Gastrostomy Feeding in Children with Cerebral Palsy, 9/2003

Poor nutrition, growth failure and the consequences of these were long regarded to be inevitable in persons with severe disabilities associated with cerebral palsy (CP). In recent years, technical advances in tube feeding and readily available commercial feeding formulas have changed that picture.

Gastrostomy, in which a tube is placed through the skin of the abdomen into the stomach, by-passes the oral-swallowing problems and gastro-intestinal dysfunctions that persist when other procedures fail to solve chronic feeding problems. However, the information about the success of this by-pass procedure is based nearly entirely upon clinical reports in a widely scattered literature. Relatively little information is available from controlled clinical evaluations.

Under the auspices of the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM)a multidisciplinary professional society, a review and analysis of the published literature on gastrostomy feeding in children with CP was recently published.¹ The report of that analysis indicates that:

• Impaired oral-motor function is a common feature of CP;

• A recent publication revealed that 27% of children with moderate-severe CP were malnourished. The consequences of malnutrition are far-reaching and clinically significant; these consequences include growth failure, higher surgical complications, delay in the healing of skin ulcers and sometimes, death. There are also often impacts on the development and functioning of other organ systems such as respiratory, cardiac and immunological;

• Nasal tube feeding is generally used only to meet short term feeding needs;

• The indications for gastrostomy include (1) nasal tube feeding beyond a relatively short-term acute period, (2) a long time required to feed orally, (3) inadequate weight gain and/or (4) unsafe swallowing (e.g. aspiration);

• CP children fed by gastrostomy have a better survival rate and a better recovery from failure to thrive than do children with genetic abnormalities, trauma or perinatal infection;

• There is usually a lessening of family stress and improved family functioning when gastrostomy feeding is used as compared to lengthy oral feeding;

• Special attention in gastrostomy feeding MUST be given to both caloric requirements to prevent under nutrition or over nutrition, and to nutritional supplementation (vitamins and minerals). Many commercial feeding formulas are inadequate in vitamins and minerals;

• Complications associated with the gastrostomy are usually easily managed (leakage, blockage, skin irritation);

• However, major complications can occur and include bowel obstruction, GI bleeding, ulceration and major infection.

COMMENT:
The authors point out that controlled trials in this area would be difficult to conduct because of the already known nutritional needs of the child with CP. Instead, they suggest the need for periodic reviews by organized panels of experts to address the knowledge available and develop consensus statements about the indications for gastrostomy and the content of feeding formulas.

We agree.

¹ Samson-Fang, L. et al. (2003) Effects of Gastrostomy Feeding in Children with Cerebral Palsy: an AACPDM evidence report. Dev Med Child Neurology 45:415-426.