3. CEREBRAL PALSY
Cerebral palsy (CP) is an umbrella term for a group of
disorders affecting body movement, balance, and
posture.
Cerebral refers to the brain
Palsy refers to a physical disorder
Infants are usually slow to reach developmental
milestones such as rolling over, sitting, crawling, and
walking.
6. Types of Cerebral Palsy
Classification of CP is related to the type of movement
disorder and/or by the number of limbs involved
7. The location of the brain injury will determine how
movement is affected.
8. Causes of Cerebral Palsy
Damage to certain parts of
the developing brain.
Injury during child birth, if
the baby got stuck in the
birth canal with no oxygen
supply.
In premature infants it can be
caused by bleeding in the
brain, brain infections such
as encephalitis, meningitis,
and herpes simplex.
Head injuries.
Sever jaundice.
Medical negligence
Many times it is unknown
10. Terminologies
Scoliosis—
Scoliosis is an abnormal curving of the spine. The spine might look like
the letter “C” or “S.”
Malrotation—
Intestinal malrotation is twisting of the intestines (or bowel) caused by
abnormal development while a fetus is in utero, and can cause
obstruction.
Intestinal Volvulus--
Intestinal volvulus is defined as a complete twisting of a loop of intestine
around its mesenteric attachment site.
Sialorrhea—
An excessive flow of saliva.
11. Other Complications
GI issues
The underlying neurologic impairment in cerebral palsy
can affect the gastrointestinal system, most notably
oral-motor function and motility (especially colonic,
which typically results in constipation).
THE BRAIN-GUT AXIS
12. Dysphagia/Oral Motor Dysfunction
Due to history of feeding difficulties, extended feeding times,
malnutrition, and/or a history of aspiration pneumonia
Medications used to reduce muscle tone can also increase
dysphagia risk
Dysmobility
Present in several forms:
Dysphagia,
Gastroesophageal Reflux Disease (GERD),
Delayed Gastric Emptying and
Dumping Syndrome
Children with severe gastroesophageal reflux that is
unresponsive to medical therapy may require a surgical
antireflux procedure (ARP)
13. Constipation
Dysmotility, hypotonia, medications, and nonambulation
contribute to constipation.
Ensuring adequate fluid intake prior to increasing fiber
intake can help prevent additional problems with
constipation.
Pulmonary aspiration
The result of swallowing dysfunction with aspiration of saliva
and/or aspiration of gastric contents.
Spinal Abnormalities
Scoliosis progression can result in diminished gastric
capacity, GERD, difficulty in positioning for feedings, and
changes in motility that can cause early satiety, nausea, and
vomiting.
14. Bone Health
Osteopenia and osteoporosis are frequently encountered
due to
Reduced ambulation and weight-bearing activity,
Malnutrition,
Limited sun exposure and
The use of anticonvulsant medication, which alters
vitamin D metabolism
Osteoporosis should be prevented with an adequate
intake of Dietary Calcium, Phosphorus and Vitamin D.
15. Nutritional Assessment of Children
with Cerebral Palsy
Medical issues, such as wounds, illness, or surgery, are
typically the primary focus in the acute care setting.
The ultimate goal in nutritional intervention should be
to optimize health, fitness, growth, and function in
individuals with cerebral palsy
In clinical practice, the Subjective Global Assessment
technique is not a good assessment tool for most
individuals with disabilities, as the body habitués is not
considered in this assessment.
A physical assessment is important to identify signs and
symptoms of dehydration and malnutrition.
16. Anthropometric Measurements
Physical examination:
The physical examination should detect signs of
malnutrition
Triceps skinfold thickness and mid-arm circumference
Head circumference
lower leg length or upper arm length
Scoliosis, increased or decreased muscle tone should be
assessed
Auscultation of the lungs may reveal signs of chronic
aspiration.
Abdominal examination and, if needed, a rectal
examination, may reveal constipation.
17. Stature Measurement:
Changes due to scoliosis, spasticity, contractures,
and/or limb differences may even make the individual
appear to “shrink”
Knee height,
Upper arm length,
Recumbent length, or
Tibial lengths
are techniques used to estimate stature
18. Weight:
Weight does not reflect the typical distribution of
body fat and muscle.
Fat stores are typically depleted and muscle stores are
low
Alterations in body composition should be considered
when estimating energy needs
19. Clinical Assessment
Nutritional history:
• The type (purees, liquids and solid food) and the amount
of food.
• If the child is able to self-feed, the amount of spilling
should be assessed.
• Signs of oromotor dysfunction
Medical history:
An assessment of gastroesophageal reflux symptoms such
as emesis, regurgitation, pain or food refusal
Chronic respiratory problems, recurrent pneumonia and
respiratory symptoms suggestive of chronic aspirations
Recurrent infections, decubitus ulcers and constipation
A review of the child’s medication
20. Growth history:
Birth weight, length and head circumference and all
previous weight, length and head circumference
measurements
It helps determine whether there is a decrease in
growth velocity.
21. Investigation:
Extensive blood work is usually not necessary.
A complete blood count may help detect iron
deficiency.
Serum albumin may reflect nutritional status, but is
not very reliable in this population.
Electrolytes are usually normal.
Phosphorus, calcium, alkaline phosphatase and
vitamin D levels may be measured in patients with
suspected osteoporosis and may be combined with a
bone density scan.
A gastric emptying scan is useful in diagnosing
delayed gastric emptying and possibly pulmonary
aspiration of gastric content.
22. Nutritional Management
Energy
Krick method
Kcal/day = (BMR × muscle tone factor × activity factor) + growth factor
Muscle tone factor: 0.9 if decreased, 1.0 if normal, 1.1 if increased
Activity factor: 1.15 if bedridden, 1.2 if dependant, 1.25 if crawling, 1.3 if
ambulatory
Growth factor: 5 kcal/g of desired weight gain
Height-based method
14.7 cal/cm in children without motor dysfunction
13.9 cal/cm in ambulatory patients with motor dysfunction
11.1 cal/cm in nonambulatory patients
Resting energy expenditure-based method
1.1× measured resting energy expenditure
The effect of medications on energy expenditure is important to
consider
23. Protein
Protein needs are estimated using the RDA and actual
weight or appropriate weight for height .
There are no guidelines for estimating protein needs of
individuals with disabilities under stress such as
surgery.
Protein intake has been increased up to 1.5–2 g/kg/day in
clinical practice for presurgical/postsurgical planning
and wound healing with normal renal status.
24. Fluid Requirements
Fluid loss through Sialorrhea or sweating.
Actual body weight is used to estimate fluid needs using
the Holliday-Segar equation
Weight Calculation
1-10 Kg 100 ml/kg
10-20 Kg 1000 ml + 50 ml/kg for each kg
>20 Kg 1500 ml + 20 ml/kg for each kg
25. Vitamin D
Shinchuk and Holick recommend supplementation if
25(OH)-D levels are less than 30 ng/mL
The recent Institute of Medicine (IOM) report
recommends supplementation only when 25(OH)-D
levels are less than 20 ng/ml.
25(OH)-D levels should be checked every three months
until levels are within normal range
26. Feeding and Feeding Regimen
Improve oral intake
Adequate positioning of the child during meals
Food consistency may be adjusted
Food caloric density may be increased
Oral intake can be maintained as long as there is no risk of aspiration
Enteral nutrition
Before 12 months of age, an infant formula should be used
Pediatric 1 kcal/ml formula is preferred. A 1.5 kcal/ml formula may be
used with careful monitoring of hydration status.
Feeding regimen:
The choice of feeding regimen will be based on
The child’s enteral access
Activities,
Caloric needs and
Tolerance to feeds.
27. Conclusion
Malnutrition should not be considered normal in CP
children.
Nutritional intervention should be provided by a
multidisciplinary team of professionals to ensure
adequate growth, improve quality of life and optimize
functional status.
Early nutritional intervention, appropriate support
and continuing follow-up are necessary to ensure
success.
28.
29.
30. Autism Spectrum Disorder (ASD)
The term autism spectrum disorders (ASD) has been
used to describe their variable presentation.
Prevalence studies indicating that they are present in 6
per 1000 children.
These disorders are characterized by three core
deficits:
Impaired communication,
Impaired reciprocal social interaction and restricted,
Repetitive and stereotyped patterns of behaviors or
interests.
31. Pervasive Developmental Disorders (PDD) is a group
of neuro-developmental disorders characterized by
impairments in communication, reciprocal social
interaction and restricted repetitive behaviors or
interests.
The term autism spectrum disorders (ASD) has been
used to describe their variable presentation.
32. Listed in the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV) and the
International Classification of Diseases, Tenth Edition
(ICD-10); ASD is used to describe 3 of the following 5
PDD--
Autistic disorder,
Asperger disorder,
Pervasive Developmental Disorder-Not Otherwise
Specified (PDD-NOS),
Rett Syndrome and
Childhood Disintegrative Disorder.
33. Autistic Disorder
Qualitative abnormalities in social
interactions,
Markedly aberrant communication skills,
restricted repetitive and stereotyped
behaviors, and
Moderate mental retardation with
intelligence quotients (IQs) of
approximately 35-50.
Three fourths of autistic children function in the
mentally retarded range.
34. Asperger’s Syndrome
Persistent impairment in social interactions and by
repetitive behavior patterns and restricted interests.
No significant aberrations or delays occur in
language development or in cognitive
development.
Generally evident in children older than age 3 years
and occurs most often in males.
Severe social impairment is associated with this
condition.
35. Pervasive Developmental Disorder- Not
Otherwise Specified (PDD-NOS)
Describes a child aged 9 years with
poor peer interactions,
normal verbal abilities, and
mild nonverbal disabilities
The mild nonverbal disabilities make it difficult for the
child to follow subtle social cues that most children
easily interpret as anxiety, anger, or sadness.
36. Rett Syndrome
Occurs almost exclusively in females.
The specific mutation on the gene related to Rett syndrome
(methyl-CpG binding protein-2 [MECP2]) was identified
late in 1999.
Initially have seemingly healthy development with low tone
and subtle slowing of development.
Early clinical feature is deceleration of head growth that
begins when the individual is aged 2-4 months.
Individuals who are less severely affected may tolerate or
even prefer interpersonal contact, show affection to others,
and suffer from learning disabilities and speech
fragmentation related to breathing irregularity.
37. Childhood Disintegrative Disorder
Also known as Heller syndrome.
Characterized by a loss of previously acquired
language and social skills and results in a persistent
delay in these areas.
Children develop normally through age 3 or 4.
Social and emotional development also regresses,
resulting in an impaired ability to relate with others.
No single causative factor for childhood
disintegrative disorder has been identified.
38. AUTISM
Autism is a complex developmental disorder that has
the following three defining core features:
Problems with social interactions
Impaired verbal and nonverbal communication
A pattern of repetitive behavior with narrow, restricted
interests
The diagnosis of autism may not be made until a child
reaches preschool or school age.
The behavioral characteristics of autism are almost
always evident by the time the child is aged 3 years
39. EPIDEMIOLOGY
ASD occurs more often in boys than girls, with a
4:1 male-to-female ratio.
The reported prevalence rates of autism and its
related disorders have been increasing worldwide
from approximately 4 per 10 000 to 6 per 1000
children.
The possibility that the increase in the reported
cases is a result of unidentified risk factor(s)
cannot be ruled out
40. ETIOLOGY
The exact cause of autism and the other ASDs is still
not known.
The etiologic theories have changed over the years.
Obstetric complications
Mothers who experienced diabetes, hypertension, or
obesity during pregnancy are more likely to have
children with autism spectrum disorders and other
neuro-developmental disabilities.
41. An infectious basis
The large number of children with autistic disorder born
to women who were infected in the rubella epidemic.
Also Cytomegalovirus infection is said to be associated
with development of autism.
Genetic factors
Autism is both familial and heritable.
1. The recurrence rate in siblings of an autistic child is
2% to 8%
2. Monozygotic twins have a higher concordance rate
than Dizygotic twins—90% and 10%, respectively.
3. Fragile X syndrome is identified to be associated
with Autism.
42. Environmental factors
1. Prenatal infections with rubella and
cytomegalovirus.
2. The role of heavy metals in the etiology of autism is
controversial.
3. Exposures to toxins, chemicals, poisons, and other
substances have been hypothesized to cause autism.
Hypothesis
The potential adverse effect of the measles, mumps,
rubella (MMR) vaccine and
Thimerosal, a mercury-based preservative used in some
vaccines.
43. Diagnosis
The severity of these impairments varies significantly
among children with ASD.
The impairments can be subtle and may not be
detected before school age.
Some of the widely used instruments for screening
these high-risk children.
1. The Checklist for Autism in Toddlers (CHAT),
2. Modified-Checklist for Autism in Toddlers (M-
CHAT),
3. Childhood Autism Rating Scale (CARS)
44. Specific tools commonly used in the assessment
include the
Autism Diagnostic Interview-Revised (ADI-R) and
The Autism Diagnostic Observational Schedule
(ADOS).
Currently, there are no laboratory or radiologic tests to
diagnose ASD.
45. FEEDING ABNORMALITIES
Restricted range of foods
Unusual eating behaviors such as food cravings and
pica.
Higher instances of food selectivity by type
Selectivity by type was defined as “eating a narrow
range of food that was nutritionally inappropriate
eating only a few different foods and often [refusing]
to eat entire food groups
46. Two types of physiological issues that can directly or
indirectly impact feeding skills and/or behavior:
1) Sensory processing issues
2) Gastrointestinal (GI) issues
Sensory modulation:
•Sensory modulation allows an individual to
appropriately filter the multitude of sensory
information that constantly bombards the nervous
system.
• Dysfunction-hyperresponsivity, hyporesponsivity,
and/or fluctuating responsivity resulting in atypical
responses such as sensory seeking or sensory avoidance
behaviors.
47. Sensory processing difficulties that both directly and
indirectly impact eating processes :-
• abnormal responses to taste and smell
• heightened sensitivity to tactile input
• auditory filtering problems
•Gastrointestinal alterations:
• Ileal lymphoid nodular hyperplasia (LNH) ,
•Mucosal abnormality
•Low cho enzymes
•Increased exocrine secretions of pancreas
•Intestinal mucosa is abnormally permeable
•Increase in immunoglobins levels
48. Pathways:
•Antigens in the diet
•Thimerosal-increased ionic conductance and
permeability
•Elevated levels of VIP-impair gut motility,
development and secretion
•Reduced secretin -the reduced blood levels of secretin
could allow gastric HCl secretion to increase
abnormally, elevate intestinal permeability
49. G.I. issues:
•GI disorders include gastroesophageal reflux
disease (GERD) and constipation, diarrhea, or other
symptoms resulting from food allergies.
•Difficulty expressing their discomfort and/or correctly
identifying its source.
•Difficulty with self-monitoring during the meal may
also affect the child’s ability to complete the meal
•This would be more likely if the child with ASD does
not connect the internal feeling of hunger with the
consumption of food.
•Children with ASD appear to eat based on external
stimuli such as the time on a clock or the presence of
food rather than on feelings of hunger
50. If a child’s appetite regulation is impaired or is
unconnected to food consumption, it could force the
child to use other methods to monitor food intake (e.g.,
visual appearance of the amount of food left on the
plate; amount of time spent at the table, etc.); this, in
turn, could lead not only to difficulty judging when
mealtime is finished, but also to over- or undereating.
51. ALTERATION IN METABOLISM:
•Decreased sulphate levels( Sulfation is important for
many reactions including detoxification, inactivation of
catecholamines, synthesis of brain tissue, sulfation of
mucin proteins which line the gastrointestinal tract.
•Increased oxidative stress-indicated by high levels ofGSSG
•Decreased NADPH, ATP(may be due to mitochondrial
dysfunction)
•Decreased SAM (impaired methylation)
• Primary amino acids: elevated glutamate-
Overstimulation leads to excitotoxicity, creating oxidative
stress, mitochondrial damage and may play a role in
neurodegeneration
52. •Decreased tryptophan may be due to decreased protein
intake, and/or impaired digestion of protein into amino
acid. Tryptophan is a precursor to the synthesis of
serotonin, so decreased tryptophan is likely to impair
serotonin synthesis (neurogenesis and
neurotransmission)
53. REMOVING CASEIN AND GLUTEN FROM
DIET
Implementation of a strict casein- and gluten-free (CFGF)
diet leads to symptomatic improvement individual,
improvement in social cognitive and communication skills.
Mechanism: During digestion, pre-opioid type compounds
from casein and gluten in the diet are activated because of
an incomplete breakdown of proteins.
These exorphins (i.e.caseomorphins and gluteomorphins)
are then absorbed into the circulation where they exert an
opioid- type action on the brain.
54. •Transfer of peptides across the lumen of the gut is
thought to occur due to the ‘leaky’ nature of the
gastrointestinal tract .
• Caseomorphins and gliadomorphins are potent
psychosis inducing factors.
•Elimination is a two step process:
•The first phase is removal of casein via removal of
milk and other dairy products.
•Benefits seen in 2-3 days in children and 10-14 days in
adults.
•Symptoms linked to casein intake include projectile
vomiting; eczema, particularly behind the knees and
in the crook of the elbow; white bumps under the skin;
ear discharges and infections; constipation, cramps,
and/or diarrhea; and respiratory disorders resembling
asthma.
55. •Gluten exclusion requires the removal of several
common cereals from the diet, wheat, barley, rye, and
oats.
• Elimination process usually takes a minimum of 3-4
weeks, and a trial period of three months is
appropriate.
•Once the main sources of food intolerance – casein,
gluten, and gliadin – are removed from the diet, other
foods may emerge as sources of symptoms.
• Parents can keep food diaries, to associate the child’s
consumption of a particular food with deterioration in
behavior, sleep patterns, or performance.
56. VITAMINS:
Vitamin B6 and Magnesium:
Vitamin B6:
•Metabolic pathways of neurotransmitters, including serotonin,
gammaamino- butyric acid (GABA), dopamine, epinephrine,
and norepinephrine.
•Study: Each child received vitamin B6 at a dose of 2.5-25.1
mg/kg body weight/day (75-800 mg per day).
•Benefits seen from this trial, included better eye contact, less
self-stimulatory behavior, more interest in surroundings, fewer
tantrums, and better speech.
•Magnesium:Required for a wide range of enzyme-catalyzed
metabolic pathways.
•An intake threshold for achieving benefit may be approximately
200 mg vitamin B6 (as pyridoxine) and 100 mg magnesium per
day for the 70 kg individual.
57. Folic Acid:
•Folic acid is essential to numerous metabolic pathways.
•Favourable results on several non-fragile X autistic children by
giving relatively large doses of folic acid (0.5- 0.7 mg/kg/day).
Vitamin C:
•Vitamin C involved in a plethora of metabolic, antioxidant, and
bio-synthetic pathways, and as a cofactor for certain enzymes
necessary for neurotransmitter synthesis.
•In a double-blind trial for 30 weeks, vitamin C (8 g/70 kg body
weight/day) improved total symptom severity and sensory
motor scores .
58. Vitamin A:
•Vitamin A is especially important for cell growth and
differentiation, especially in epithelial tissues of the
gut, brain
•Core autism symptoms, such as language, eye
contact, ability to socialize, and sleep patterns, were
consistently improved .
Zinc:
•Zinc is needed for the development and maintenance
of the brain, adrenal glands, GI tract, and immune
system.
•Serotonin synthesis relies on zinc-activated enzymes
and for antioxidant enzyme activity and other proteins
important for growth and homeostasis, cognition.
59. Lithium: low levels are seen,supplementation improved
mood stabilization.
ESSENTIAL FATTY ACIDS:
•Essential fatty acids, particularly the omega-3s, are
deficient in other neurodevelopmental disorders.
•Essential fatty acids (EFAs) function as homeostatic
constituents of cell membranes, helping to relay signal
information from outside the cell to the cell interior and
are precursors to eicosanoids that influence other cells,
similar to hormones.
60. CARNITINE: is an amino acid indispensable for energy
generation.
• Valproate, a drug prescribed for seizures, is known to deplete
carnitine.
• Constipation and self-abuse decreased while mood improved.
BIOPTERIN:
•Biopterin, in its reduced form (5,6,7,8- tetrahydrobiopterin,
R-BH4), is a limiting factor for the biosyntheses of dopamine,
epinephrine, and serotonin.
•Autistic children, particularly those six years or younger, can
have relatively low R-BH4 in their cerebrospinal fluid (CSF)
and abnormally high urine R-BH4, indicating increased loss
from the body.
•Also, the enzyme (dihydropteridine reductase) that recycles
biopterin into its biologically active reduced form, R-BH4, is
lower in autism.
61. INOSITOL:
is a precursor for the synthesis of phosphatidylinositol
(PI), a phospholipid that is part of a complex cellular
transmission pathway that facilitates serotonin
receptor function.
62. CLEFT LIP /PALATE
CLEFT LIP
Craniofacial malformation
An opening in the upper lip between the mouth and
the nose... it can range from a slight notch in the
coloured portion of the lip to complete separation in
one or both sides of the lip extending up and into the
nose.
63. CLEFT PALATE:
“the roof of the mouth is not joined
completely ranging from just an opening at
the back of the soft palate to a nearly complete
separation of the roof of the mouth (soft and
hard palate).
CLEFT LIP PALTE:
Infants are born with a cleft lip and palate (i.e.
cleft lip + palate). This type of cleft extends
from the lip to the hard or soft palate
64. • CLEFT LIP occurs when an epithelial bridge fails,
Due to lack of mesodermal delivery and
proliferation. CL usually occurs at the junction
between the central and lateral parts of the upper
lip on either side. The cleft may affect only the
upper lip, or it may extend more deeply into the
maxilla and the primary palate. (Cleft of the
primary palate includes CL and cleft of the
alveolus.)
• If the fusion of palatal shelves is impaired also, the
CL is accompanied by CP, forming the CLP
abnormality.
• In general, patients with clefts have a deficiency of
tissue and not merely a displacement of normal
tissue.
65.
66. ETIOLOGY:
•Family History: Cleft lip more likely to be inherited than
cleft palate
•Race: More common in Native American, Hispanic &
Asian patients
•Sex: Males 2x as likely to have cleft lip; Females 2x as likely
to have cleft palate
•Environmental factors: exposure of fetus to alcohol,
cigarette smoke, or drugs
•Maternal Nutrition Deficiencies:especially lack of folate.
DIAGNOSIS: USG, Genetic testing, physical examination
67. SUCKING PERFORMANCE AND FEEDING
PROBLEMS
Cleft of lip :Without adequate closure around the
nipple, the infant may have problems producing a suck
powerful enough to extract milk from the breast or
bottle nipple
Cleft of the lip and palate will usually result in an
inability to form a complete seal, and negative air
pressure cannot be generated .
68. EXTENSIVE FEEDING PROBLEMS
Nasopharyngeal reflux, choking, prolonged feeding time,
and slow or little weight gain, inadequate nutritional
intake.
Feeding is an immediate concern due to the delay in
growth of children born with clefts. This can be a major
concern for infants who will be undergoing surgery to
correct their cleft
A primary feeding concern associated with cleft palate is
the formation of negative air pressure, necessary for
adequate swallowing Without negative air pressure, a
swallow cannot be properly triggered and aspiration or
choking may occur.
69. •Recurrent aspiration will lead to respiratory
infections including pneumonia and even death.
•Signs and symptoms -inefficient or ineffective suck,
and excessive air intake. This excessive air intake may
result in choking and/or gagging.
• Infants witth clefting of the hard palate may limit the
normal use of the tongue to compress the nipple.
• If the soft palate is not intact when it is elevated it
does not create a barrier in which food and liquid
cannot pass through the nasopharynx.
• Signs and symptoms associated with the inability to
seal off the nasal cavity include: nasal reflux, and
inefficient or ineffective suck
70. •The impact of a cleft is not necessarily restricted to the
oral cavity. There may be airway deficits due to a cleft
palate
• Clinical signs or symptoms associated with an upper
airway obstruction are:
Inspiratory stridor
Glossoptosis
Micrognathia
• Clinical signs or symptoms related to neurological
impairments coinciding with a cleft include:
Incoordination of suck
Swallow and respiratory sequence
Hypotonicity and hypertonicity
71. DIFFERENT FEEDING TECHNIQUES
ARTIFICIAL NIPPLES:
Infants with isolated cleft palate may benefit most
from being fed using crosscut nipples.
Artificial nipples with large holes are recommended
so that infants may passively receive a bolus of milk
where a cleft palate prevents them from extracting it
independently from the bottle
72. •Advantage:
Faster feeding times, less vomiting,
satisfactory weight gain, and parental
acceptance for infants.
•Disadvantage:
The rapid flow may imperil the infant’s ability
to synchronize sucking, swallowing, and
breathing if milk is delivered directly to the
pharynx.
73. COMPRESSIBLE BOTTLES:
•Compressible bottles allow the feeder to deliver milk
to the infant who is unable to generate suction and
extract fluid independently. Gentle squeezing of the
plastic bottle forces formula from the tip of the nipple
avoiding necessity of negative pressure created by
sucking.
• Advantage:
easier to use for the feeding of babies born with cleft
condition
the feeder is able to control
the amount of milk expelled into the
infant’s mouth.
•Disadvantage:
No effect on child’s weight and growth
74. HABERMAN FEEDER:
The Haberman feeder is specifically designed for cleft
lip +/- palate use. Its elongated nipple can be
compressed if the infant has difficulty in applying
adequate negative pressure.
Advantage:
1) it has flow lines on the nipple that assist in helping
the infant achieve optimal flow from the nipple.
2) flow can be monitored without the necessity of
squeezing the bottle.
3) Valve that prevents back flow, which reduces the
excessive air buildup. The excessive air
build up can cause uncomfortable
gas and stomach problems as well as
burping.
75. BREAST FEEDING AND PROSTHESES:
•Feeding obturators are passive devices designed to
provide a normal contour to the cleft alveolus and hard
palate. They separate the oral and nasal cavities and in
doing so provide a surface to appose the nipple during
suckling.
• Feeding device is inserted over the infant's hard palate,
which allows him or her to compress the nipple easier
because it provides a contact point and helps the infant to
express milk.
76. •Advantage:
Reduced choking, nasal discharge, and bottle feed
duration and improved parental confidence in their
sample of infants with cleft lip and palate who were
prescribed feeding obturators. . It facilitates feeding,
reduces nasal regurgitation and shortens the length of
time required for feeding
•Disadvantage:
A feeding appliance can be costly and needs to be
replaced as the child grows to fit his or her mouth. Oral
hygiene is also a concern because it is a plastic
appliance, which can cause irritation to the palate.
77. •However,Strong (Level I) evidence show that obturators do
not facilitate feeding or weight gain in breastfed babies with
a CLP, and that they do not improve the infant’s rate of
bottle feeding.
•There was moderate evidence (Level II-2)obturators do not
facilitate suction during bottle feeding.This is because
obturators do not facilitate complete closure of the soft
palate against the walls of the throat during feeding.
78. Position ,pacing and other care
•Infants should be in an upright position with good head
neck and trunk support.
•Feeding times should be limited so that infants do not
experience hunger and unsatisfactory feeding.
•Burping the infants after feeding
•Oral care after feeding- one can use
clean water, or water with
hydrogen peroxide
79. TRANSITION TO SOLID FOODS
Spoon feeding for infants with a cleft lip +/- palate
should begin at approximately six months of age.
Strained, thin pureed, foods should not be a problem
for infants with clefts
Avoid thickened foods to ensure that these
consistencies do not get lodged in the cleft area .
80. PREOPERATIVE CARE:
•Assess fluid and calorie intake daily.
•Assess weight daily (same scale,same time, with infant
completely undressed).
• Observe for any respiratory impairment.
• Provide 100–150 cal/kg/day and 100–130 mL/kg/day of
feedings and fluid.
• Facilitate breastfeeding.
•Hold the infant in a semisitting position.
•Give the mother information on breastfeeding the infant
with a cleft lip and/or palate such as plugging the cleft lip
and eliciting a let-down reflex before nursing.
81. BENEFITS OF BREAST MILK IN INFANTS WITH CL/CLP
Feeding with breastmilk protects against otitis media in
infants with a CP
Babies are more prone to otitis media than the general
population due to the abnormal soft palate musculature.
Moderate to weak evidence that breastmilk can promote
intellectual development and school outcomes in babies
with clefts.
Antibacterial agents in breastmilk promote postsurgical
healing and reduce irritation of mucosa.
Breastfeeding facilitates the development of oral facial
musculature speech,bonding, and pacifying infants
postsurgery
82. POST-OPERATIVE CARE:
•CL repair (cheiloplasty) is generally carried out within a few
months of birth and CP repair (palatoplasty) takes place between 6
and 12 months of age.
•Maintain intravenous infusion as ordered.
•Begin with clear liquids, then give half-strength formula or breast
milk as ordered.
•Give high-calorie soft foods after cleft palate repair
•(Levels I and II-2) It is safe to commence/recommence
breastfeeding immediately following CL repair and moderate
evidence (Level II-2) for initiating breastfeeding 1 day after CP
repair.
•There is strong evidence (Level I) that breastfeeding immediately
following surgery is more effective for weight gain, with lower
hospital costs, than spoon feeding.
83.
84.
85. BIBLIOGRAPHY:
Adams.J. Nutritional and metabolic status of children with autism vs.
neurotypical children, and the association with autism severity. Nutrition &
Metabolism 2011, 8:34
Agarwal.A. A feeding appliance for a newborn baby with cleft lip and
palate.Natl J Maxillofac Surg.2010;Jan-Jun(1):91-93.
Goplakrishna.A. A status report on management of cleft lip and palate in
India.Indian J Plastic Surgery 2010;43(1):66-75
Hooper B. Feeding interventions for growth and development in infants with
cleft lip, cleft palate or cleft lip and palate (Review). Cochrane Database of
Systematic Reviews 2011, Issue 2.
Julie Reid.A review of feeding intervention in infants with cleft
palate.Craniofacial J.2004;41:268-277
Justine Ashby.Feeding therapy and technique for children with cleft
lip/palate.Southern Illinois University,2009
Kidd P. Autism, An Extreme Challenge to Integrative Medicine. Part II: Medical
Management. Alternative Medicine Review .2002;7(6):472-499.
Reilly S. Guidelines for Breastfeeding Infants with Cleft Lip, Cleft Palate,or
Cleft Lip and Palate.Breastfeeding medicine.2007;2:243-250
Twatchmann J. Addressing Feeding Disorders in Children on the Autism
Spectrum in School-Based Settings: Physiological and Behavioral Issues.
LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS .2008;39:261–
272
86. White J Intestinal Pathophysiology in Autism.Experimental Biology and Medicine 2003,
228:639-649.
