Growth, Nutritional Status, and Feeding Difficulties in Children with Cerebral Palsy
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Cerebral palsy (CP) is the most common cause of chronic motor disability in childhood, and is caused by an early injury affecting the parts of the brain responsible for body movement and control. In addition to motor problems, children with CP often struggle with conditions such as epilepsy, chronic pain, feeding difficulties, and poor growth. Despite extensive research, the cause of a child’s cerebral palsy is often unknown, but for most children the brain injury has occurred before birth. Many children with CP are small at birth, which could be a result of poor nutritional supply as a fetus, but could also be due to the brain injury. This thesis is based on data from the Cerebral Palsy Registry of Norway (CPRN), five European CP registries that are a part of the Surveillance of Cerebral Palsy in Europe collaboration (SCPE) and the Medical Birth Registry of Norway (MBRN). The aim of this thesis was to assess growth, prevalence of feeding difficulties and prevalence of gastrostomy tube feeding in a population of children with cerebral palsy. An additional aim was to study how fetal growth, assessed by birth weight, length, and head circumference, was associated with the risk of CP in term-born children. The results confirm previously published studies that have shown that feeding difficulties are common in children with CP and that those problems are more significant in children with poor speech and poor motor and hand function. The data further reveal that difficulties are associated with poor growth and nutritional status: a considerable proportion of the children with the highest degree of disability had poor nutritional status. Nutritional status was calculated from body mass index (BMI) and not by better validated methods; hence, the results regarding poor nutritional status should be interpreted with caution. A low BMI in children with CP may not be due to malnutrition, but may be explained by low muscle and bone mass as a direct result of the neurological damage. In Norway, over the last decades the use of gastrostomy tube feeding has increased in order to improve nutrition in children with CP. Insertion of gastrostomy tube at an early age was associated with improved growth. Within Europe there were significant variations in the use of tube feeding as well as age at insertion. Interestingly, despite how common feeding difficulties are in this group of children, feeding abilities was not assessed in a standardized way in the different European cohorts. Rates of overweight and obesity are increasing in the CP population. Overweight and obesity will add to children’s existing functional limitations, and in the long-term excessive weight may lead to lifestyle-related chronic illnesses. Small newborns (i.e. those with low birth weight, length, and head circumference) have increased risk of CP. The finding is especially evident in the case of spastic unilateral and spastic diplegic subtypes, and is consistent with the notion that the brain injury occurs before delivery, although it could not determine whether the studied newborns’ poor growth was a result of or the cause of their brain injury. Also children who were large at birth were at increased risk of CP, especially the CP subtypes spastic quadriplegia and dyskinesia, which may be consistent with complicated deliveries. For many children with CP, growth deviations begin already in the fetal period. To date, we have not been able to determine whether the fetal growth deviations cause the brain injury or vice versa. Later in life, as an infant, child, and teenager, many children with CP will experience feeding difficulties and poor growth. Moreover, an increasing proportion of children with CP are overweight and obese. Based on the findings in this thesis greater emphasis should be placed on growth and nutrition in children with CP. Being either underweight or overweight at a critical phase in life is very unfortunate and could affect these children’s health and quality of life in both the short-term and longterm.