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

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

3. Disease Description 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.

4. Disease Description Continued
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

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

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

7. Percutaneous Endoscopic Gastrostomy
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.

8. Evidence Based Nutrition Recommendations
According to the American Society for Parenteral and Enteral Nutrition (ASPEN)
“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.

9. Tube Feeding Formula 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

10. Evidence Based Nutrition Recommendations
Interventions for Feeding and Nutrition in Cerebral Palsy
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.
One cohort study indicated data of overfeeding with gastrostomy.
One case series indicated the potential for GERD with gastrostomy.
Six case series indicated significant weight increase after gastrostomy in 6-20 months.
One of these case series reported improvements on all weight and growth related outcomes.
One case series assessed health care utilization for overall health and found the number of hospitalizations significantly reduced over the year following gastrostomy.
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).
There is limited data on role of feeding interventions for adults with CP.
AHRQ. Interventions for feeding and nutrition in cerebral palsy. Comparative Effectiveness Review. Number 94. March Accessed December 2013.

11. Evidence Based Nutrition Recommendations
Percutaneous Endoscopic Gastrostomy (peg):
Retrospective Analysis of a 7-year Clinical Experience
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
Wound infection (n=3, 0.8%),
Tube leakage (n=4, 1.10%),
Stoma leakage (n=2, 0.56%)
Inadvertent PEG removal (n=9, 2.5%)
Tube blockage (n=4, 1.1%).
Major complications
Hemorrhage (n=4,1.1%)
Tube migration (n=3, 0.8%)
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 January 14; 17(2):

12. Evidence Based Nutrition Recommendations
Growth and Nutrition Disorders in Children with Cerebral Palsy
Kuperminc M, et al
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:
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:
Diminished muscle mass.
Weakened respiratory system
Increasing risk for pneumonia.
Cardiac conditions
Contributing to heart failure.
Compromised immune system
Increasing the susceptibility of disease and impaired wound healing.
Neurological implications
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):

13. Evidence Based Nutrition Recommendations
Continued….
Growth and Nutrition Disorders in Children with Cerebral Palsy
Kuperminc M, et al
Intervention
interpretation of nutritional status
Past medical history
Physical examinations
Diet history
Anthropometry.
Deterimine target weight
Maximizing oral intake
optimizing caloric intake
nutrition support
increasing feeding frequency
addition of supplements.
If unable to consume foods orally due to dysphagia or other swallowing difficulties
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):

14. Case Presentation
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

15. NCP: 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).

16. NCP: 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

17. Prescribed Medications
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

18. NCP: ADIME Nutrition-Focused Physical Findings (PD-1.1.5)
Significant weight loss of 30# since previous hospitalization noted
Prior to admission – mal-nourished
Dysphagia

19. NCP: 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
Weight
IBW
BMI
6’ 1”
73 inches
185 cm
1st : 140 # /64 kg
2nd: 121# /55kg
lbs
166 to 202 lbs
75 to 92 kg
1st: 18.4 (underweight)
2nd: (underweight)

20. NCP: 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)

21. NCP: ADIME Nutrient Needs during Initial Assessment
Energy requirements (CS-1.1.1)
Admission weight of 140# / 64 kg
1600 to 1900 calories (25-30cal/kg),
Protein requirements (CS-2.2.1)
64-76 grams protein (1-1.2g/kg).
Since the patient was under stress his nutrient requirements for protein were elevated.
Fluid requirements (CS-3.1.1)
1900 ml fluid (30ml/kg),

22. Lab Values Lab Measurement Value Normal Value Rationale WBC 25.6 H
K/uL
Infection /stress
Glucose
109 H
65-99 mg/dL
Stress
BUN
20 H
7-8 mg/dL
Dehydration, excessive protein catabolism, renal disease
Albumin
3.0 L
G/ dL
Malnutrition, short-term protein and energy deficiency, acute inflammation, fluid retention
Creatinine
0.44 L
mg/dL
Effective kidney function

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

24. Nutrition Diagnosis / PES Statements
NCP: ADIME
NCP: Nutrition Diagnosis
Upon reassessment the patient….
Nutrition Diagnosis / PES Statements
Domain
Problem/Nutrition Diagnosis
r/t
Etiology
aeb
Signs/Symptoms
Intake
(NI-2.3)
Less than optimal enteral nutrition composition  
related to
Adjusted calculated needs
as evidenced by
20 lb weight loss
Clinical
(NC-2.1)
Impaired nutrients utilization
Polymeric tube feeding formula
(NC-3.4)
Unintended weight loss
Insufficient energy intake
Calculated needs

25. NCP: ADIME NCP: Interventions
Mr. G’s energy requirements were recalculated, accounting for his physical activity:
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.
Protein (CS-2.2.1)
IBW of 75kg was multiplied by 1.5 (for stress)
~105 grams protein per day
Monomeric formula
70 ml/hr to provide 1680 ml, 2100 calories, and 112 grams amino acid.

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

27. NCP: ADIME Recommendations for discharge Anthropometric Measurements
Body composition – Weight (AD-1.1.2) monitored daily via bed scale.
Biochemical Data, Medical Tests and Procedures
Protein profile- Albumin (BD ). 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.

28. Conclusion
Cerebral palsy and PEG tube formula introduced many barriers and complications for calculating his energy, protein, and nutrient needs.
Mr. G lost over thirty pounds due to these complications.
After trial and error, Mr. G’s caloric needs where able to be recalculated to meet his actual needs.
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.
Mr. G tolerated the polymeric formula well when considering residual, despite this, he was unable to absorb the nutrients at an optimal rate.
Changing Mr. G’s formula to a Monomeric formula greatly enhanced absorption.
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.

29. References
1. Percutaneous Endoscopic Gastrostomy. my.clevelandclinic.org/services/
percutaneous_endoscopic_gastrostomy_peg/hic_percutaneous_endoscopic_
gastrostmy_peg.aspx.Cleveland Clinic. Updated January 1, 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, Accessed December 2013.
3. Cerebral palsy. cdc.gov/ncbddd/cp/index.html. Centers for Disease Control and
Prevention. Updated October 17, Accessed December 2013.
4. Kuperminc M, Stevenson R. Growth and nutrition disorders in children with cerebral
palsy. Dev Disabil Res Rev. 2008; 14(2):
5. Thompson M, Prithviraj R. Percutaneous endoscopic gastrostomy and
Gastroesophageal reflux in neurologically impaired children. World J of
Gastroenterology January 14; 17(2):
6. Holliday MA and Segar WE. The Maintenance Need for Water in Parenteral Fluid
Therapy. Pediatrics 1957; 19; pg
7. Theberge C, Illing A. Nutrition in cerebral palsy. nafwa.org/cp1.ph. Nutrition and Food
Web Archive. Updated Accessed December  
8.  Charney P, Malone AM. ADA pocket guide to nutrition assessment. American
Dietetic Association. 2009; 2nd ed:
9. Perative®. Abbott Nutrition.
10. Journal of Parenteral and Enteral Nutrition, Vol. 33, No. 2, (2009)
11. Nelms M, Sucher KP, Lacey K, Roth SL . Nutrition Therapy & Pathophysiology.
Belmont, CA. Cengage Learning
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. 4th 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 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 Dec; 20(4): Accessed December 2013.

30. Questions?