Cerebral Palsy Secondary

to Hypoxic Ischemic
Encephalopathy:
Nutrition Support and Medical
Nutrition Therapy in a Pediatric Patient

Sean Servalish - Andrews University

 Overview
Patient Overview
Background of Patient
Diseases and Conditions
HIE, Cerebral Palsy and
Respiratory Complications in
CP
CP Patient
Social History, Medications,
Lab Values
Admission Timeline (Day 1-6)
Nutrition Care Process
Involved
Assessment, Diagnosis,
Interventions,
Monitoring/Evaluation
Prognosis of Patient
References
 Patient Summary
11-year-old female. Past Medical History
Current Medical Condition: Hypoxic Ischemic Encephalopathy
(HIE) at birth with demise of twin.
Cerebral Palsy Epilepsy with seizures occurring
Labored breathing, noticeably occasionally.
increased coughing, nasal Reoccurring upper respiratory
congestion and snoring. infection with frequent Pneumonia
diagnoses is the past.
Blood work/clinical findings
G-tube placement with dependence
revealed RSV (Respiratory on tube feeding.
Syncytial Virus).
 Hypoxic Ischemic
Encephalopathy (HIE)
(Also known as Intrapartum Asphyxia)

The lack of oxygen to the brain, resulting in permanently damaged

brain tissue.
This occurs most often in infants during birth. Most commonly in
multi-fetal and premature births.
The area of the brain affected or damaged determines the severity
of the hypoxic event.
There are three levels of HIE: mild, moderate, and severe.
HIE at birth is the most common cause of Cerebral Palsy.
 Risk Factors for HIE
The direct cause of HIE is difficult to determine and was not
specified in this patient. The following factors make a
pregnancy high-risk for infant HIE:
Maternal Obesity and High BMI Maternal immune system
Diabetes in the disorders(HIV/AIDS)
mother(especially if undetected or
improperly treated)
Maternal use of alcohol or
tobacco during pregnancy
High Blood
pressure(Preeclampsia) Intrauterine growth restriction
Multiple gestations, including (IUGR)
twins, triplets or more children at History of prior abruption, IUGR,
once or preterm birth
The Cerebrum
 Cerebral Palsy
The most common disorder in children that impairs motor
function.
Prevalence: estimated 764,000 individuals in the US living with
CP.
Incidence: about 10,000 babies each year will develop CP.
Cerebral Palsy affects body movement, muscle control, muscle
coordination, muscle tone, reflex, posture and balance. It can
also impact fine motor skills, gross motor skills and oral motor
functioning.
Classifying Cerebral Palsy
It can be classified specifically using different systems:
Severity level
Topographical distribution
Motor function
Gross motor function
Typically an initial diagnosis is specific and extensive,
but the classification system used depends on policy
and preference of the physician.
 Classification Based on Severity

Mild: a child can move without assistance; his or her

daily activities are not limited.
Moderate: a child will need braces, medications, and
adaptive technology to accomplish daily activities.
Severe: child will require a wheelchair and will have
significant challenges in accomplishing daily
activities.
 Classification Based on
Topographical Distribution
Paresis = weakened
Monoplegia/paresis = one limb is
affected
Diplegia/paresis = two limbs
affected
Hemiplegia/paresis= arm and leg
on one side of body are affected
Tetraplegia/paresis = all four
limbs, three limbs more than the
fourth.
Plegia= paralyzed
Paraplegia = lower half of body
affected
Triplegia/paresis = three limbs
affected
Double Hemi= all four limbs involved,
but one side more than the other.
Quadriplegia= all four limbs equally.
Pentaplegia= all four limbs with
head/neck complications also.
 Classification Based on
Motor Function
Spastic vs Non-Spastic
Spastic (Pyramidal) CP: increased muscle tone.
Hypertonia, contractures
Non-Spastic (Extrapyramidal) CP: decreased or
fluctuating muscle tone
Hypotonia
Having both spastic and non-spastic CP is possible (Mixed
CP).
 Classification Based on Gross
Motor Function
5 Levels of Gross Motor Function Classification System (GMFCS).
These are used to determine the most appropriate growth chart as
well.
GMFCS Level 1: walks without limitations
GMFCS Level 2: walks with limitations. Limitations include walking long
distances and balancing, but not as able as Level I to run or jump
GMFCS Level 3: walks with adaptive equipment assistance.
GMFCS Level 4: self-mobility with use of powered mobility assistance.
GMFCS Level 5: severe head and trunk control limitations. Requires
extensive use of assisted technology and physical assistance
 Respiratory Complications in CP
Patients
Patients with CP are at higher risk of
Respiratory Complications like URI, RSV
and Pneumonia due to a decreased ability to
clear respiratory secretions and in severe
cases of CP, increased aspiration risk.
Also, immune systems are weaker and
patients with CP who are bed/wheelchair
bound has had less exposure to
bacteria/viruses in everyday life, causing a
decreased ability to fight them off.
Back to the
patient
 Social History/Background
Lives at home with her mother, father and two younger
brothers.
She receives PT and nursing services in-home through Lakeland
Homecare.
Attends a special needs school in Berrien Springs
Completely dependent upon her family for nutrition through her
G-tube (PEG) and for ADLs (activities of daily living).
Uses a special car-seat, bath chair, suction machine and a
wheelchair at home.
Works with Bronson Healthcare group for CP-related follow-ups
(Medical and nutrition related)
 Medications Prior to Admission
Medication Purpose
Albuterol (PRN) For wheezing, shortness of breath.
(Bronchodilator)
Diazepam For seizure control, muscle disorders
and/or anxiety.
Calcium To increase calcium levels and bone
density
Keppra Anticonvulsant for seizures
Pediatric Meet daily requirements for vitamin
Multivitamin intake
 Abnormal Lab Values
upon Admission

White Blood Cell Count

14.8 (High)
Random Glucose 112
(High)
Blood Urea Nitrogen (BUN)
4 (Low)
Creatinine 0.3 (Low)
Likely Cause of Abnormal Lab Values
in this Patient
High glucose infection/stress
High WBC infection
Low BUN/creatinine may indicate liver
damage, or a lack of protein in the diet
(her formula does not supply high
amounts of protein)
 Admission Timeline (Day 1)
Patient admitted to Lakeland Hospital ED by parents with
complaints of labored breathing, increase sputum/nasal congestion
and coughing.
Mother of patient reports that she and another child in the
house have had URI symptoms this week, and the patient had
recently started experiencing similar symptoms.
Chest X-Ray came back negative for pneumonia. Typically, this
would not call for an admission. With her CP condition and
insistence of the parents, she was admitted to the Pediatric Unit at
Lakeland.
 Admission Timeline (Day 2)
RSV positive.
O2 saturation varying from high 80s to low
90s. O2 via nasal canula being
supplemented.
Patient family report she had an epileptic
event prior to symptoms starting,
aspirating pneumonia is now suspected.
 Admission Timeline (Day 3)
Fever, labored breathing and O2 levels have
not improved with current treatment.
White blood cell count elevated higher than
admission numbers.
Antibiotics (clindamycin) to begin if fever,
WBC and neutrophil count fail to improve.
 Admission Timeline (Day 4)
Patient experienced an episode of pain today, with
unclear etiology.
An ultrasound of the gallbladder was performed and
gallstones were detected in the patient.
This was suspected due a history of them. Her urologist
in Kalamazoo was referred to for a cholecystectomy.
Clindamycin dosing initiated due to no
improvement in symptoms.
 Admission Timeline (Day 5)

Fever and WBC count improved with

clindamycin dosing.
No further signs of pain/episodes of
pain.
To discharge in the morning if
improvement continues.
 Admission Timeline- Discharge
(Day 6)
Patient was discharged home on day 6 of her time at Lakeland.
All of her home medications were continued, while adding
Clindamycin to her daily regimen until she completes the
prescription.
Her RSV was not resolved during her admission and her
diagnoses of gallstones, aspirating pneumonia and HIE remain
unresolved. However, she is not stable and has had
improvement in her condition enough to discharge home.
 Abnormal Lab Values Upon
Discharge
Blood Urea Nitrogen 3 (Low)
Creatinine 0.3 (Low)
Patients random glucose and WBC
were back within normal range by
discharge.
Nutrition
Care Process
for Patient
 Nutrition Assessment
High risk patient due to form/method of nutrition (enteral via
PEG)
Admission weight of 34.5 kg/75.9 lbs.
There was no current height within the past year; this is a
challenge to obtain accurately with contractures and other
condition related barriers.
Nutrition support regimen at home:
Nutren Junior: 3.5 ounces mixed with 2.5 ounces H20, six times daily.
Tube flushes after each feeding of 120 ounces.
 Growth Charts in Pediatrics
Instead of BMI in infants, we use growth charts to assess weight,
height (length) and head circumference.
After 36 months or age 3, we no longer observe head circumference
in children.
Ideally we use weight-for-stature from ages 2-5 and can start using
BMI-for-age from ages 5-20.
From birth to 24 months, we use WHO growth charts (World Health
Organization). For children ages 2 and up, we use CDC growth
charts. (Centers for Disease Control)
CDC Growth
Chart
 Growth Chart
Interpretation
To assess the weight-
for-age for this patient
we must use a Special
Needs growth chart for
cerebral palsy children.
Her weight-for-age is
just under the 90th
percentile. This
indicates her weight is
high compared to
females her age with CP.
Height-for-age and BMI
was not
observed/assessed due
to a non-current height.
 Calculating Needs in Pediatrics
Determining the REE for children is typically done
using the WHO or Schofield equation. In this patient,
Age the WHO equation
Kcal/d Age was used.Kcal/d
Males: Females:
0-3 60.9W-54 0-3 61W-51
3-10 22.7W+495 3-10 22.5W+499
10-18 17.5W+651 10-18 12.2W+746
18-30 15.3W+679 18-30 14.7W+496
Activity/injury factors are multiplied by the REE to obtain for more
specific needs.
 The Math.

12. 2 (34.5kg) +
745
= 1,166 kcal daily
 Cerebral Palsy Considerations
Cerebral Palsy patients have a lower energy expenditure,
especially wheelchair confined, low activity individuals like this
patient.
To accurately calculate their needs from their REE, you multiply
by 0.50 to 0.61 to receive the REE for a CP patient.
50-61% of the previously calculated 1,166 calories = 583-
712 kcals.
The activity factor for CP with acute illness is 1.1. This gets to a
recommended range of 642-783 kcal.
 Protein Calculations
Protein requirements are not typically altered for CP
specifically. For her age 0.85 g/kg is recommended.

Age g/kg/day
0.92 x 34.5kg Range
= ~32g 9-11
years
0.92

of Protein in a 12-13 0.92

day. years
14-16 0.85
years
 Fluid Calculations
Cerebral palsy fluid/hydration needs are also
pretty standard.
Weight in kg Fluid Needs
1-10 kg 100 ml/kg
11-20 kg 1000 ml + 50 ml/kg for
each kg >10 kg
>20 kg 1500 ml + 20 ml/kg for
kg is 14.5 kg over
each 20 kg.
kg >20 kgTherefore, the calculation is: 1500 ml + 20
= 1790 ml fluid
 Current Regimen
Nutren Junior: 3.5 oz. mixed This is below her recommended
with 2.5 oz. of water at each calculated range for calories and
feeding. protein.
Flushes: 120 ml H20 after
feeds. Her history shows that she has
always received less than her
Feeding 6 times daily.
recommended range and has
This provides: 630 kcal, 19 gcontinued consistent growth
of protein and 1707 ml trends, while remaining at a
fluid high percentile for age.
 Formula Considerations for
Patient
Her epileptic medications, especially
phenobarbital, can reduce motility. There
has been no signs of poor gastric emptying
in her history and her growth patterns are
consistent.
She is close to needing an adult formula.
Nutren 1.0 with fiber is similar to Nutren
Junior with more adult nutrient content.
 Nutrition Diagnoses
Decreased energy needs r/t decreased energy expenditure
AEB estimated needs in child with spastic quadriplegic
cerebral palsy; requires enteral feedings, following
consistent growth patterns per weight on growth chart.
Inadequate oral intake r/t inability to consume sufficient
energy AEB enteral nutrition via PEG tube, dysphagia and
Cerebral palsy condition.
 Nutrition Goal

Our nutrition related goal for this patient

was to continue to meet >75% (ideally 90-
100%) of her nutritional needs via enteral
nutrition over 1-4 days.
 Nutrition Interventions
Order enteral formula/solution
same provisions as prior to
admission.
Order feeding tube flushes same
provisions as prior to admission.
Order vitamin and mineral therapy
pediatric multivitamin and calcium
that was being supplemented prior
to admission.
Nutrition Monitoring/Evaluation
Growth patterns, enteral nutrition
formula/provision (tolerance while acutely
ill with gastric mobility affecting
medications, need for adult formula),
digestive system (aspiration, vomiting,
diarrhea with antibiotics), medications
(antibiotics, epileptic meds), electrolyte
and renal profile and medical plan
(cholecystectomy possibility).
 Prognosis of Patient
RSV symptoms resolved. However aspirating
pneumonia remains a risk in this patient due to
her condition of CP from her HIE. Unfortunately,
cerebral palsy in not curable and is currently only
manageable. Therefore, the likelihood of another
respiratory infection or related disease is high.
50% of CP patients will live until age 13 and 25%
until age 30. Longevity of life is very reduced in
general.
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