Author: Joshua Alexander, MD
CASE REPORT
JK was referred to the UNC Feeding Team at 29 months of age to address his failure to gain weight, difficulty with oral feedings, constipation, and persistent gastroesophageal reflux (GER).
He had spastic tetraplegic cerebral palsy and had been previously diagnosed with severe GER documented by pH probe testing.
His feeding at the time of referral was limited to about 500 calories per day of a casein based formula, and small amounts of mashed foods. His foster mother had grown very frustrated trying to feed him and despite her best efforts, his weight was still well below the 5th percentile compared to other children his age.
He was started on oral motor training to improve his swallow, treated for constipation, and calculations were made to provide him with enough calories to catch up in his weight. He was started on prokinetic medicines, designed to help empty his stomach more quickly, but this did not significantly reduce his vomiting after meals. A gastric (stomach) emptying study was performed and demonstrated persistent, delayed gastric emptying.
Soon afterwards, the feeding team re-evaluated him and recommended a switch to a hydrolyzed whey based elemental formula that had the same calorie and protein concentrations as the casein based formula. No other significant changes were made.
After starting the new formula, JK stopped vomiting, began tolerating larger amounts of oral (by mouth) feedings, and showed good weight gain on follow-up examinations. His foster mother was able to feed him larger amounts of formula and reported a significant improvement in her satisfaction with feeding him.
DISCUSSION
Difficulty taking in enough calories is often a major factor contributing to failure to gain weight in a child with cerebral palsy. This can be due to many associated problems such as decreased control of the muscles required to chew and swallow food, gastroesophageal reflux, and/or small stomach capacity. In this case, the slow emptying of JK's stomach contributed to his GER and also limited how many calories he could consume at each mealtime. This was managed by reducing his constipation, using prokinetic medicines to speed up stomach emptying and, when these two steps failed, trying a different formula that could be more easily digested. Unlike casein-based formulas that curdle in the stomach, hydrolyzed, whey based, elemental formulas remain liquid in the stomach and have been shown to empty more quickly. While this type of special formula is usually more expensive and not covered by all insurers, it can sometimes be the final ingredient of a successful multidisciplinary treatment plan to treat failure to grow in children with cerebral palsy.
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