Professional Documents
Culture Documents
8, 111-120.
he term cerebralpalsy describes a nonprogressive posture and movement disorder caused by brain injury
(Healy & Smith, 1988). The brain injury can occur
before, during, or after birth and usually is manifested
by muscle tone abnormalities in the first 2 years of life.
The degree of abnormal motor fimction ranges from
mild to severe and can involve one or all parts of the
body. Depending on the areas of the brain that are
injured, young children with cerebral palsy are at significant risk for feeding problems. Feeding problems
may sometimes precipitate the diagnosis of cerebral
palsy. Once a feeding disorder is recognized in an infant
with cerebral palsy, the problem tends to persist for a
long time.
The process of eating, even for a newborn, necessitates that the oral motor structures and the neurologic
control that orchestrates safe ingestion of liquids and
solids are intact and functioning. In the healthy term
infant, the separate actions of sucking, swallowing, and
breathing occur in a predictable sequence under med-
JOURNAL
+ 0
Association
of Pediatric
25/l/48618
OF PEDIATRIC
HEALTH
CARE
Nurse Associates
OFFICE ASSESSMENT
111
lournal
112
Zickler
8; Dodge
gums, or gingival hyperplasia. In some children inadequate swallowing and drooling tend to make feeding
experiences for both the child and the caretaker unpleasant (Limbrock, Hoyer, & Scheying, 1990). Orthopedic concerns such as muscle spasms and dislocated
hips result in pain that also negatively impacts on the
feeding experience (Lee & Lyne, 1990). Unless the pain
and discomfort are treated, the oral intake may be dramatically diminished.
The young child with cerebral palsy may have highenergy expenditures due to athetoid movements or
increased tone (spasticity). Children with spasticity are
often unable to manipulate the food/fluid bolus to the
back of their mouth and choke when it reaches the
esophagus. The exaggerated jaw and tongue movements
result in uncoordinated
suck-swallow-breath cycles.
Rhythmic tongue protrusions and the constant wormlike writhing movements seen in athetosis tend to increase drooling and inhibit effective swallowing.
Children who chronically aspirate experience recurrent lung infections, which puts them at increased risk
for weight loss. This is especially true when the cerebral
palsy involves the entire body (quadriplegia). With each
infection the childs intake of necessary nutrients is decreased, at the precise time when necessary nutritional
stores are being utilized (Frank & Zeisel, 1988).
Drvaric, Roberts, Burke, King, and Falterman (1987)
noted that children with quadriplegia and abnormal
weight-for-height before surgery were at greater risk for
surgical complications, such as poor wound healing,
wound infections, and aspiration.
PARENT-INFANT
INTERACTION
PROBLEMS
journal of Pediatric
May-June 1994
Health
Care
Zickler
Section
I - Physical
Name
Patient
Number
Todays
&eWeight
113
Data
Birthdate
Patient
& Dodge
---
Date
I
I-
Percentile
Percentile
Length
Head
Percentile
Circ.
Section
Number
II - Eating
Length
Consistency
of Time/Meal
Number
History
Snacks/Day
of Meals/Day
of Food
of TBSPlOuncesKtay
GrainsHigh
Fruits-
MeatsMilk -
Other-
Additives/per
Section
meal
III - Feeding
FormulaCalorie
Chewina
Choking-
Drooling-
Tongue
Constipation-
Gross
Concerns
Thrust-
IV - Current
Medications/Treatments
V - Adaptive
Section
VI - Developmental
Fine
Gulping
ApneaFood Refusal-
Section
Motor
Vomiting
Gag&a--
DiarrheaSection
Juices -
VBggies-
Equipment
Level
Motor
P/S
Language
Section
Worksheet
8 FIGURE 1 Nutritional
for evaluating
gowth
VII - Medical
and development
assessment.
Diagnosis
DISTURBANCES
ANTHROPOMETRIC
DATA
lournal
centiles on the NCHS graphs are called growth channels, and crossing from one growth channel to another
is a marker for concern (Henry, 1992). Infants born
prematurely should have their growth parameters corrected before the numbers are plotted on the NCHS
growth chart. By subtracting the number of weeks of
prematurity from the infants chronologic age, the corrected age is obtained. Age correction is performed
until the infant is 2 vears of chronologic age. (Kelsey,
1993).
The childs length is measured in the recumbent position on children under the age of 3 years or when a
standing measurement is impossible because of the degree of motor handicap. Segmental measurements are
obtained in patients with contractures and scoliosis, but
these tend to be unreliable Because length is important
in determining the weight-for-height
of the child, a
more accurate measure should be obtained (Dietz &
Kandini, 1989). Spender, Cronk, Charney, and Stall@
( 1989) have established procedures for measuring children with cerebral palsy by obtaining upper arm lengths
or lower leg lengths. Plotting these measurements on
specialized body-segment growth charts, the evaluator
is able to extrapolate lengths and thus determine appropriate weight for length ratios. Length, rather than
Behavioral
children
in
Once an abnormal growth pattern is identified, a determination of the cause of the problem should begin
with a feeding history. A general description of the
mealtimes, who feeds the child, and when feedings generally occur, the food the child can and cannot eat, and
the length of time it takes to complete a feeding session
are significant. Information on spitting, choking, gagging, recent illnesses, and breathing problems should
be obtained. Questions regarding sleeping and elimination patterns help in identifying the related health
concerns that may be affecting appetite. Data on positioning and adaptations that must be made to accommodate the mealtime process are also significant. Any
past hospitalizations should be noted. If previous pneumonias have occurred, the child is at risk for reflux or
aspiration. If siblings or parents have a history of gastrointestinal or feeding problems, this should be noted
because inheritance of related disorders does occur. A
S-day dietary record is an accurate way to gather data
on total caloric intake and is preferable to a dietary recall
(Crump, 1987). Caloric intake can be calculated by a
dietitian who can assessthe adequacy of such essential
nutrients as protein and calcium.
A listing of all the medications that the child presently
takes may give clues as to potential sources of the poor
weight gain, because many medications cause upset
stomach and anorexia (Brizee et al., 1990; Dietz &
Bandini, 1989). If children have multiple caretakers,
such as occurs when baby-sitters or respite or child care
workers have the child for part of a day, the need to
determine when feedings are better and when they
seem to be less successful is important. The kind and
degree of motor impairment usually relate to the degree
of oromotor impairment.
m THE PHYSICAL ASSESSMENT
The childs disposition and the quality of the parentchild interaction can assist the practitioner in determining the overall level of contentment and bonding with
the child. The general appearance of the skin, hair, and
subcutaneous tissue often reflects the wellness level of
the child, The physical examination should include a
concern for the integrity of the oral cavity, the oral
hygiene, and presence or absence of teeth. The chest
should be auscultated for air movement, signs of fluid
present in the deeper airways, the depth and quality of
respiratory effort, and the presence of upper airway
congestion or obstruction. The abdominal examination
should determine the presence of bloating or timpani
or the presence of a fecal mass. Auscultation of bowel
sounds indicates hyperactive peristalsis or decreased motility. The rectal vault should be manually assessed if
constipation is suspected.
An assessment of the childs muscle tone, especially
Journal of Pediatric
May-June 1994
Health
Care
Zickler
TABLE
velocities
Median
(50th
percentile)
O-6 mo
Weight
(mglday)
Length
(cm / mo)
Head circumference
(cm / mo)
23.0
2.8
1.4
& Dodge
postterm
6-12
mo
14.4
1.6
0.7
115
growth
12-24
6.8
1.0
0.2
mo
24-36
mo
5.5
0.7
0.1
Journal
116
Zickler
& Dodge
24 CALORIE! 02 FORMULA
13 OZ of formula CONCENTRATE Plus 9 OZ of water
* powdered formula can be used but it tends to mix unevenly and thus get less
con&&ant solutions
24 CALORIE/O2 WHOLE COWS MILK (WC&l)-VITAMIN D FORTIFIED
24 OZ WCM Plus 6 Tablespoons (Tbsp) of Polycose Powder
or
24 OZ WCM Plus 2 Tbsp of liiht Karo syrup
Infants under 12 months of age or under 10 kg should use formulas as milk
base liquid
l
27 CALORIE/ 02 FORMULA
24 Calories par oz formula plus 3 Tbsp Polycosa Powder
or
24 Calories par oz formula plus 25 cc Light Karo Syrup
27 CALORIE/ 02 WCM
24 OUNCES OF WCM plus 4 TBSP LIGHT KARO SYRUP
30 CALORIE/ 02 FORMULA
24 CALORIE per OZ FORMULA plus 3 Tbsp and 1 teaspoon of POLYCOSE
POWDER plus 1 TBSP VEGETABLE OIL
30 CALORIE/O2 WCM
24 OZ WCM plus 3 TBSP Karo plus 1TBSP VEGETABLE
B FIGURE 2 Increasing
calories
OIL
in beverages.
Eating and drinking between meals should be discouraged. Children should be properly positioned in a
high chair or child seat and not held in an adults lap.
Parents should make sure that the food selected is
appropriate for the childs level of oromotor functioning. Some assistance with taking in adequate quantities is often necessary until children are able to use a
spoon and fork easily, but any self-feeding that the
child can do should be encouraged. High-calorie milkbased beverages should be served first and then solids
because solids tend to fill up the stomach and decrease
appetite. The amount of juice or water that the child
drinks should be limited because these also fill the child
without adding needed protein and fats in the diet.
Finger foods that are cut in small pieces and are soft
enough to eat without lots of chewing are most appropriate for encouraging independence. Mealtime should
be free of distractions and conducted in the same location. Parents should ignore food refusals and temper
tantrums at meals but should praise the accomplishments of the child. Parents should try to keep mealtime
pleasant and comfortable for both themselves and the
child interacting. Food preparation and mealtimes can
be time consuming; if at all possible, both parents
should be encouraged to share in this responsibility, or
Journal of Pediatric
May-June 1994
Health
Care
. FIGURE 3 The
Zickler
custom-fitted
orthodontic
plate
for
children.
(Photo
courtesy
of Brian
Sanders,
& Dodge
117
DDS,
MS.)
lournal
118
Zickler
81 Dodge
sitioning adjustments, dietary and behavioral adaptations. the child may require gastrostomy supplementation. If the child has accompanying GER, the gastrostomy should be accomplished by surgical correction
of this problem with a Nissen fimdoplication or related
procedure (Rempel, Calwell, & Nelson, 1988; Shapiro,
Green, Krick, Allen, & Capute, 1986). This surgical
procedure is done by wrapping the esophagus into the
gastroesophogeal sphincter, tying a band around the
site, and inserting a gastrostomy tube directly into the
Journal of Pediatric
May-June 1994
Health
Care
CONCLUSION
Zickler
& Dodge
119
Bower-Hulme,
J., Shaver, J., Acher,
S., MuIlette,
L., & Eggert,
C.
( 1987). Effects of adaptive seating devices on the eating and drinking of children
with multiple
handicaps.
American
Journal
of Occupational
Therapy, 41, 81-89.
Brizee, L., Sophos, C., & McLaughlin,
J. (1990).
Nutrition
issues in
developmental
disabilities.
Infanti
and Young Children,
2, 10-21.
Carruth,
B.R., Skinner,
J.D., St Nevhng,
W.L. (1993).
Eating reaclness: Reading the cues. Pedi&ric
Bash, 63, 2-8.
Crump,
I. (1987).
Evaluation
of the nutritional
status of the hancicapped child. In I. Crurnp,
(Ed.) Nutritiun
andfeeding
of the handicapped child. Boston:
A College-Hill
Publication.
Diem, W., & Bandini, L. (1989).
Nutritional
assessment of the handicapped child. Pediutrh
in Review, 11, 109- 115.
Drvaric,
D., Roberts,
J., Burke, S., King, A., & Falterman,
K. (1987).
Gastroesophageal
evaluation
in totally involved
cerebral palsy patients. Journal of Pediatric Orthpediq
7, 187-190.
Fee, M., Chamey,
E., & Robertson,
W. (1988).
Nutritional
assessment of the young child with cerebral
palsy. Imfunti and Toting
Children,
1, 33-40.
Fox, C. (1990).
Implementing
the modified
barium swallow
evaluation in children
who have multiple disabihties.
Infunts and Totmg
Children,
3, 67-77.
Frank, D., SiIva, M., & Needhnan,
R. (1993).
Failure
to thrive:
Mystery,
myth, and method.
Contempmary
Pediatria,
2, 114-133.
Frank, D., & Zeisel, S. (1988).
Failme to thrive. Pediatric
Clinics of
North America,
35, 1187-1202.
Gardner,
S., & Hagedom,
M. (1991).
Physiologic
sequelae of prematurity:
The nurse practitioners
role. Part V. Feeding difficulties
andgrowthfailure.
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122134.
Harris, M.B. (1986).
Oral-motor
management
of the high-risk
neonate. In J.K. Sweeney (Ed.). The high-tik
neonate: Development&
tbcmpy perspectives. New York
Haworth
Press.
HeaIy, A., & Smith, B. (1988).
Cerebral
palsy: Setting the stage for
the future. Contempvravy
Pediutth,
5, 44-64.
Henry,
J. (1992).
Routine
growth
monitoring
and assessment
of
growth
disorders.
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PEDIATFUCHEALTH
CARE, 6, 291301.
Huddleston,
K., & Ferraro, A. (1991).
Preparing
families of children
with gastrostomies.
Pediatrit Nursing,
17, 153-158.
Humphry,
R. (1991).
Impact
of feeding problems
on the parentinfant relationship.
Infan&
and Young Children,
3, 30-38.
Kelsey, K. (1993).
Failure to thrive. In S.W. Ekvall (Ed.) Pediatric
nut&on
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dirwllws:
Prevention,
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New York: Oxford
University
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Lee, J., & Lyne, E. (1990).
Pathologic
fractures
in severely handicapped chiklren
and young adults. Jorcrnal of Pediatric Orthopedics,
10, 497-500.
Limbrock,
G., Hoyer,
H., & Scheying,
H. (1990).
Drooling,
chewing, and swallowing
dysfunctions
in children
with cerebral palsy:
Treatment
according
to CastiIIo-Morales.
Journal
ofpediatvit
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445-451.
Peterson,
K., & Frank, D. (1987).
Feeding and growth
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and small-for-gestational-age
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of the bi&risk
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Pinyerd,
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Pipes, P., & Glass, R. P. (1989).
Nutrition
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In P. Pipes (Ed.)
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Rempel,
G., Colwell,
S., & Nelson,
R. (1988).
Growth
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Pediahs,
82, 857-862.
Shapiro,
B., Green, P., Krick,
J., AIlen, D., & Capute,
A. (1986).
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Zickler
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alternative
measures
to height or length. Devebpmcntal
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and Child Neumkgy,
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Stevenson,
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The development
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Pediatric
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CERTlFlCA-nQN FOR
PEDIATRK IdJRSE FRACTlTiONERS
The National Certification
Board of Pediatric Nurse practitioners and Nurses will administer the Ma&ma! Q&@krg
ExaRrinaPianfor Pe#Wic Nurse Frahher
Certik&on
on Octsber 14, iQ94,at sites throughout the United States.
Certification
provides:
* Recognition for professional competency to employers, consumers,
health care system
* Appropriate
credentials to state licensing boards
* Enhancement of professional mobility and financial gain
ralilnl
Certification
my
Board tiny
13
the National