Samantha McInerney

Case Study
8/8/16

Cerebral Palsy
Cerebral palsy is a condition that affects infants and children.
Cerebral palsy is a non-progressive syndrome that covers a range of
posture and motor impairments.
It is the most common developmental disorder among children.
Characteristics of cerebral palsy include spasticity, movement
disorders, muscle weakness, ataxia, and rigidity, impaired cognition,
communication, and sensory perception, behavioral abnormalities,
seizure disorders, or a combination of these features. Ataxia is the loss
of full control of bodily movements and rigidity is stiffness and nonflexibleness.
There are different types of cerebral palsy: spastic, dyskinetic,
and ataxic. Spastic is the most common type. This type is described by
increased muscle tone that causes movements to appear stiff. There
are also different sub categories within the spastic type: spastic
hemiplegia/hemiparesis, spastic diplegia/diparesis, and spastic
quadriplegia/quadriparesis. Spastic hemiplegia/hemiparesis affects the
arm, hand, and leg on one side of the body. Only one side is affected.
Spastic diplegia/diparesis involves muscle stiffness that is
predominantly in the legs. The arms may be affected to a lesser extent
however.
Spastic quadriplegia/quadriparesis is the most severe form of cerebral

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Case Study
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palsy. It is caused by widespread damage to the brain or significant
brain malformations.
Dyskinetic is a form that is characterized by uncontrollable, jerky
movements of the hands, feet, arms or legs.
Ataxic, the last form, affects balance and depth perception. Individuals
will usually have poor coordination and walk unsteadily.
Individuals can also have a mix of these types. Not everyone with
cerebral palsy will end up in a wheel chair. Most individuals, about
60%, with cerebral palsy will walk, 10% will walk with an aid, and 30%
will use a wheel chair.
Cerebral palsy results from a mistake in the development of the
central nervous system. This can happen in the uterus, during delivery,
or during the first two years of life. Depending on the extent and
location of the injury to the central nervous system, the damage can
be irreversible to the brain, brain stem, or spinal cord. Causes linked
to the development of cerebral palsy include multiple births,
chorioamnionitis, maternal infection, antepartum vaginal bleeding,
second stage labor lasting longer than 4 hours, untreated
hyperbilirubinemia, fetal anoxic events, or fetal infection.
Chorioamnionitis is inflammation of the fetal membranes due to a
bacterial infection. The inflammation results from bacteria ascending
into the uterus from the vagina and is most often associated with

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Case Study
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prolonged labor. Antepartum vaginal bleeding is bleeding from the
birth canal after the 24th week of pregnancy. Untreated
hyperbilirubinemia causes jaundice in the newborn.
Some signs of cerebral palsy may occur as the newborn begins
to grow. Clinical signs of cerebral palsy can be seen anytime before
age 3 years old but most children who have cerebral palsy are born
with it.
Epilepsy, intellectual delays, and psychosocial abnormalities are
possible results from brain damage caused by cerebral palsy. The first
sign of cerebral palsy is difficulty swallowing and poor oral motor skills.
As the child gets older, development signs can appear, such as:
sitting, rolling over, crawling or walking. A third of individuals with
cerebral palsy will have seizure disorders. However, a small number of
acquire cerebral palsy cases result from infections such as bacterial
meningitis or viral encephalitis, problems with blood flow to the brain,
head injury from a motor vehicle accident, a fall, or child abuse. Signs
can occur during childbirth too. A low birth weight less than 5.5 pounds
and premature birth before 37 weeks can be two signs. Other signs can
be a breeched birth, complicated labor and delivery, jaundice, or
seizures.
Cerebral palsy can be managed with therapy, medications and
surgery. Physical therapy can help by exercises such as resistant

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strength training and activities for balance and motor skills.
Occupational therapy can improve posture and everyday activities like
getting ready for school or getting dressed.
Recreational therapy is activities such as playing sports, participating
in art programs, or culture programs. These can help the child expand
physical and cognitive skills. Speech and language therapy is another
treatment option, which can help with swallowing disorders or drooling
and learning sign language. Medication is another treatment of
cerebral palsy. Muscle relaxation medications such as: Diazepam,
baclofen, dantrolene sodium, tizanidine can help with muscle stiffness.
Spastic muscles are shown to improve with Botox because it can help
contract muscles. Surgery is another treatment option. Orthopedic
surgery can be an option if walking and moving is painful or difficult.
Surgeons will lengthen muscles if needed and this has been shown to
improve spinal deformities. Cutting nerves is another technique that
can be used if other treatments have failed to reduce pain or spasticity.
A surgeon will cut certain nerves to relax muscles and relieve pain.
Nutrition is an important aspect of cerebral palsy. Because
cerebral palsy has different types and severities, not all individuals
need specialized nutrition therapy but most do. Nutrition complications
include oral motor dysfunction,
GERD, chronic constipation, swallowing difficulties. Swallowing

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Case Study
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difficulties can lead to aspiration, which can cause pneumonia or other
complications. Individuals are at nutritional risk with cerebral palsy
related to: frequent infection, hospitalization, feeding difficulties,
requiring a consistency change in diet, poor appetite, and poor motor
skills. Feeding tubes may be required for patients who cannot eat on
their own, have serve oral motor difficulties, or who cannot tolerate
regular foods. Tube feeding has been shown to improve weight gain.
Nutritional status of patients can be measured using different
tools. However, it may be difficult to measure nutritional status
because children may be wheel chair bound or inactive. BMI has been
shown to not be as accurate for patients with cerebral palsy because
fat stores are usually depleted and muscle stores are usually low.
Height for weight charts can be skewed because some patients cannot
stand up and are in wheel chairs and others may have scoliosis or
muscle spasms. To measure body composition a skinfold-thickness
measurement or bioelectrical impedance analysis (BIA) may be used
with caution. Determining nutritional needs is important for every
patient. Predictive equations often over estimate because most
patients have limited mobility and activity. Factors to consider for
calories are muscle tone, muscle spasticity, and epileptic activity. The
recommendation for protein is to use the DRIs, which is 0.8g/kg body
weight. An equation for fluid can be used called the

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Case Study
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Holliday-Segar equation. For children weighing
1-10kg, they should drink 100ml/kg of fluid. For children weighing
10-20 kg, the recommendation is 1000ml + 50 ml/kg for each kg above
10kg. For children over
20 kg, the recommendation is 1500ml + 20m/kg for each kg above
20kg. Unfortunately, there is little to no research for adult nutritional
needs.
Common nutritional deficiencies include calcium and vitamin D and
these levels should be checked regularly.
The patient for the case study is a 22-year-old female who is five
foot and currently weighs 73 pounds. The patient has a gastrostomy
tube (gtube) placed for feeding. The patient currently falls within the
50th percentile on a growth chart that is for children who cannot walk.
The patient does not eat regular food and only feeds through the
gtube. Her home diet is 3.5 cans bolus per day of Compleat with 4oz of
water flushes three times a day and a continuous tube feed during the
night of 4 cans. Her current regimen provides 1988kcals/day, 90g
protein/day, 11g fiber/day, and 1960mL of water/day. The patient has
several intolerances to other formulas and only tolerates Compleat
well. The patient is currently on IV fluids of 70mL/hr, Carafate, Senokot,
Prilosec, and Zofran at the hospital.

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Case Study
8/8/16
The patient has an extensive medical history. She has cerebral
palsy, seizure disorder, spasticity, dysphagia, recurrent urinary tract
infections, respiratory failure, hip surgery, and decubitus ulcers. The
patient currently has a wound vacuum on her sacrum due to a stage 4
pressure ulcer. Her family history includes peptic ulcer disease, stroke,
heart disease, and diabetes. She lives at home with her mother and
father. She was admitted to Reid Health for altered mental status. Her
parents stated she has not been acting himself and has been
unresponsive. The patient has also not been tolerating her at home
diet well. The patients BMI is 14.3, ideal body weight is 100#, and per
percent ideal body weight is 73%. The patients lab values include:
glucose: 125, 56, 77; BUN: 35; CR 0.4; Albumin: 3.2; Potassium: 3.1;
Sodium: 141; Phosphorus: 2.3.
The patients PES statement is how the dietitian will help this
patient. The PES statement is increased nutrient needs for protein and
calories related to increased biological demand as evidenced by
patient with stage 4 pressure ulcer and patient is at 73% ideal body
weight and inadequate enteral nutrition infusion related to acute
intolerance of tube feeding as evidenced by patient day 2 without tube
feeding and per patients mother, patients had nausea and vomiting.
The goals of the nutrition staff for the patient are: to provide adequate
nutrition and fluid to patient, to prevent weight loss, to provide

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Case Study
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adequate calorie and protein for wound healing, and to advance tube
feeding to patients home regimen and have patient tolerate this well.
The intervention starts with making the patient NPO. The patients
estimated energy needs are calculated using her admission weight:
33.2kg * 30-35kcals= 969- 1162 kcals/day, 33.2kg * 1.5-2g protein=
50-65g protein/day, and 1500 ml fluid for adult minimum. The tube
feeding order has been started at 10cc/hr to advance by 10cc/hr every
eight hours to a rate of 30cc/hr as tolerated with 50cc flushes 7 times a
day. The formula that will be used will be Compleat. To monitor and
evaluate the patient, the dietitian will continue to monitor tube feeding
tolerance, continue to monitor advancement and rate of tube feeding,
continue to monitor laboratory values, and continue to monitor
progress of pressure ulcer.

Cerebral palsy is a complicated disease that can be managed many

ways through medication, nutrition, or therapy. This patient was
managed with medication and nutrition by the dietitians.

Samantha McInerney
Case Study
8/8/16

Works Cited
Aisen, M., Kerkovich, D., Mast, et al. Cerebral palsy: clinical care and
neurological
rehabilitation. Lancet Neurol. 2011; 10: 844-852.

Arvedson, J. Feeding: CP and swallowing difficulties. European Journal

of Clinical
Nutrition. 2013; 15(2): 9-12.
Day, S.M. Improving growth charts for children and adolescents with
cerebral palsy

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through evidence-based clinical practice. Developmental
Medicine & Child Neurology. 2010; 52:793, DOI: 10.1111/j.14698749.2010.03733.x

Growth references for children with quadriplegic cerebral palsy.

Kennedy Krieger
Institute. Retrieved from https://www.kennedykrieger.org/patientcare/patient-care-centers/cerebral-palsy-neurodevelopmentalmedicine-phelps-center/cp-growth-references on June 8, 2016.

Koman, A., Paterson Smith, B., & Shilt, J. Cerebral palsy. The Lancet.
2004;
363(9421): 1619-1631.

Sullivan, P., Morrice, J., Vernon-Roberts, A., et al. Does gastrostomy

tube feeding in
children with cerebral palsy increase the rick of respiratory
morbidity?. Archives of Disease in Childhood. 2006; 91(6): 478462.

Samantha McInerney
Case Study
8/8/16