITH SAM
 Time frame for the management of the child with
severe acute malnourished CP

Stabilization Transition Rehabilitation

10 STEPS
Days 1-2 Days 3-7 Weeks 2-6

1. Hypoglycemia
2. Hypothermia
3. Dehydration
4. Electrolytes
5. Infection
6. Micronutrients no iron with iron
7. Initial feeding
8. Catch-up growth
9. Sensory stimulation
10. Prepare for follow-up
Nutritional requirements: energy and protein

Phase Initial feeding Catch-up

growth feeding
Energy/protein
Energy 60-70% x 100 60-70%
(kcal/day) kcal/kg/day (150-220)
kcal/kg/day
Protein 1-1.5 4-6 g of
(g/day) g/kg/day protein/kg/da
y
WHO, 2013
 Nutritional requirements:
micronutrients

Give daily for at least two weeks:

• a multivitamin supplement
• folic acid 5 mg on day 1, then 1 mg/day
• zinc 2 mg Zn/kg/day
• copper 0.3 mg/kg/day
• once gaining weight, ferrous sulfate 3 mg/kg/day
• vitamin A orally (aged < 6 mo: 50000 IU, aged 6 mo – 12 months:
100.000 IU, older children 200.000 UI 20,.000 daily) – on day 1
Topic 4
DETERMINING MODE OF FEEDING
Mode of feeding

Oral nutrition support

Enteral nutrition
support

Bell KL & Samson-Fang L. Eur J Clin Nutr 2013;67:S13-S16.

Mode of feeding: enteral

GASTRIC ROUTE
Nasogastric tube
Gastrostomy
PYLORUS
POST-PYLORIC ROUTE
Nasojejunal tube
Jejunostomy

Bell KL & Samson-Fang L. Eur J Clin Nutr 2013;67:S13-S16.

 Oral nutritional support
• Use of non-nutritive oral (pacifier for preterm infants;
“mouth toys” in older children: suck fingers with small
foods on them; 2-3 drops of water via a spoon)
• At risk for aspiration !
• Needs additional positioning and physical support
during meal time
• Use adaptive equipments
• Modified food texture and fluid thickness maybe
necessary
• Smaller more frequent meals maybe beneficial

Arvedson JC. Eur J Clin Nutr 2013;67:S9-S12

Bell KL & Samson-Fang L. Eur J Clin Nutr 2013;67:S13-S16.
 Enteral nutritional support (1)
• Functional gastrointestinal tract
• Unable to meet their nutritional requirements
orally, SAM, significant feeding and swallowing
dysfunction (risk of pulmonary aspiration and
prolonged and stressful oral feeding
• Nasogastric tube feeding: short-term use:
before gastrostomy insertion, nutritional
rehabilitation before surgery

Arvedson JC. Eur J Clin Nutr 2013;67:S9-S12

Bell KL & Samson-Fang L. Eur J Clin Nutr 2013;67:S13-S16.
 Nutritional support: enteral (2)
• Gastrostomy: for long-term use, improved
comfort and reduced need for frequent tube
changes; preferred route
• Post-pyloric feeding: for children with
gastroesophageal reflux and vomiting
resulting in growth faltering and increased at
risk of aspiration; high frequency of
complications and tube replacement

Arvedson JC. Eur J Clin Nutr 2013;67:S9-S12

Bell KL & Samson-Fang L. Eur J Clin Nutr 2013;67:S13-S16.
Topic 5
DETERMINING FORMULA
SELECTION
Formula selection
ORAL ROUTE
• Home prepared formulations
• Commercially oral nutritional supplements (sip feeds)
• Commercially modular products (carbohydrate, fats, proteins)

GASTRIC ROUTE
• Home prepared formulations
• Commercially oral nutrition supplements (sip feeds)
• Commercially modular products (carbohydrate, fats, proteins)
• Bolus or continuous drip
POST-PYLORIC ROUTE
• Elemental formulations
• Continuous drip

Bell KL & Samson-Fang L. Eur J Clin Nutr 2013;67:S13-S16.

 Home prepared formulations
• Including F-75 and F-100
• Concern regarding the nutritional adequacy
(insufficient weight gain) and safety
• Addition of extra fat (energy booster): oil,
nuts, avocado
• Addition of proteins: dry milk powder, dairy
products, eggs

Bell KL & Samson-Fang L. Eur J Clin Nutr 2013;67:S13-S16.

 Sip feeds
• designed to provide complete nutrition
• polymeric
• energy density: standard (1 kcal/ml), high (1.5
kcal/ml), low (0.75 kcal/ml)
• may contains fiber (potential benefit for
preventing both diarrhea and constipation),
whey-based (for delayed gastric emptying)

Bell KL & Samson-Fang L. Eur J Clin Nutr 2013;67:S13-S16.

 Modular products
• designed to provide addition to polymeric
formula
• contains specific nutrient (carbohydrates, fat,
proteins)
• Carbohydrates: carbohydrates polymers
• Proteins: protein powders
• Fats: combined carbohydrates and fat
supplements
Bell KL & Samson-Fang L. Eur J Clin Nutr 2013;67:S13-S16.
Topic 6
FOLLOW UP AND MONITORING
 Follow up and evaluation
• Measures of actual nutrient delivery (energy,
protein, micronutrients) and comparison with
measured or estimated needs
• Weight gain is sensitive indicator for adequate
intake
• Management of difficulties with tolerance,
ensuring safety of feeds and nutrient intake,
balancing enteral tube feeding with oral intake
and working towards weaning off tube feeding
Bell KL & Samson-Fang L. Eur J Clin Nutr 2013;67:S13-S16.
 Management of complication
• Constipation: adequate intake of fiber
(fiber containing feeds) and fluids
• Vomiting or regurgitation: correct tube
place, reducing infuse rate, smaller more
frequent bolus feeds, positioning child
upright during feeds, if fails change to
post-pyloric feeding as well as medical or
surgical treatment
Bell KL & Samson-Fang L. Eur J Clin Nutr 2013;67:S13-S16.
 Management of complication
• Diarrhea: slowing the feeds infusion rate,
reducing bolus size, changing to continuous
feeds, changing to feeds with lower osmolarity,
changing to semi-elemental formula in children
with impaired gut function, incase of microbial
contamination use sterile commercially products
and with appropriate level of hygiene
• Excess weight gain: reducing feeds volume or by
using formula with lower energy density

Bell KL & Samson-Fang L. Eur J Clin Nutr 2013;67:S13-S16.

THANK YOU SO MUCH