Author: Sharon Wallace, RD, CSP, CNSD, LDN
Matthew is a 15 month- old boy with diplegic cerebral palsy. He was born 3 months early and had a lengthy hospital stay with many complications. His doctors and parents are very pleased with the developmental milestones he seems to be achieving, despite his rocky medical course. Matthew is rolling over and ?cruising? , seems to understand what his parents and older brother say, is playing and seems to overall enjoy life.
The main concern for Matthew?s parents is his nutrition. Matthew is a very ?picky? eater and will only eat a few select finger foods. Most of his foods are still in the form of stage two to stage three baby foods. He will take a bottle, but will push it away and gag after drinking only a few ounces. His parents report that he seems to do better if they add ?a lot? of rice cereal to his bottle, so they add 2-4 Tablespoons of cereal per 4-5 ounces of his Enfamil with Iron formula. Matthew appears quite small compared to children of the same age, and his growth chart shows his weight and height are less than the 5thpercentile for a 15 month old for both measures. His parents are very concerned about this and are looking for ways to ?bulk him up.? They want to avoid a feeding tube, as Matthew had a naso-gastric tube (a tube for feeding inserted through the nose into the stomach) for the first 3 months of his life and it brings back ?bad memories? for them.
A nutritionist met with the family to gather more information about Matthew?s eating habits and to help the family come up with a nutrition plan. A calorie count was completed to better evaluate how many calories and how much protein Matthew consumed each day. From his parents? report, Matthew drank about 15 ounces of Enfamil with Iron per day and had about 15-16 added scoops of rice cereal in the formula per day. He averaged about 3 jars of stage two baby food and occasional cheerios, goldfish or crackers (although they report he tended to gag on these). He preferred bottles of juice over formula. Upon further inquiry, it turned out that Matthew vomited at least once per day, often 30 minutes to one hour after taking a bottle, and had hard stools every other day.
With his parents knowledge, the nutritionist talked over Matthew?s case with his physician and they decided to order a swallowing study to be sure Matthew was not aspirating liquids, and to see if he needed a certain consistency for his food or fluids. His swallow study results were normal. The nutritionist showed Matthew?s parents his growth chart and pointed out that although his height and weight were low for a 15 month old, he was technically born 3 months early, so for a corrected age of 12 months, he actually plotted at the 5-10th percentile for both weight and height. They were further reassured when they were shown that Matthew?s weight for height measurement (how a child individually plots for their own weight and height), was at the 25thpercentile, and that this was a good proportion for a child who has cerebral palsy.
The nutritionist then addressed other important aspects of Matthew?s nutrition with his parents. He needed a larger amount of fluid (including water and only a small (4 ?6 ounces per day) amount of juice) to meet his fluid goals, which would likely help decrease his constipation. She also pointed out that over one-third of his total calories were coming from the rice cereal, which could decrease the amount of protein he received over the course of the day (and, with that amount, could have possibly contributed to the constipation). They decided to try a high calorie nutrition supplement called Pediasure until his eating habits were improved. The doctor changed his medications for reflux to see if this helped with the vomiting and food refusal. Matthew was also referred to an occupational therapist who could work on helping Matthew accept more foods and different food textures. The family was happy with the nutrition plan and were relieved that he was not as underweight as they thought prior to the nutrition consult.
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