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Cerebral Palsy and PEG Olivia Cossari ARAMARK Dietetic Internship Southern Ocean Medical Center December Cerebral Palsy and PEG Olivia Cossari ARAMARK Dietetic Internship Southern Ocean Medical Center December 22, 2013

Case Report Presentation Contents l l l Disease Description Evidence-Based Nutrition Recommendations Case Presentation Case Report Presentation Contents l l l Disease Description Evidence-Based Nutrition Recommendations Case Presentation Nutrition Care Process (NCP): ADIME Conclusion

 Disease Description l l Cerebral Palsy – A group of disorders caused by Disease Description l l Cerebral Palsy – A group of disorders caused by any insult or damage to a premature brain Rick Factors – Maternal - Rubella, varicella, cytomegalovirus, toxoplasmosis, syphilis, toxin exposure, and thyroid problems – Infant - bacterial meningitis, viral encephalitis, and untreated jaundice – Delivery - premature birth, low birth weight, breech delivery, and multiple gestations.

 Disease Description Continued l l Signs and Symptoms – Inability to verbalize – Disease Description Continued l l Signs and Symptoms – Inability to verbalize – Delayed blinking – Inability to turn head – Seizures – Difficulty holding objects – Swallowing difficulties – Lack of focus – Deafness Complications – Poor muscle tone of body and face – Speech impairment – Learning disabilities – Feeding difficulties – Sensory impairment

Disease Description continued… l Management – Develop a Care plan l Diagnosis l Assembly Disease Description continued… l Management – Develop a Care plan l Diagnosis l Assembly of a care team l Assessment of abilities l Determining goals l Creating a care plan l Maintaining records. – The care plan may include l Optimizing mobility l Pain control l Preventing compilations l Maximizing dependence l Enhancing social interaction l Maximizing learning potential l Enhancing the quality of life

Disease Description Continued l Forms – Spastic - stiffness and movement difficulties l Hemiplegia Disease Description Continued l Forms – Spastic - stiffness and movement difficulties l Hemiplegia – affects half of the body l Monoplagia – affects only one limb l Quadriplegia – affects either both arms or both legs. l Triplegia – affects either both arms and one leg or both legs and one arm – Non-spastic –muscle tone l Dyskinetic – uncontrolled movements of neck, face, hands, or limbs. l Ataxic – Uncontrolled movements of the entire body – Disturbed sense of balance and depth perception

Percutaneous Endoscopic Gastrostomy l Percutaneous Endoscopic Gastrostomy (PEG tube) tube placed through the skin Percutaneous Endoscopic Gastrostomy l Percutaneous Endoscopic Gastrostomy (PEG tube) tube placed through the skin into the stomach using an endoscope Indications – normal gastro-intestinal function – need to bypass the upper gastro-intestinal tract Advantages – long term use – reduced risk of tube displacement – choice of continuous or bolus feeding Disadvantages – surgical procedure – risk of irritation and infection at insertion site. – http: //www. gastrosanmarcos. com/peg. html

Evidence Based Nutrition Recommendations According to the American Society for Parenteral and Enteral Nutrition Evidence Based Nutrition Recommendations According to the American Society for Parenteral and Enteral Nutrition (ASPEN) l l “Long-term access is dependent on the estimated length of therapy, the patient’s disposition, and the special needs of the patient and caregivers. ” “Two studies of adult patients with persistent dysphagia due to neurological diseases randomized patients to naso-gastric (NG) feedings or percutaneous endoscopic gastrostomy (PEG) placement. ” “These studies found that the patients with PEGs had greater weight gain and fewer missed feedings. ” “The patients fed by NG had a significant decrease in the amount of formula they received because of tube difficulties compared to the PEG patients who had no such difficulties. ” ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 148.

Tube Feeding Formula l l l Enteral formulas can be used in a PEG Tube Feeding Formula l l l Enteral formulas can be used in a PEG tube. Polymeric– Whole protein sources – Nutrients in whole form – Useful for patients with normal functioning GI tract. – Examples: Ensure, Glucerna, Jevity, Nepro, Monomeric– hydrolyzed, or predigested, nutrients. – Useful for patients with diminished digestive or absorptive ability. Some enteral formulas contain fiber to support bowel function – Examples: Perative, Pivot 1. 5, Peptamen

Evidence Based Nutrition Recommendations l Interventions for Feeding and Nutrition in Cerebral Palsy l Evidence Based Nutrition Recommendations l Interventions for Feeding and Nutrition in Cerebral Palsy l AHRQ (2013) Systematic review of 1, 055 citations and 553 articles. Reviewed studies including classification and spectrum of disorder, feeding difficulties and interventions, clinical uncertainties. Results – 2. 7 % (n= 15) met inclusion criteria – 40. 0 % (n=6) of these studies included data about the effectiveness of tube feeding for feeding difficulties. l One cohort study indicated data of overfeeding with gastrostomy. l One case series indicated the potential for GERD with gastrostomy. l Six case series indicated significant weight increase after gastrostomy in 6 -20 months. l One of these case series reported improvements on all weight and growth related outcomes. l One case series assessed health care utilization for overall health and found the number of hospitalizations significantly reduced over the year following gastrostomy. l One study reported significant correlations between severity of motor impairment and feeding problems including choking, underweight, prolonged feeding times, vomiting, and need for gastrostomy feeding (p values typically <0. 005). l There is limited data on role of feeding interventions for adults with CP. l l l AHRQ. Interventions for feeding and nutrition in cerebral palsy. Comparative Effectiveness Review. Number 94. March 2013. Accessed

Evidence Based Nutrition Recommendations Percutaneous Endoscopic Gastrostomy (peg): Retrospective Analysis of a 7 -year Evidence Based Nutrition Recommendations Percutaneous Endoscopic Gastrostomy (peg): Retrospective Analysis of a 7 -year Clinical Experience l l l l Vanis N, Sara A, et al. (2012) 7 year Retrospective analysis of 359 patients receiving PEG tube placement. Assessment of indications, success, and complications Cerebral Palsy indication for PEG : 11% (n=38) patients Success rate (n= 341, 95. 0%) Complications (n=30, 9. 2%): – Minor l Wound infection (n=3, 0. 8%), l Tube leakage (n=4, 1. 10%), l Stoma leakage (n=2, 0. 56%) l Inadvertent PEG removal (n=9, 2. 5%) l Tube blockage (n=4, 1. 1%). – Major complications l Hemorrhage (n=4, 1. 1%) l Tube migration (n=3, 0. 8%) l Buried bumper syndrome (n=2, 0. 56%) Conclusion – PEG provides durable access for enteral nutrition – prevents malnutrition – reduces hospitalization Thompson M, Prithviraj R. Percutaneous endoscopic gastrostomy and Gastroesophageal reflux in neurologically impaired children. World J of Gastroenterology. 2011 January 14; 17(2): 191 -196.

Evidence Based Nutrition Recommendations l Growth and Nutrition Disorders in Children with Cerebral Palsy Evidence Based Nutrition Recommendations l Growth and Nutrition Disorders in Children with Cerebral Palsy – – Kuperminc M, et al. 2008. Multicenter study of 273 children with moderate to severe cerebral palsy. Growth and development - key measures of determining health in children. Patients who suffer from cerebral palsy often experience: l l Slower growth than children without health disorders Diminished body fat composition Adequate nutrition is important for motor functioning, neurological, and physiological functions. – Malnutrition may lead to: l l Diminished muscle mass. Weakened respiratory system – Increasing risk for pneumonia. l Cardiac conditions l Compromised immune system – – l Increasing the susceptibility of disease and impaired wound healing. Neurological implications – – Contributing to heart failure. Diminished growth, delayed cognitive development, and abnormal behavior. About 35% (n= 96) of patients with cerebral palsy are malnourished. Kuperminc M, Stevenson R. Growth and nutrition disorders in children with cerebral palsy. Dev Disabil Res Rev. 2008; 14(2): 137 -146.

Evidence Based Nutrition Recommendations Continued…. l Growth and Nutrition Disorders in Children with Cerebral Evidence Based Nutrition Recommendations Continued…. l Growth and Nutrition Disorders in Children with Cerebral Palsy – Kuperminc M, et al. 2008. Intervention – interpretation of nutritional status l l – – Deterimine target weight Maximizing oral intake l l – Past medical history Physical examinations Diet history Anthropometry. optimizing caloric intake nutrition support increasing feeding frequency addition of supplements. If unable to consume foods orally due to dysphagia or other swallowing difficulties l l l Utilize tube feeding regimens Nasogastric is recommended for short term supplementation. PEG tube is optimal for long term supplementation. Monitoring changes in weight gain is essential to ensure successful treatment Kuperminc M, Stevenson R. Growth and nutrition disorders in children with cerebral palsy. Dev Disabil Res Rev. 2008; 14(2): 137 -146.

Case Presentation l l Mr. G is a 57 year old male that resides Case Presentation l l Mr. G is a 57 year old male that resides at a long care facility. He was brought in to the hospital when his family and caregivers noticed unusual behavior. He was admitted with pneumonia with chief complaints of fever and altered mental status. Mr. G was started on the polymeric formula Glucerna 1. 0 at 75 ml/hr (5 cans/day) providing 1800 calories, 1800 ml fluid, and 75 grams protein via PEG per MD order

NCP: l ADIME Client History (CH-2. 1) – Mr. G has dysphagia and recurrent NCP: l ADIME Client History (CH-2. 1) – Mr. G has dysphagia and recurrent aspiration pneumonia resulting in a previous PEG tube placement. *The Academy of Nutrition and Dietetics recommends that providers of medical nutrition therapy use the Nutrition Care Process as a means of describing and providing standardized care. The NCP was utilized for the case subject, as well as, ARAMARK standards and the International Dietetics and Nutrition Terminology Reference Manual (IDNT).

NCP: l ADIME Food/Nutrition Related History (FH-1. 1. 1) – At the long-term facility, NCP: l ADIME Food/Nutrition Related History (FH-1. 1. 1) – At the long-term facility, Mr. G is on the monomeric formula, Peptamen, at the rate of 60 ml/hr, or 6 cans per day. This would provide Mr. G with 1850 calories, 1210 ml fluid, and 82 grams protein. – No known food allergies – No supplement prior to admission

Prescribed Medications Medication Rationale Side-Effects Enoxaparin (Lovenox) Anti-Coagulant Diarrhea Clonazepam (Klonopin) Treats seizure disorders Prescribed Medications Medication Rationale Side-Effects Enoxaparin (Lovenox) Anti-Coagulant Diarrhea Clonazepam (Klonopin) Treats seizure disorders Diarrhea and Nausea Lactobacillus Acidophilus Maintain normal flora Flatulence Vancomycin Anti-biotic Nausea, Vomiting, Flatulence Midodrine (Proamatine) Increase blood pressure Dizziness Naproxen (Naprosyn) Reduce inflammation Nausea and Vomiting Albuterol Bronchodilator Shakiness

NCP: l ADIME Nutrition-Focused Physical Findings (PD-1. 1. 5) – – – Significant weight NCP: l ADIME Nutrition-Focused Physical Findings (PD-1. 1. 5) – – – Significant weight loss of 30# since previous hospitalization noted Prior to admission – mal-nourished Dysphagia

NCP: l ADIME Anthropometric Measurements (AD-1. 1) – 73 inches – Admission body weight NCP: l ADIME Anthropometric Measurements (AD-1. 1) – 73 inches – Admission body weight (10/15) : 140 #, BMI 18. 4, Underweight – Current body weight (11/15) : 121 # , BMI 15. 9, Underweight – Ideal body weight (IBW) 184# – Current weight is 65. 8% of IBW Height 6’ 1” 73 inches 185 cm Weight 1 st : 140 # /64 kg 2 nd: 121# /55 kg IBW 184 +- 18. 4 lbs 166 to 202 lbs 75 to 92 kg BMI 1 st: 18. 4 (underweight) 2 nd: 15. 5 (underweight)

NCP: l ADIME Biochemical Data, Medical Tests and Procedures – – – Glucose profile NCP: l ADIME Biochemical Data, Medical Tests and Procedures – – – Glucose profile (BD-1. 5) Gastrointestinal profile (BD-1. 4) Acid-base balance (BD-1. 1) Protein panel (BD-1. 11) Electrolyte and renal profile (BD-1. 2)

NCP: l ADIME Nutrient Needs during Initial Assessment – Energy requirements (CS-1. 1. 1) NCP: l ADIME Nutrient Needs during Initial Assessment – Energy requirements (CS-1. 1. 1) l l – Protein requirements (CS-2. 2. 1) l l – Admission weight of 140# / 64 kg 1600 to 1900 calories (25 -30 cal/kg), 64 -76 grams protein (1 -1. 2 g/kg). Since the patient was under stress his nutrient requirements for protein were elevated. Fluid requirements (CS-3. 1. 1) l 1900 ml fluid (30 ml/kg),

 Lab Values Lab Measurement Value Normal Value Rationale WBC 25. 6 H 4. Lab Values Lab Measurement Value Normal Value Rationale WBC 25. 6 H 4. 1 -10. 9 K/u. L Infection /stress Glucose 109 H 65 -99 mg/d. L Stress BUN 20 H 7 -8 mg/d. L Dehydration, excessive protein catabolism, renal disease Albumin 3. 0 L 3. 4 -5. 0 G/ d. L Malnutrition, short-term protein and energy deficiency, acute inflammation, fluid retention Creatinine 0. 44 L 0. 8 -1. 3 mg/d. L Effective kidney function

 NCP: l ADIME ARAMARK Nutrition Status Classification – 20 nutrition care points = NCP: l ADIME ARAMARK Nutrition Status Classification – 20 nutrition care points = Status 4 -Severely compromised l 3 points for nutrition history (Swallowing problems ) l 4 points for feeding modality (TPN/PPN and NPO >4 days) l 4 priority points for unintentional wt loss ( >10% in 6 months) l 3 points for weight status (BMI 16. 0 -16. 9) l 2 points for serum albumin (3. 0 -3. 4 g/d. L) l 4 points for diagnosis/condition (malnutrition) – Follow up should be scheduled in 1 -4 days

NCP: A l DIME NCP: Nutrition Diagnosis – Upon reassessment the patient…. Nutrition Diagnosis NCP: A l DIME NCP: Nutrition Diagnosis – Upon reassessment the patient…. Nutrition Diagnosis / PES Statements Domain Problem/Nutrition Diagnosis r/t Etiology aeb Signs/Symptom s Intake (NI-2. 3) Less than optimal enteral nutrition composition related to Adjusted calculated needs as evidenced 20 lb weight loss by Clinical (NC-2. 1) Impaired nutrients utilization related to Polymeric tube feeding formula as evidenced 20 lb weight loss by Clinical (NC-3. 4) Unintended weight loss related to Insufficient energy intake as evidenced Calculated needs by

NCP: ADIME NCP: Interventions Mr. G’s energy requirements were recalculated, accounting for his physical NCP: ADIME NCP: Interventions Mr. G’s energy requirements were recalculated, accounting for his physical activity: l Energy requirements (CS-1. 1. 1) – Harris-Benedict equation – An activity factor of 1. 3 (active), – Ideal body weight of 75 kg – ~2100 calories per day. l Protein (CS-2. 2. 1) – IBW of 75 kg was multiplied by 1. 5 (for stress) – ~105 grams protein per day l Monomeric formula – Perative @ 70 ml/hr to provide 1680 ml, 2100 calories, and 112 grams amino acid.

NCP: ADIME l Nutrition Care Process: Monitoring and Evaluation – High nutritional risk follow-up NCP: ADIME l Nutrition Care Process: Monitoring and Evaluation – High nutritional risk follow-up 3 to 5 days. l Food and Nutrition-Related History – Food and Nutrient Intake l Energy intake - Total energy intake (FH-1. 1) Meet needs l Protein intake - Total protein (FH-1. 5. 2. 1) Meet needs – Food and Nutrient Administrationl Enteral nutrition intake – Formula/solution (FH- 2. 1. 4. 1). Evaluated for total energy and protein intake.

NCP: ADIME l Anthropometric Measurements – l Body composition – Weight (AD-1. 1. 2) NCP: ADIME l Anthropometric Measurements – l Body composition – Weight (AD-1. 1. 2) monitored daily via bed scale. Biochemical Data, Medical Tests and Procedures – Protein profile- Albumin (BD-1. 1). Monitored daily to evaluate effectiveness of nutritional therapy and state of malnutrition. Recommendations for discharge – – Monitor weight Continue to follow up 3 -5 days or as needed per MD or RN request.

Conclusion l Cerebral palsy and PEG tube formula introduced many barriers and complications for Conclusion l Cerebral palsy and PEG tube formula introduced many barriers and complications for calculating his energy, protein, and nutrient needs. l Mr. G lost over thirty pounds due to these complications. l After trial and error, Mr. G’s caloric needs where able to be recalculated to meet his actual needs. l Mr. G’s activity factor greatly implemented his needs. This activity factor was misleading due to his immobility. Also, Mr. G’s tube feeding was overlooked. l Mr. G tolerated the polymeric formula well when considering residual, despite this, he was unable to absorb the nutrients at an optimal rate. l Changing Mr. G’s formula to a Monomeric formula greatly enhanced absorption. l Mr. G was shortly discharge as his symptoms resided, it is unclear whether nutrition ultimately resolved these symptoms but it is clear that his weight loss was attributed to the incorrect formula at an incorrect rate.

References l l l l l l l l 1. Percutaneous Endoscopic Gastrostomy. clevelandclinic. References l l l l l l l l 1. Percutaneous Endoscopic Gastrostomy. clevelandclinic. org/services/ percutaneous_endoscopic_gastrostomy_peg/hic_percutaneous_endoscopic_ gastrostmy_peg. aspx. Cleveland Clinic. Updated January 1, 2013. Accessed December 2013. 2. Kim S, Pellegrino L. Types of cerebral palsy causes symptoms and treatment. everydayhealth. com/health-center/types-of-cerebral-palsy. aspx. Everyday Health. Updated September 30, 2010. Accessed December 2013. 3. Cerebral palsy. cdc. gov/ncbddd/cp/index. html. Centers for Disease Control and Prevention. Updated October 17, 2013. Accessed December 2013. 4. Kuperminc M, Stevenson R. Growth and nutrition disorders in children with cerebral palsy. Dev Disabil Res Rev. 2008; 14(2): 137 -146. 5. Thompson M, Prithviraj R. Percutaneous endoscopic gastrostomy and Gastroesophageal reflux in neurologically impaired children. World J of Gastroenterology. 2011 January 14; 17(2): 191 -196. 6. Holliday MA and Segar WE. The Maintenance Need for Water in Parenteral Fluid Therapy. Pediatrics 1957; 19; pg 823 -832. 7. Theberge C, Illing A. Nutrition in cerebral palsy. nafwa. org/cp 1. ph. Nutrition and Food Web Archive. Updated 2005. Accessed December 2010. 8. Charney P, Malone AM. ADA pocket guide to nutrition assessment. American Dietetic Association. 2009; 2 nd ed: 167 -191. 9. Perative®. Abbott Nutrition. http: //abbottnutrition. com/brands/products/perative. 10. Journal of Parenteral and Enteral Nutrition, Vol. 33, No. 2, 122 -16753 (2009) 11. Nelms M, Sucher KP, Lacey K, Roth SL. Nutrition Therapy & Pathophysiology. Belmont, CA. Cengage Learning. 2011. 12. ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 148. 13. Academy of Nutrition and Dietetics. Pocket Guide for International Dietetics & Nutrition Terminology Reference Manual. 4 th ed. Chicago, Il: Academy of Nutrition and Dietetics ; 2013. 14. AHRQ. Interventions for feeding and nutrition in cerebral palsy. Comparative Effectiveness Review. Number 94. March 2013. Accessed December 2013. 15. Vanis N, Saray A, et al. Percutaneous Endoscopic Gastrostomy (peg): Retrospective Analysis of a 7 -year Clinical Experience. ACTA INFORM MED. 2012 Dec; 20(4): 235 -237. Accessed December 2013.

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