Alternative Feeding Routes

Many children with CP are not able to meet some or all of their calorie needs by mouth due to one or more of the following conditions: oral motor dysfunction, excessive energy needs, recurrent infections, illnesses, and orthopedic surgical interventions. Consequently, if the gastrointestinal tract is functioning, supplemental or total tube feedings may be indicated. Early intervention with enteral nutrition may prevent protein-energy malnutrition and its complications. Studies have shown improvements in weight gain (fat mass as opposed to fat-free mass) with supplemental tube feedings, which better enables individuals to endure short-term medical insults.

Enteral nutrition may be delivered by nasogastric, nasojejunal, gastrostomy, gastrostomy-jejunal, and jejunostomy tubes. The degree of GER and risk of aspiration determine where the tube is placed, whereas the length of time needed for tube feedings determines whether a nasoenteral or surgically placed tube is required. The decision regarding continuous, intermittent, or combination tube feeds is dependent on the individual needs of the patient.

Tube feedings should be considered a tool to improve nutritional status rather than failure of the child's ability to eat. Based on the medical diagnosis and developmental stage of the child, the prognosis for return to oral feeding varies, and the length of time to achieve this goal is extremely variable. For some children, the goal of returning to full or partial oral feeding is not realistic. In a study evaluating the health of children with CP, Liptak describes those who were tube fed as having the lowest mental age, requiring the most health care resources, using the most medications, and having the most respiratory problems. These children were characterized as especially frail and required numerous health-related resources and treatments. Oral motor therapy

Table 7 Benefits of nonnutritive oral stimulation

Maintains oral sensation and tolerance Facilitates saliva production, swallowing, and other oral motor patterns

Maintains or develops coordination of respiration and swallowing Facilitates parent-child interactions should focus on maintaining existing oral motor skills, encouraging pleasurable oral experiences, and tolerance of oral hygiene practices. Nonnutri-tive oral stimulation must be performed when tube feedings are employed as the route of nutrition. The benefits are listed in Table 7. Improvement in nutritional status can result in positive changes in oral feeding.

Parenteral nutrition should only be used when the gastrointestinal tract is dysfunctional. When initiating feedings in patients with major weight loss or failure to thrive, whether enteral or parenteral nutrition is used, it is important to be aware of the 'refeeding syndrome.' This syndrome refers to phosphorus depletion and alterations in potassium, magnesium, and glucose metabolism, resulting in severe metabolic and physiological complications. It is imperative to increase calorie delivery slowly with close laboratory monitoring.

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