Final Case Study

Cerebral Palsy
JESSIE BRAND
  Prevalence
 Life Expectancy
 Review
 Co-Occurring Conditions
 Medications

Overview  Measuring height, weight, skinfold

 Nutrition recommendations
 Tube Feeding
 Nutrition Care Process
 Case study patient
 Review
 Group of disorders affecting an
individual’s ability to move and
maintain balance and posture

Cerebral: having to do with the brain

What is it?
Palsy: weakness or problems using
the muscles

Cause: abnormal Before, during, or

brain development after birth
Prevalence & Incidence

 Current number of adults & children:

764,000 (0.2% of US population)
 Current number of children <18: 500,000
(65.4% of total)
 2-3 children out of 1000 have CP
 10,000 babies born yearly will develop CP
 Diagnosis
 8,000-10,000 babies/infants per year are
diagnosed with CP
 1,200-1,500 preschool-age children are
diagnosed with CP per year
Life Expectancy
 Review - Cerebral Palsy

Types
 Spastic
 Increased muscle tone
 Dyskinetic (athetoid)
 Uncontrollable movements
 Ataxic
 Balance & coordination problems
 Mixed
 Spastic-dyskinetic
  Chew/swallow
 Self-feeding
Nutrition  Food preparation

Related  Nutritional needs

 Poor appetite
Difficulties  Tooth decay
 Food insecurity
  Oral-motor function/Dysphagia
 Autoimmune Diseases
Higher Risk  Constipation
for GI Issues  Dysmotility
 Spinal Abnormalities
 Cognitive/learning disabilities

Communication difficulties

Common Co-
occurring Hearing/visual impairment

Conditions
Epilepsy

Constipation
Common Medications
 Anticholinergics – uncontrolled body
movements
 Side effects: dry mouth, blurred
vision, constipation
 Anticonvulsants – seizure medication
 Side effects: may include
constipation, convulsions,
incontinence, nausea
 Anti-inflammatories – pain
 Antidepressants
 Side effects: constipation, dry mouth,
nausea, stomach upset, weight gain
 Antispastic – muscle relaxer
 Side effects: constipation, diarrhea,
weakness, incontinence, liver
damage, nausea
 Stool softeners
Measuring Spasticity – Ashworth Scale

Modified Ashworth Scale Instructions

 Patient in supine position
 For muscles that primarily flexes a
joint, place joint in maximally flexed
position; move to maximally extended
position over 1 second
 For muscles that primarily extends a
joint, place joint in maximally
extended position; move to maximally
flexed position over 1 second
Measuring Height & Weight
Height
 Measuring body segments
 Knee height, upper arm length,
recumbent length, tibial length
 Take height measurement upon each
admission
Weight
 Use Hamwi method to determine
IBW
 Males: 106# for 5’, +6# per inch over
5’
 Females: 100# for 5’, +5# per inch
over 5’
 BMI is not useful
 Fat and muscle stores are typically
depleted in CP patients
Height
Prediction
Equations
Skinfold Measurements

 CP individuals typically have lower fat stores compared to healthy

individuals
 Severely disabled have more normal fat stores to non-disabled individuals
 Serial skinfold measurements over time
 Triceps Skinfold:
 <10th percentile indicates depleted fat stores in this population  use IBW to
calculate energy & protein needs
 25th-90th percentile: Use actual body weight to calculate energy & protein needs
 Obese individuals: Use adjusted body weight to calculate energy & protein needs
Frisancho
Triceps
Skinfold
Percentiles
Jackson Pollock 7 Formula

Males

Females
 Nutritional Recommendations

 Energy
 No standards for adults with CP are available at this time
 Needs vary based on the individual
 20-35 kcal/kg/day
 DRI equation may be best predictive equation for this population in the acute setting
 Resist temptation to change nutrition regimen the patient was previously on

DRI Equations TEE = 669 + [height*9.7] + [ambulation*385.5] –

Males: 662-(9.53*age)+PA*[(15.91*weight)+(539.6*height)] [%bodyfatskinfold*11.74] + [sex*134]

PA: Sedentary 1.0; Low Active 1.11; Active 1.25; Very Active Height: cm
1.48 Ambulation: 0 non-ambulatory, 1 ambulatory
% Body Fat: estimate from Jackson Pollock
Females: 354-(6.91*age)+PA*[(9.36*weight)+(72*height)] Sex: 0 female, 1 male
Age: years Weight: kg Height: m
PA: Sedentary 1; Low Active 1.12; Active 1.27; Very Active
Predictive Formulas
Nutritional Recommendations

 Protein
 Use the RDA/DRI
 Actual weight, otherwise, use IBW if <90% or >125% of the IBW
 No guidelines when under stress (such as surgery)
 Presurgical/postsurgical planning and wound healing: 1.5-2 g/kg/day
 Leucine supplementation
Nutritional Recommendations

 Fluid
 CP patients tend to lose additional fluid through sialorrhea or sweating
 Rule of thumb (1 mL/kcal) may underestimate fluid needs if the patient is
hypometabolic
 Use actual body weight with Holliday-Segar equation

Weight Calculation
1-10 kg 100 mL/kg
10-20 kg 1000 mL + 50 mL/kg for each kg above 10 kg
>20 kg 1500 mL + 20 mL/kg for each kg above 20 kg
  Vitamin D: 800 IU/day
 Calcium: RDA (1000 mg)
Magnesium: RDA (420 mg/day for
Micronutrients 
males 31+)
 Phosphorus: RDA (700 mg/day for
males 19+)
Affects on Needs

 CP individuals tend to have differences in body composition & physical

activity level compared to the general population
 TEE study using doubly labeled water
 Athetosis may cause CP adults to have a higher RMR than controls
 Best predictors of TEE: % body fat (DXA), ambulation status, & sex
 Best predictors of TEE (more available): height, ambulation status, % body
fat (skinfold), & sex
 Hypotonia vs. Hypertonia
Study Conclusion

 Final 3 conclusions
 TEE is highly variable in adults with CP – there is a high interindividual variability in energy expenditure during PA
 TEE significantly impacted by ambulation status
 RMR and energy expended during PA contributed to TEE differently between ambulatory and non-ambulatory
subjects
 High variability
 TEE variable: range in these subjects was 1396-3890 kcal/day
 RMR variable: range in these subjects was 970-2130 kcal/day
 Energy expended in PA: range in these subjects was 119-1561 kcal/day
 Difficult to provide general guidelines for energy requirements for adults with CP
 Ambulation status is an important determinant of energy needs
Research Study
A SURVEY OF BOLUS TUBE FEEDING PREVALENCE AND PRACTICE IN ADULT
PATIENTS REQUIRING HOME ENTERAL TUBE FEEDING
Methods

 Dietitians from 10 centers in the UK

 Data collected on adult home enteral tube fed (HETF) patients receiving
bolus tube feeding (n=604, avg. age=58 years)
 Long-term tube fed, living at home and sedentary
 CP subjects: 12% of the subjects; 31 years avg.; 94% sedentary
Results

 CP subjects had received bolus tube feeding the longest (mean: 7

years)
 Mean bolus TF volume: 168 mL/bolus
 Mean daily total bolus TF volume: 465 mL/day
 Total mean energy intake from enteral TF: 1498 kcal/day (25
kcal/kg/day)
 Total mean PRO intake from enteral TF: 61 grams/day (1 g/kg/day)
Table 2. Demographic characteristics of whole bolus-fed population, by primary
diagnosis and by feeding method (Numbers of patients; mean values and standard
deviations; percentages)
Table 3. Feeding regimen characteristics of whole bolus-fed population, by
primary diagnosis and by feeding method (Numbers of patients; percentages)
Table 1: Characteristics and associated hazard ratios of people with CP aged >15 years
(total: 23,795 subject, 2,6000 death)
Job of RD

Assessment Diagnosis Intervention Monitoring

• Weight • Swallowing • Tube feeding • Labs
• Contact difficulties • Oral • Weight
home • Inadequate supplements • Swallow
• Labs oral intake • Micronutrient studies
• Co-existing • Malnutrition s • Meds
conditions
Case Study Patient D.W.
Patient D.W.

 Age: 34  Weight History

 Height: 5 foot 5.95 in
2/11/20 131 lb
 IBW: 124 lb
 142 lb – 13% for quadriplegia 1/23/20 125 lb
 Admission date 1/20/20 130 lb
 Initial: 1/14/20
1/12/19 122 lb
 Readmit: 2/4/20
 Admission Diagnosis 9/18/19 125 lb
 2/4: Septic Shock 7/18/19 125 lb
 Living situation: group home
6/14/19 123 lb
6/29/19 132 lb
 Past Medical History

 Ascites  Large hiatal hernia

 Bladder stones  Quadriplegia
 Constipation  Renal calculus, bilateral
 Cerebral palsy, spastic  Small bowel obstruction
 Gastrostomy tube in place  Scoliosis
 GERD  Seizures
 Idiopathic profound intellectual  Torticollis
disability  Ulcerative colitis

Past Surgical History: G tube placement, Nissen fundoplication

Active Problem List
Traumatic ulcer with fat
layer exposed
Cellulitis of left elbow
Small bowel obstruction
Seizure-like activity
History of Nissen
fundoplication
Spastic quadriplegic cerebral
palsy
Cognitive dysfunction
Acute on chronic respiratory
failure with hypoxemia
S/P PEG tube placement
Ulcerative colitis
Malnutrition
Sinus tachycardia
Acute cystitis with hematuria
Septic shock
Cellulitis of buttock
Abscess of anal or rectal
region
Seizure disorder
Non-healing surgical wound
Nephrolithiasis
AKI
Decubitus ulcer of coccyx
 Timeline

Admitted CT scan: multiple

Firm, distended Bipap not effective
Intubated Abdomen firm & kidney stones
abdomen 4pm: trickle d/t secretions
Tachycardic distended Back to ICU Overnight, PEG
Dextrose hung feed still going Elevated heart
Fever Mother requests Started on bipap pulled out
this AM at 10 mL/hr rate
feeds stopped Abdominal distension accidentally
Leaking – hold Na normal, K Put on comfort
Tube to gravity to improving
tube feeds low cared
drain TF held d/t concern
Passed away
of SBO or perforation
2/6 2/10 2/12 2/14 2/17 2/19

2/4 2/7 2/11 2/13 2/16 2/18 2/20

Less leaking PEG tube replaced

Out of ICU TF @ goal rate
Start trickle Flushes only – G AM: drain output Diarrhea  rule out
Continuing 10 Not on Propofol
feed tube to gravity 250 mL C. diff
mL/hr trickle feed Fluid flush
Right ureteral In PM, resume Clear, yellow fluid & Feeds started; no
No output increased to 250
stent placed trickle feed air leaking
overnight mL Q4 per MD
May need surgical Abdomen distended Recommend
Plan to increase No IVFs
intervention if Gut isn’t functioning lactinex
TF slowly to goal
leaks again properly More lethargic; less
Na elevated responsive to stimuli
Initial Assessment: 2/6/20

WBC 34.68(H)
 Reason: Saw patient d/t mechanical
RBC 3.0(L)
ventilation and no G tube feedings
since admission Hgb 9.6(L)
 PES: Swallowing difficulty r/t altered Hct 31.5(L)
motor function AEB PMHx of cerebral Na 142
palsy and seizure disorder and use of K 3.3(L)
G tube for nutrition support.
BUN 41(H)
 Intervention: Begin trickle feed Creatinine 1.23
GFR 76
Glucose 97
Ca 7.5(L)
Albumin 2.0(L)
 Estimated Nutrient Needs

Kcal needs based on IBW (56 kg)

Kcals/day equation Kcal/kg (25-30)

Kcals/day 1400-1680

Protein needs based on Actual body weight (58.6 kg)

Grams/protein/kg 1.0-1.2

Grams/protein/day 58-70

Fluid needs based on mL/kg (min 40 mL/kg)

mL fluid/day Min 2344

Home Tube Feeding

 Jevity 1.0  Juven

 75 mL/hr for 20 hours infusing from  2 packs/day
2300-0700 daily  160 calories
 Total Volume: 1500 mL/day  5 grams protein
 1500 calories
 Infant Foods Water Bolus
 66 grams protein
 300 mL 5x/day
 22 grams fiber
 1500 mL fluid
 1244 mL free water
 Total fluid: 2744 mL/day
Hospital Tube Feeding

Goal Rate Starting Rate

 Jevity 1.5  Jevity 1.5: Trickle feed at 10 mL/hour
 50 mL/hour for 20 hours infusing from  360 calories
2300-0700 daily
 15 grams protein
 1500 calories
 5 grams fiber
 64 grams protein
 182 mL free water
 22 grams fiber
 760 mL free water
 Flush: 20 mL Q4
 Flush: 240 mL Q4  120 mL fluid
 1500 mL/day
 Total fluid: 2260 mL/day
 Reassessments
 2/7
 Eval: G-tube feeding held d/t
leaking around G-tube
 Goal: Resume/tolerate G-tube
feeding when medically
appropriate
 2/10
 Eval: Pt was extubated on 2/7. G-
tube no longer leaking after
stopping feeds.
 Intervention: Resume trickle
feeds – Jevity 1.5 at 10 mL/hr
 Goal: Tolerate trickle feeds w/o
leaking. Increase volume if no
leaking.
 2/12
 Eval: G-tube not leaking on trickle feeds. On IVFs – D5 & KCl 20
mEq @60 mL/hr
 Intervention: (1)Increase infusion by 10 mL/hr ever 2 hrs, to
goal 50 mL/hr over 20 hours, 2300-1900. (2)Begin water flush 60
mL Q4; if maintenance IVF d/c, flush 200 mL 5x/day
 Goal: Tolerate higher rate of feeding
 2/17
 Eval: Infusion increased to goal of 50 mL/hr for 20 hours. No
maintenance IVFs. G-tube dry, clean, and intact. Elevated Na,
spoke with Dr. Save regarding water flushes.
 Intervention: (1) Flush 250 mL Q4 to provide total of 1500 mL
+ 760 mL from formula, total free water 2260 mL/day. (2) Jevity
1.5 at 50 mL/hr for 20 hours from 2300-1900 daily to provide
1500 kcals, 64 g PRO, 22 g fiber, 760 mL water.
 Goal: Tolerate TF at goal volume.
Date: 2/7/20 2/10/20 2/11/20 2/12/20
Weight (lbs) 130 lb 11.7 oz 135 lb 9.3 oz 131 lb 9.8 oz
Sodium (135-145) 147(H) 148(H) 144 144
Potassium (3.2- 3.1(L) 3.5 3.2(L) 3.5

Lab
5.1)
Chloride (98-107) 110(H) 105 103 98
CO2 (21-32) 26 43(H) 50(H) 44(H)
BUN (5-20) 32(H) 5 3(L) 2(L)
Creatinine (0.52-
1.18)
Est. GFR (>60)
Glucose (65-100)
0.91

>90
97
0.54(L)

>90
92
0.50(L)

>90
93
0.57

>90
95
Value
Trends
Calcium (8.3-10.3) 8.2(L) 7.7(L) 7.6(L) 7.5(L)
Magnesium (1.6- 2.2 1.2(L) 1.2(L) 1.7
2.4)
Comments: Large hiatal Incontinent of Increase
hernia green mushy feeding by 10
1+ BLE edema stools mL every 2
Lasix x1 (2/6) G-tube to gravity hours to
No Propofol and only flushes reach goal
KCl 40 mEq (2/7) draining out
 Daily Meds

2/6/20 2/7/20 2/10/20 2/12/20 2/17/20

Enoxaparin Baclofen Baclofen Baclofen
Famotidine Balsalazide Balsalazide Balsalazide
Levetiracetam Famotidine Enoxaparin Enoxparin
Meropenem Levetiracetam Famotidine Famotidine
Depacon Meropenem Levetiracetam Levetiracetam
IV Levophed Depacon Meropenem Meropenem
IV Propofol IV D5 w/ KCl 20 mEq Depacon Depacon
@50 mL/hr
IV D5 w/ KCl 20 IV D5 w/ KCl 20
mEq @60 mL/hr mEq @60 mL/hr
Final Outcomes & Reflection
Final Outcomes
 Patient seemed to tolerate trickle
feeds better than goal volume
 Patient passed away on 2/20 after
being put on comfort care
Wish I Would Have Done
 Consider assessing patient for muscle
tone
 Speak with patient’s mother
 Contact the group home
 Take segmental lengths
 Take triceps skinfold
 Monitored bowel movements more
closely
Limitations

 Patient seemed to be non-verbal for the most part

 Did not know how patient tolerated tube feedings prior to admission
 Since patient is deceased, did not access the EMR for this presentation
 Limited research on adults with CP
 The research that I could find was either old, used a small sample size,
or both
Summary

 CP patients vary greatly with symptoms and nutritional needs

 Need to look at them individually
 Use predictive equations, but use clinical judgment
 Monitor weight changes
Questions?
THANK YOU 
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