Gastrointestinal Issues in the Child with Neurodevelopment Delay

1
Gastrointestinal Issues in the Child with
Neurodevelopment Delay

• Robert Issenman
• McMaster University and
• McMaster Childrens Hospital
• Hamilton, Ontario, Canada

2
Declaration

• Funded Lectures
• Canadian Paediatric Society
• American Academy of Paediatrics
• Astra Pharmaceuticals
• Abbott Laboratories
• Funded Research
• Abbott
• Centocor
• Advisory Boards
• Childrens Digestive Health Foundation Scientific
  Advisory Board

3
Gastrointestinal Issues

• Feeding and swallowing
• Gastroesophageal Reflux
• Dysmotility
• Over and under nutrition
• Elimination

4
Introduction

• Feeding Disorders are present in
• 25-45 normal children
• 
  (Shapiro 1986, Boyle 1991,Reilly 1996)
• 89 of children with developmental delay
• 
  
  (Motion 2002)
• Sorting out variation in normal from abnormal is
  particularly difficult as
• Eating is highly charged in healthy children and
  families with children with failed feelings bring
  a lot of feelings of guilt and failure (Rudolph)

5
Normal Feeding Swallowing and Gastric Retention
Depends Upon

• The brain-gut axis
• Children with developmental abnormality are at
  risk of impaired feeding and swallowing as well
  as reflux and GI dysmotility because of impaired
• Proprioception
• Normal Muscle Function
• Coordination

6
Feeding and Swallowing

• Neuromuscular control of eating
• Involves 26 muscles
• The pattern of contraction must be exquisitely
  organized
• Feeding and swallowing difficulties may be the
  presenting symptom in children with disordered
  coordination

7
Feeding the Neurologically Disabled

• Children are unable to communicate
• Food preferences
• Hunger
• Satiety
• Caretakers often
• Overestimate the childs dietary energy intake
• Underestimate the time to feed the child

8
Feeding Difficulties in CP

• Feeding problems occur in 40-50 of CP
• Poor suck (58) and difficulty breastfeeding
• Difficulty swallowing (38)
• Difficulties introducing solid foods
• Gagging and choking with feeds
• Feeding difficulties antecede diagnosis in 60

9
Children with CP

• As much of 50 of food may be lost due to lower
  nutrient intake resulting from
• Poor hand to mouth coordination
• Excessive spillage
• Inadequate lip closure
• Drooling
• Persistent extrusion reflex
• Tongue thrust preventing swallowing

10
Children with CP have Different Energy Needs than
other children

• These children have lower height for age and
  lower weight for age
• The 50 for CP children is the 10th ile on
  charts of the NCHS growth charts
• They have lower resting energy expenditure
• These differences increase with increasing age
• Neurological disease may depress linear growth
  even in the absence of malnutrition

11
Appetite and SatietyThe principle of caloric
constancy

• Healthy infants eat to a caloric set point
  the appetite centre in the lateral hypothalamus
• Children with CP may have lower resting energy
  expenditure
• Concentrated formula dulls appetite and induces
  feeding resistance

12
Assessment

• Growth Charts
• Weight for height (BMI)
• Anthropomorphic measurement
• Subcutaneous skin folds
• Bone Age

13
Growth Charts An Essential Pediatric Tool
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The Use and Misuse of Growth Charts

• Growth charts represent cross sectional data on
  hundreds of infants
• These growth charts are based on white american
  children
• Charts may not be appropriate for others
• Real infants grow in fits and spurts

15
Seasonality of Growth

• Canadian children grow
• Faster in summer
• Slower in winter
• Slower with repeated intercurrent illness
• Slower on first exposure to groups of other
  children

16
Big Mother Small Father- Catch Down Growth

• Birth weight reflects mothers weight
• Infant born to big mother and small father will
  adjust growth between the 6th and 18th month

17
Overfeeding the Small Child

• A constitutionally small child will grow at the
  3rd percentile or below you cant feed them out
  of this
• Many disabled children are constitutionally small
• Overfeeding will result in feeding resistance and
  vomiting

18
New CDC Growth Charts

• Mostly based on NHANES data
• Correct some of the previous problems
• Available at www.cdc.gov/growthcharts
• Palm Pilot Growth Chart Calculator developed
  Andrew S. Chen
• www.statcoder.com\
• Calculates BMI and growth deficit as z scores

19
The Feeding and Swallowing (FAST) Team

• Occupational Therapy
• Speech and Language
• Nutrition
• Social Work
• Pediatric GI/ Nutrition MD
• Pediatric Surgeon
• Dentist
• Radiologist

20
Clinical Approach Rudolph

• Medical History
• Developmental history
• Transition of normal milestone
• Temporal relation to medical surgical problems
• Symptoms of GERD
• Airway breathing problems
• Hx of recurrent pneumonias

• Neurological disease
• Infant Feeding Observation
• Vigorous or weak suck
• Efficiency of suck swallow breathing
• Cough gag
• Lethargy
• Duration of feeding
• Parent Child Interaction

21
Laboratory Assessment

• CBC and diff
• Protein/Albumin
• Calcium/Phosphate/Alkaline Phosphatase
• Urea/Creatinine/Electrolytes
• Ferritin, Zinc
• Urine analysis

22
Radiological and Endoscopic Studies

• Investigation
• Chest X-ray
• Abdominal plain film
• Upper GI
• Video Flouroscopy
• 24 Hr pH
• Upper Endoscopy

• Indication
• Chronic lung disease
• Chronic constipation
• Reflux,Dysmotility
• Swallowing dysfunction
• Reflux
• Esophagitis

23
Video fluoroscopy (VFSS)

• A feeding study done in collaboration between
  OT/Speech Path and Radiologist
• Administration of formula/food of graded
  consistency
• Simultaneous clinical assessment and video
  fluoroscopy
• High correlation with clinical assessment for
  liquids but not solids
• DeMatteo, Madovitch,Hjartarson A, CaseP

24
Developmental Medicine and Child Neurology (In
Press)

• A Comparison of Clinical And Videofluoroscopic
  Evaluation of Children with Feeding and
  Swallowing DifficultiesCarol DeMatteo, Dip POT,
  M.Sc.
• Diana Matovich, B.HSc.OT
• Aune Hjartarson, B.HSc.OT
• Trish Case, B.HSc.OT

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Clinical Implications

• VFSS remains the best test to determine the
  presence of aspiration and penetration but it may
  not always be needed as part of a swallowing
  assessment.
• Experienced therapists are very accurate in
  their detection of fluid aspiration and
  penetration
• They are not very accurate in the detection of
  solid aspiration

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Clinical Implications continued

• Experienced therapists should use their
  uncertainty about the presence or absence of
  penetration or aspiration as an indicator that
  VFSS is required
• Cough is the best predictor of fluid aspiration
  and penetration
• Cough does not seem to predict solid aspiration

27
Good Indications for VFSS

• To determine presence of aspiration.
• Query re safety of different texture.
• To provide concrete evidence of paralysis or
  in-coordination unexplained by clinical evidence.
• To assess progress and readiness in known
  aspiration cases.

28
Nutritional Therapeutics Tools of the Trade

• Foods and formulae
• Feeding Tubes
• Gastrostomy/Jejunostomy
• Total Parenteral Nutrition

29
Special Formulae

• Nutritional Components
• Fat
• Protein
• Carbohydrate
• Vitamins/Minerals
• Non Nutritive Components
• Fluid
• Fibre

30
Protein Choice Usually Drives the Choice of
Formula

• Food
• Single source
• Polypeptides
• Hydrolysates
• Casein hydrolysates
• Whey hydrolysates
• Amino Acids

31
Other Ingredients

• Carbohydrate
• Contribute most of the osmotic load
• Lactose intolerance 2o bacterial overgrowth
• Starches/glucose polymers osmotic load
• Fat
• Lower fat gastric emptying
• Fibre
• Helps dysmotility

32
Feeding the Disabled -Principles

• Most disabled children will thrive on regular
  foods modified for ease of delivery
• Children should be fed the simplest (least
  expensive) food or formula
• Protein hydrolysates may be used to facilitate
  gastric emptying
• Amino Acid formulae reserved for patients with
  severe allergy or malabsorption

33
Modular Components

• Formula may be tailored to the individual with
  the addition of modular components
• Fat - Microlipid
• Carbohydrate - Polycose
• Protein Pro-Mod , Casec

34
Concentrating FormulaA Nutritional Charade

• The stomach brings all foods to iso-osmolarity
  based on the number of molecules in the feed
• Low volume concentrated feeds take the same
  gastric volume as higher volume normal feeds
• Concentrated formula should be prescribed for
  cause
• Fluid restriction in cardiac or renal disease
• Gastric Volume Limitation premature, SGA
• Susceptibility to reflux?

35
Tube Feeding

• When the infant or child
• Can not swallow
• Will not swallow
• Is seriously not maintaining weight
• Is not growing
• To bypass the stomach
• To establish a diagnosis

36
Dangers of Enteric Feeding

• Enteric feeding tubes, gastrostomy and
  jejunostomy tubes provide the illusion of control
  
• Excessive feeding beyond the set point will
  produce reflux and /or vomiting
• Problems may worsen when none networked
  community nutritional services set a normal
  weight target for the child

37
GI Reflux in Children with Developmental Delay

• Up to 75 of children with developmental delay
  have evidence of gastroesophageal reflux

38
Gastroesophageal Reflux
Definitions

• Reflux - Regurgitation of gastric contents into
  the esophagus with or without vomiting
• Simple Reflux- The absence of complications and a
  healthy growing infant
• Regurgitation - effortless oral dribbling
• Vomiting-forceful expulsion from the mouth
• GERD - Gastroesophageal reflux disease

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Factors Contributing to Reflux

• Transient LES post prandrial relaxation
• Gravitational clearance
• Decreased peristaltic clearance
• Slow gastric emptying
• Proprioception - developmental factors effect
  receptors in the greater curve
• Reflects neurological integration

40
Gastric Emptying and Reflux

• Gastric emptying is effected by
• Volume/ consistency of feeding
• Fat content/ protein composition
• Temperature of the meal
• Effective esophageal clearance and gastric
  emptying requires coordination
• Stress (physical or emotional) delays gastric
  emptying

41
Progression to Pathologic Reflux

• The Vicious Cycle of GERD
• regional blood flow and local prostaglandin
  content leads to mucosal permeability,
  susceptibility to
  inflammation
• inflammation impairs LES function
• impaired LES function reflux

42
Developmental and Genetic Associated with GI
reflux

• Adrenal Genital Syndromes
• Fetal Alcohol
• Williamss Syndrome
• Turners Syndrome
• Praeder Willy
• Fragile X
• Cornelia De Lange
• Trisomy

43
Available GI Investigations
44
Medications

• Over the counter antacids
• Algicinate acid buffers (high aluminum content)
• Intestinal prokinetics
• Erythromycin (Inconsistent response)
• Metaclopramide (extrapyramidal side effects)
• Domperidone (Pediatric data - poor)
• Cisapride (Arrythmias- Special access only)
• Systemic Antacids
• H2 antagonists and acid blockers (esophagitis)

45
Proton Pump Inhibitors

• Omeprazole, lansoprazol, pantoprazol,esoprazol
• Very effective for acid suppresssion
• Variable PPI dosing in erosive esophagitis in
  children - omeprazole Hassal et al.
• 50 respond to 0.6 mg/kg
• 25 respond to 0.9 mg/kg
• 25 respond to 1.2 mg/kg
• Doses as high as 3.5 mg/kg have been used
• Lansoprazol omeprazole 1.5mg 1.0 mg
• 
  

46
Constipation - definition

• Hard stool.
• Pain with passage of stool
• Ineffective evacuation
• Failure to pass 3 stools/week
• Intestinal Transit times

1-3 M 8.5 h 4-24 M 16 h 3-13 Y 26 h After
puberty 30-48 h
47
The Brain Gut Axis and Constipation

• The neuroenteric nervous system has more nerves
  than the spinal cord
• There is continual cross talk between the gut
  and brain. The Brain Gut Axis
• There is an inverse correlation between age no.
  of high amplitudes propagated contractions before
  after a meal.
• Children with developmental delay have impaired
  motility and are prone to constipation

48
Organic Causes of Constipation

• Anatomic
• Anal stenos.
• Imperforated anus.
• Anterior displaced anus.
• Sacral teratoma.
  
• 2) Metabolic Gastrointestinal
• Hypothyroidism.
• Hypocalcemia.
• Hypokalemia.
• Cystic fibrosis.
• Diabetes Mellitus

• Neurologic
• Hirschsprungs disease.
• Spinal cord dysplasia/hypotonia syndromes.
• Visceral myopathies Neuropathies .
  
• Abnormal Abdominal Musculature
• Prune belly.
• Down syndrome.
• Autoimmune
• Scleroderma

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Other causes

• Antacids (Aluminum Antacids)
• Antispasmotics
• Narcotics (Codeine).
• Phenobarbital.
• Iron.
• 7) Others
• Peri-anal Strep Cellulitis
• Lead poisoning.
• Botulism

50
Laxatives- Tools of the Trade

• Osmotic agents
• Magnesium citrate
• Lactulose
• Polyethylene Glycol PEG Solutions
• Lubricants Mineral Oil, Lansoyl
• Stool softeners - Docusate sodium
• Bulking agents - Psyllium
• Stimulants Senna, Biscodyl

51
The Ins and Outs of Fibre

• Soluble Fibre
• Pectins and guar gums
• Found in most fruits and vegetables
• Lower glycemic index/bind cholesterol
• Insoluble Fibre
• Cellulose and Hemi-cellulose
• Retain water and treat constipation

52
References

• Canadian Paediatric Society. Undernutrition in
  children with neurodevelopmental disability.
  Ottawa 1994. www.cps.ca/english/statements/N/n94-0
  4.htm
• Gremse D. Gastroesophageal Reflux Disease in
  Children An Overview of Pathophysiology,
  Diagnosis and Treatment, Journal of Pediatric
  Gastroenterology and Nutrition 2002 35 (Supp 4)
  S297-299
• North American Society for Pediatric
  Gastroenterology, Hepatology and Nutrition.
  Pediatric Gastroesophageal Reflux Clinical
  Practice Guideline. Journal of Pediatric
  Gastroenterology and Nutrition 2001 32 (Supp 2)
  1-31. www.naspghan.org.

53
References - Continued

• DeMatteo, C., Matovich, D., Hjartarson, A. (in
  press). A comparison of videofluoroscopy and
  clinical evaluation in children with feeding and
  swallowing problems.  Developmental Medicine and
  Child Neurology
• Dematteo, C. (2003) Feeding and Eating
  Interventions for Children and Youth with Brain
  Injury. KC 03-1,  CanChild Keeping Current.
• DeMatteo, C., Law, M., Goldsmith, C.  (2002). The
  effect of food textures on intake by mouth and 
  the recovery of oral motor function in the child
  with a severe brain injury. Physical
  Occupational Therapy in Pediatrics 22(3/4)

54
References - Continued

•  Persad R. Issenman RM. Bringing Up GERD in
  Children, Canadian Journal of CME, STA
  Publications August 2003. www.stacommunications.co
  m/journals/cme/archive.html
• Rudolph CD, Link DT. Feeding disorders in infants
  and children. Pediatr Clin North Am
  20024997-112
• Telch J, Telch F. Practical Aspects of Nutrition
  in the Disabled Pediatric Patient. Clinical
  Nutrition Rounds 200332

55
References - Continued

• Rudolph CD, Mazur LJ, Liptak GS et. al.
  Guidelines for evaluation and treatment of
  gastroesophageal reflux in infants and children
  recommendations of the North American Society
  for Pediatric Gastroenterology and Nutrition. J
  Pediatr Gastroenterol Nutr 2001 32 Suppl. 2,
  S1-31
• Nelson SP, Chen EH, Syniar GM, Christofel KK. One
  year followup of symptoms of gastroesophageal
  reflux during infancy. Pediatrics 1998102 (6) e67

56
References Continued

• Heine RG, Cameron DJ, Hill DJ, et. al.
  Esophagitis in distressed infants poor
  diagnostic agreement between esophageal pH
  monitoring and histopathologic findings. J
  Pediatr 200214014-9
• Orenstein SR, An overview of reflux-associated
  disorders in infants apnea, laryngospasm and
  aspiration. Am. J. Med 2001 111 (Supp 8a) 60S-63S
• Marchand V, Motil KJ Nutrition Support for
  Neurologically Impaired Children. North American
  Society for Pediatric Gastroenterology,
  Hepatology and Nutrition, 2005, In press