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Nutritional
STRATEGIES

Nutrition – Nutritional Strategies

As a parent, you want to provide the best nutrition for your child, as well as enable enjoyable mealtimes with all the family.


However, children with cerebral palsy (CP) may have specific nutritional needs that need special care, depending on the severity of their physical impairment and the feeding difficulties.

For further information, check out the section related to feeding difficulties.


Knowing how and what to feed your child is yet another challenge to overcome; but, before you know it, it will become an achievement. 


We are here to help you with answers and reassurance and to accompany you during this challenging period.


Usually, following diagnosis, you will discuss your child’s nutritional needs and plans with your doctor or dietitian. Together with your healthcare professional, you will identify the most appropriate nutritional solution for your child.


If you have any questions or doubts, talk to your doctor. It is important that you fully understand the reason why your child needs special nutritional support and how to make things work.


Before trying something new or changing your child’s feeding routine, check with your healthcare professionals. They will guide you and help you adapt according to your child’s specific needs.

In the following sections, you will get familiar with possible nutritional strategies or solutions for children with CP.

Thickeners can be a solution


A large number of children with cerebral palsy (CP) suffer from dysphagia, and therefore cannot tolerate liquids. Thickeners can be a solution to modify the texture and to help them take in the required liquids.

Juices and/or soups are examples of liquids that can be thickened. Your healthcare professional will recommend the exact amount of thickener needed to get the desired consistency.

Thickened liquids can have different consistencies:

  • Naturally Thick is now Level 1 (slightly thick) Thicker than water. Requires a little more effort to drink than water
  • Stage 1 (syrup) is now Level 2 (mildly thick) Sippable, pours quickly from a spoon but slower than thin liquids
  • Stage 2 (custard) is now Level 3 (moderately thick) Can be drunk from a cup
  • Stage 3 (pudding) is now Level 4 (extremely thick) Usually eaten with a spoon

A speech and language therapist will determine the most appropriate consistency for your child.


→Click here to watch the full video in our real stories section

 

Oral nutritional supplements can complement the diet


When a child is losing weight, supplements may be necessary to complement his/her meals and to ensure an adequate nutrition. If your child can be fed orally, this solution can help provide your child with the nutrition he/she needs. There are different types and flavours of Oral Nutritional Supplements (ONS). Ask your healthcare professional for advice.


→Click on this link to watch the full video in our real stories section

Tube feeding doesn’t have to be scary

Tube feeding is a way of getting nutrition through a tube by using a liquid form of diet.

Healthcare professionals suggest that tube feeding should be considered when a child is unable to meet his/her individual nutritional requirements and takes more than 3 hours to eat per day.

The decision-making process is very complex, and we encourage you to communicate with your healthcare professional to better understand and adapt to your child’s nutritional needs.

Tube feeding can be a temporary solution until your child gains weight, or it can be a permanent solution, depending on your child’s needs. Remember that sometimes, even if your child may be able to eat, tube feeding would still be recommended to ensure he/she is getting all of his/her nutritional requirements.

The decision to start tube feeding does not usually need to be made quickly. You will be given time to consider different options and to evaluate the pros and cons of including tube feeding in your daily routine.

There are different locations and routes through which a feeding tube can be placed.



“ You can actually feed anywhere, anytime"

Suzanne, Nathan’s mum

→Click on this link to watch the full video in our real stories section



Below is a brief summary of the different tube feeding routes:

NG and NJ tube feeding

Nasogastric and Nasojejunal tube feeding.

These forms of feeding include a tube that passes through the nose, down the throat and oesophagus and then into the stomach (NG) or small intestine (NJ).

It may seem unfamiliar at first but with time and experience, you will feel confident that your child is getting the right amount of nutrition and maintaining a healthy weight. You will also reduce feeding time dramatically, relieving so much of the stress and frustration involved with feeding. This will free up more time for other daily activities with your child.

PEG and PEJ tube feeding

PEG:

The feeding tube is inserted through the skin directly into the stomach. The technical term of PEG is: Percutaneous Endoscopic Gastrostomy.

PEJ:

The feeding tube is surgically inserted into the middle section of the small intestine (the jejunum). The technical term of PEJ is: Percutaneous Endoscopic Jejunostomy.

At first, this may seem very invasive and frightening. However, you can think of PEG/PEJ- tube feeding as an umbilical cord.

Tube feeding can be a safe and reliable form of feeding that allows you to track the amount of food and hydration your child is receiving.

“ It’s much tidier than people think"

Mariam, Yehoshua’s mum

→Click on this link to watch the full video in our real stories section

There are different ways to deliver tube feedings and different types of feeding schedules, depending upon what your healthcare professional has prescribed for your child.

Nutrition can be delivered continuously or in multiple deliveries (intermittent nutrition).

Continuous nutrition can be done by gravity or using a pump.

  1. By gravity : A bag filled with formula or the pack of the formula hangs above the child to let the formula drip down into the tube and then into stomach. Roller clamps can be used to control the rate of flow.
  2. Pump Feeding: A feeding pump can be programmed to run at whatever times and feeding rates required to deliver bolus feedings. Make sure your healthcare professional demonstrates how to use the pump before you go home.

Intermittent nutrition can be done by gravity, using a pump or using a syringe.

  1. Intermittent feeding is a type of tube feeding that provides a certain amount of formula over a short amount of time (usually 30-60 minutes), and is typically provided several times per day.
  2. With a syringe: formula is poured into the syringe, then the plunger is used to push the food directly into the tube.

It may be difficult to understand at first, but as you gain more experience, tube feeding can and will become second nature.1 Even though your child is being tube fed, being included in family mealtimes and social events that involve food is just as important for your child as it is for you and your family. Speaking about tube feeding with your child will help alleviate any confusion and will allow your child to feel more reassured and comfortable during mealtimes.

There is also a wide range of formulae for your healthcare professional to choose from.

Each formula is adapted to a child’s specific needs (e.g.: energy content, fibre content, mineral content, etc.).

Click on the Types Of Formulae section to better understand the different types of formulae available for feeding.

As you continue to tube feed your child at home, it’s natural to have questions, or to need some help. Your child's healthcare team can help you answer questions such as:

  • What can I expect from the tube feeding experience and the different tube feeding options available?
  • What type of equipment is needed and how do I set it up?
  • How do I know if my child is getting enough nutrition?
  • How do I know my child is having feeding intolerance?

Mealtime is an important opportunity for socialisation and development, and a part of life that children should be involved in and enjoy from an early age. Even though your child is being tube fed, being included in family mealtime and social events that involve food is just as important for your child as it is for you and your family.

Your child's healthcare team is there to make sure that your home tube feeding experience, for you and your child, is as comfortable and problem-free as possible.

If your child is being tube fed and not taking anything by mouth, it is important to maintain oral stimulation. This is a normal part of feeding and promotes growth and development. It allows a younger child to develop skills for eating and swallowing, and helps an older child who has already learned these skills to maintain them while they are being tube fed. Your healthcare professional will be able to provide you with ideas to maintain oral stimulation.

If people ask when your child is going to stop using a tube to eat, it’s fine to say, “We don’t know.” For now, the focus can be on the immediate goals. 

We advise you to speak with your child's healthcare team for guidance on managing feeds away from home, based on how your child is being tube fed and the feeding schedule. Your healthcare team will also help you to create a feeding plan for your child if they are attending school.

With tube feeding, there are many markers of progress. “Wins”—both big and small—are worth celebrating.

→Click here to better understand the different types of formulae available for feeding

 

Which formulae are available?

There is a wide range of tube feeding formulae available for children. Formulae come in a variety of formats and packaging. They can be based on casein or whey protein. Whey based formulae may be easier to digest and may offer an improved feeding tolerance.1

Your healthcare professional will consider your child's medical diagnosis, unique nutritional requirements and the feeding schedule when recommending a formula. Tube feeds should only be used under medical supervision on a recurring basis.

Some parents say that their child does taste the tube feeding formula, as an aftertaste or the result of regurgitation or burping, and may want a flavoured formula.

Here are some examples of different types of formulae:

Standard

A standard tube feeding formula is a formula that is designed for children who have normal digestion and will include all of the nutrients required for a growing child. Some standard formulae can be used for both tube feeding and oral feeding and some contain added ingredients, such as fibre, to help with regular bowel movements.

Peptide based formulae

Peptide based formulae are nutritionally complete, which means they contain all of the essential nutrients required for a growing child. They are different because they contain some nutrients, such as proteins, that are "broken down" into smaller components called peptides to make them easier to digest.



Rest assured that all tube feeding formulae are specially formulated to provide all of the nutrients needed to support a child's growth and development, in a form and amount that your child can tolerate.

Because a "complete feeding" of formula provides all of the nutrition your child needs, tube feeding can replace feeding by mouth completely — even though your child may also be taking some food or liquid by mouth.

Tube feeding formulae are also considered complete nutrition because they contain the protein, carbohydrate, fat, vitamins, minerals and water to help support your child's growth, development, and nutrition needs. The type and amount of each of these important nutrients will vary in different formulae, so your healthcare team will be able to advise to meet your child's needs.

If you suspect that your child is not tolerating a formula, inform your doctor or dietitian. Sometimes it can be as simple as a change in formula. Certain formulae are specially designed to help improve tolerance, which can help relieve digestive symptoms. Your doctor or dietitian can recommend an alternative formula that is appropriate for your child's needs.

If your child has symptoms of a food allergy, it is important to see your child’s healthcare professional for further testing. Possible food allergy symptoms can range from mild to severe, and include:

  • Nausea, vomiting
  • Diarrhoea
  • Blood in the stool
  • Rash, hives or itchy skin
  • Shortness of breath or wheezing
  • Swelling of the lips or eyelids
  • Anaphylaxis: a severe allergic reaction that is life threatening

It is important to pay close attention to these signs of food allergy. In fact, food allergy is different than food intolerance and requires a stricter diet. Food allergy is an immunological response to one or more proteins in the diet. When an immediate family member has a food allergy, the chances increase that your child may have an allergy. Common foods that cause allergies include cow's milk protein, peanuts, tree nuts, fish, shellfish, eggs, soy, and wheat. It is important for you to know that many tube feeding formulae contain milk or soy protein, or may be made in the same manufacturing facility as other products that contain allergens such as wheat or nuts. Check immediately with your healthcare professional if you suspect your child has symptoms of a food allergy following the ingestion of a formula.

Finally, just as any food, tube feeding formulae need to be carefully stored. It is always advised to adhear to the specific instructions written on the label of the formula, but generally make sure to:

  • Store unopened formula in a cool and dry place.
  • Shake before use. Once spiked administer within 24 hours.
  • Recap and refrigerate, use within 24 hours.
  • In order to maintain a constant flow, the use of a pump may be needed.
  • If poured out of the pack, cover tightly and use within 6 hours.
  • Do not heat formula in a microwave or on a stovetop.

So far, and throughout all of the different sections of this website, we have covered together a wide range of information that can help you better understand your child’s journey with cerebral palsy.

Eventually, as you both become at ease during feeding, mealtimes can provide pleasurable and precious moments between you and your child.

We believe that hearing the stories of how other families coped with CP can help you even more than you think.

→Click here to check out some real stories we have compiled from caregivers of CP children

 

References:

  1. Alexander D et al. Nutritional and health benefits of semi-elemental diets: A comprehensive summary of the literature. World J Gastrointest Pharmacol Ther. 2016;7(2):306-19.