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Pediatric-Onset Rehabilitation

Nutrition

In children with significant neurologic deficit, neurogenic bowel changes are part of, and contribute to, the development of secondary co-morbidities. Generally, this population is at risk of developing long-term nutritional consequences (i.e., obesity, malnutrition) and are confronted with the need to develop behavioral modifications related to performing a physiologic function in a modified way (e.g., neurogenic bowel regimen).

These youths can face numerous individual, social, and environmental barriers to a healthy lifestyle (Bandini 2015) which has been postulated to be related to three different mechanisms: 1) biological, medical, and developmental factors, such as metabolic abnormalities and medication disrupting appetite regulation or altering the metabolism and restricting physical activity; 2) parent, family, and caregiver related factors, such as lack of knowledge about the interplay between nutrition and the actual physical activity level (which is decreased in many instances). Over- or underfeeding may also occur because of a lack of awareness of child’s satiety, use of food as a reward, or because other health issues faced by a child with disabilities may make weight seem less important. Parents and caregivers may also exhibit overprotective instincts and there is also the possibility of lacking anticipatory guidance from health care professionals, as other comorbidities are taking priority in the care of a child with complex medical status; and 3) school and community-related factors, exemplified by the lack of tailored services for children with disabilities and lack of guidance and support during transitions to a more independent living state.

Author, Year

Country

Study Design

Sample Size

Study Characteristics

Results

(Wang et al., 2017)

China

Observational

N=45

Population: Time since injury: <1 yr=22, 1-5 yr=23; Level of injury: paraplegia=40, tetraplegia=5; Severity of injury: AIS A=29, AIS B/C=7, AIS D=9; Gender by Age Groups: 1) Males 0-5 yr=7, 2) Males 6-12 yr=5, 3) Females 0-5 yr=24, Females 6-12 yr=4) 9.

Intervention: None. Measurements and survey.

Outcome Measures: Height, height-for-age (HAZ), weight, weight-for-age (WAZ), body mass index (BAZ), appetite level (% of meals eaten), Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP).

1.         Mean WAZ, HAZ and BAZ values and STAMP scores were not significantly different among the different gender and age groups.

2.        Using STAMP, 22 (48.9%) children were classified as low risk (STAMP: 0–1), 18 (40.0%) were classified as medium risk (STAMP: 2–3) and 5 (11.1%) were classified as high risk (STAMP: 4–5); there were no motor score differences among these three groups of children.

3.        The mean WAZ, HAZ and BAZ values and appetite levels were significantly different between the low, moderate and high-risk STAMP groups; values decreased with increasing degree of malnutrition risk (p<0.001 for all).

4.        STAMP scores also showed a significant negative correlation with WAZ, HAZ and BAZ levels in regression analysis (p<0.001 for all).

5.        There were no significant differences in gender, age, cause of injury, time since SCI, level of injury, completeness of injury, AIS category and walking ability between those with risk or no risk of malnutrition.

6.        A total of 20 patients (44.4%) were found to have a normal status, 12 (26.7%) were found to have mild undernutrition, 3 (6.7%) showed moderate undernutrition, 6 (13.3%) were overweight and 4 (8.9%) were obese.

7.        The agreement between the nutrition status and malnutrition risk was moderate (k=0.603).

(Wong et al., 2011)

United Kingdom

Observational

N=62

Population: Median age: 13 (1-18) yr; Gender: males=37, females=25; Mean time since injury=4 yr; Level of injury: tetraplegia=27 (13 complete, AIS A), paraplegia=31 (18 complete AIS A).

Intervention: None. Measurements and survey.

Outcome Measures: Height, weight, body mass index, biochemistry, Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP).

1.         There were no significant differences between genders on anthropometric, biochemical or nutritional indices, apart from a higher concentration of serum creatinine in the boys (p<0.05).

2.        In total, 47.1% (24/51) of children screened with STAMP were found to be nutritionally at risk and 23.5% (12/51) were at ‘high risk’.

3.        Comparing well-nourished and undernourished patients via STAMP, those at risk of under-nutrition were found to receive more medications p=0.048); no other relationships were uncovered.

4.        Undernourished patients with paraplegia were found had lower height centile than well-nourished patients with paraplegia (p<0.05)

5.        Of the 51 screened patients, 15 (29.4%) were deemed to be at risk of under-nutrition after assessment by dietitian.

6.        When comparing the well-nourished and undernourished patients, as identified by the dietitian’s assessments, undernourished patients were found to have statistically significant lower BMIs and BMI centiles (p=0.041), less appetite (p=0.01), higher C-reactive protein (p=0.029) and received more prescribed medications (p=0.017).

7.        Undernourished patients determined by STAMP were more likely to have had a past need for artificial nutritional support (p=0.01).

8.        Undernourished patients determined by a dietician experienced more previous intensive care (p<0.05), mechanical ventilation (p<0.01), and to have had a past need for artificial nutritional support (p<0.01).

9.        Malnutrition risk was common in new admissions than in those with chronic SCI (readmissions) (p=0.034).

Discussion

Two papers were identified that assessed nutritional status in children with SCI. Both used height, weight, body mass index (BMI), and the Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP) as outcome measures and were observational in nature. Wang et al. (Wang et al. 2017) looked at 45 children with SCI, stratified according to time since injury and level and severity of injury, and concluded that mean weight, height, BMI values, and STAMP scores were not significantly different among the different gender and age groups. 48.9% of children were classified as low risk for malnutrition, (STAMP: 0–1), 40.0% were classified as having a medium risk (STAMP: 2–3) and 11.1% were classified as high risk (STAMP: 4–5) for developing malnutrition, but there were no motor score differences among these three groups. STAMP scores showed a significant negative correlation with weight, height, and BMI levels in regression analysis (p<0.001 for all), and the mean weight, height, and BMI values and appetite levels were significantly different between the 3 different STAMP groups. There were no significant differences in gender, age, cause of injury, time since SCI, level of injury, completeness of injury, AIS category, and walking ability between those with different risks of malnutrition. Of the 45 children, 44.4% were found to have a normal status, 26.7% were found to have mild undernutrition, 3 6.7% showed moderate undernutrition, 13.3% were overweight and 8.9% were obese.

Wong et al. (2011)  also conducted an observational study examining 62 participants with SCI using height, weight, BMI, STAMP, and biochemistry as outcomes; in addition, 51 of 62 children were assessed by a dietician regarding their nutritional status. This cohort was characterized by a median age of 13 (1-18) years, with 59.6 % males (n=37), mean time since injury of 4 years; 43.5 % with tetraplegia (n=27; 13 complete, AIS A) and 56.5 % with paraplegia (n=31: 18 complete AIS A). Again, there were no significant differences between genders on anthropometric, biochemical or nutritional indices, apart from a higher concentration of serum creatinine in the boys (p<0.05). Nearly half (47.1%, 24/51) of children screened with STAMP were found to be nutritionally at risk and nearly a quarter (23.5%, 12/51) were at ‘high risk’. Those undernourished were more likely to receive more medications, to have had a past need for artificial nutritional or ventilator support, have less appetite, and have a higher C-reactive protein level. Malnutrition risk was less common in children with chronic injuries.

In conclusion, the pediatric populations with SCI exhibit abnormalities in their nutritional intake (and caloric consumption), placing them at risk for the gamut of disturbances ranging from undernourished (most common in the acute period following the injury) to obesity, in the long term. The nutritional and metabolic disturbances do not seem to correlate with gender, age or level, and grade of neurologic injury, although prior need for nutritional and ventilator support and higher numbers of medication intake appeared to correlate with an undernourished status.

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