NON-SURGICAL NUTRITIONAL INTERVENTIONS IN CHILDREN WITH CEREBRAL PALSY: DEVELOPING A TARGETED INTERDISCIPLINARY APPROACH IN A LOW-COST SETTING

Christineil Thompson MD 1, Keneisha Bailey-Correa MD 1. 1 Department of Pediatrics, The Brooklyn Hospital Center, New York, New York

Background: 
The feeding difficulties surrounding children with cerebral palsy are a well-documented occurrence. As advancements continue into perinatal and neonatal care, the prevalence of premature and low birth weight infants have increased over recent years. This trend is reflected in the current number of children who develop cerebral palsy in later years. In addition, the growing frustration surrounding mealtimes in both the child and caregiver is a significant factor which compounds each interaction. These difficulties frequently result in failure to thrive which complicates the global development of this population even further and often necessitates a surgical intervention.

Methods: 
A review of recent existing literature limited between 2005 and 2020 was conducted utilizing the PubMed database using the search terms “Pediatric patients with Cerebral Palsy” linked with the Boolean operator AND to the term “Feeding Techniques”. Results were then analyzed to determine the baseline clinical status of patients, the type of feeding intervention used, inpatient versus outpatient intervention and the response to treatment. For implementation purposes, the two key selection criteria were the ability to maintain long term positive outcomes and the generalizability of the intervention to regular clinical practice in low-cost settings.

Results: 
The initial search resulted in thirty-two (32) articles. Sixteen (16) articles were selected which focused exclusively on patients with cerebral palsy and their nutrition after the removal of any duplicated articles. Of this number only four (4) articles or twenty-five (25) percent of the selected articles described protocols in their entirety which could be directly applicable. Seventy-five (75) percent of these focused on children with varying severities of cerebral palsy while twenty-five (25) percent focused specifically on children with spastic diplegic cerebral palsy. Twenty-five (25) percent focused solely on a behavioral therapeutic approach, however all four of the protocols included behavioral training. All protocols included the modification of feeds through increasing the caloric intake and thickening consistency of the feeds. Appropriate feeding utensils and positioning were utilized in all articles. Fifty (50) percent of the reviewed articles clearly outlined an outpatient treatment plan with twenty-five (25) percent using a daily outpatient protocol while twenty-five (25) percent used a fortnightly protocol. In reference to the key implementation criteria, one article utilized a protocol which focused on a low socioeconomic status intervention with broad generalizability into clinical practice while another used an interdisciplinary approach with multiple specialized therapists. Of these, one article was able to demonstrate the ability to maintain and develop long-term positive outcomes demonstrated by continued patient weight gain by using their protocol. It is of importance that none of the articles reviewed were able to achieve a long-term positive outcome through a low-cost protocol as outlined in the flow chart.

Conclusions: 
A heightened awareness of the wide range of therapeutic interventions and the ability to achieve positive outcomes through appropriate patient-specific interventions is essential when treating patients with cerebral palsy. An analysis of previous literature elicits pervasive challenges in formulating treatment plans which are both cost effective and produce consistent positive outcomes. By combining the pertinent aspects of the two protocols from the literature which were able to meet the criteria of either low cost or long-term weight gain we can translate the result into a practical setting. In developed countries with resource-limited environments, a targeted interdisciplinary team including the physician, social worker, nutritionist, physical therapist along with a speech and swallow therapist may be beneficial to long-term gains in patient care. The provision of appropriate social counselling for families utilizing a patient-centered partnership can assist in allaying fears and feelings of inadequacy amongst caregivers.

NON-SURGICAL NUTRITIONAL INTERVENTIONS IN CHILDREN WITH CEREBRAL PALSY: DEVELOPING A TARGETED INTERDISCIPLINARY APPROACH IN A LOW-COST SETTING

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