Nutritional Considerations in Pediatric Spinal Cord Injury
Pamela Patt, RD, LD, CNSD
Edited by Kathryn Hickey, BA, RN
Introduction
Pediatric spinal cord injury (SCI) is a devastating event that encompasses many nutritional issues and potential complications. Nutritional assessment and interventions can have a tremendous impact on long-term health maintenance and quality-of-life. Children and teens with SCI present many nutritional challenges including alterations in weight, prevention of pressure ulcers, urinary tract infections (UTI), and bowel management. Nutritional education and continual reinforcement is essential as these children grow, develop, and transition into adulthood. Recommendations provided to them are similar to those for able-bodied individuals. Good nutritional status, however, can have a greater impact on the quality of life and life satisfaction for individuals with SCI.
Assessment
The initial assessment of a child or teen with SCI should include the level and severity of the injury, pre-injury nutritional status, weight alterations, and gastrointestinal function. Other factors that can contribute to post-injury nutritional status include constipation, calcium consumption, presence of gastro-esophageal reflux, and dietary habits or restrictions observed by the family. It is important to know about the use and purpose of any vitamins, minerals, and other nutritional supplements used prior to the injury. Also, information about self-perception of body image prior to injury can be valuable. A thorough dietary history can assist in identifying potential problems (Queen & Lang, 1993).
Education
All members of the patient care team should address nutritional education. Families need to understand the importance of good nutrition for healing, growth, and emotional well-being. Nurses and therapists, in particular, have the ability to reinforce information in daily interactions with children and their families. Concrete examples help them to understand the importance of good nutrition. For example, families need to know that pressure ulcers may result because children can lose a significant amount of weight or because the diet was too low in protein. Also, bowel impaction and incontinence may result because of a change in diet. They need to know that constipation, urinary tract infections, bladder and kidney stones, and nausea may occur as a result of inadequate hydration. Nutritional education must include information on supplements, vitamins, minerals, and herbs, as well as possible interactions with medications.
Weight Control
Weight control and active lifestyle may not be primary concerns for newly injured individuals, but they need to understand the long-term impact of immobility on skeletal muscle mass and calorie requirements. Immobility results in decreased lean body mass (Kocina, 1997). Typically, immobile children have lower calorie requirements when compared to able-bodied peers. They may have more difficulty in controlling weight and risk obesity. They may benefit from activities that develop upper body strength and work the cardiovascular system.
Following SCI, height and weight should be monitored two or more times per year to observe individual growth patterns. This also provides a basis for comparison to age appropriate growth charts and tracking of Body Mass Index (BMI) into adulthood. Newly injured individuals should be monitored more frequently (i.e., two times per week) while hospitalized to assess adequacy of intake and initial weight loss. Compared to able-bodied peers, body weight recommendations and calorie needs for adults with SCI decrease by approximately 5% for those with paraplegia and 10% to 15% for those with tetraplegia (Jeffcoat & Lindsey, 1996; Kocina, 1997). No body weight or calorie recommendations exist for pediatric SCI, although similar changes can be expected.
Overweight/Obesity
Attention to dietary choices is essential when caring for children and teens with SCI. In this “super-sized,” fast- food world, parental influence can have significant impact on weight outcomes. Sedentary activities, such as television and computer games, require little calorie expenditure. Parents need to understand the importance of their influence on the child’s lifestyle choices. Once children and adolescents with SCI become overweight or obese, it can be difficult to achieve weight loss. Upper body exercise requires significantly less calorie expenditure than lower body exercise. Also, exercise options may be limited for children with SCI due to accessibility issues and restricted physical education programs at school.
Obesity may lead to many increased health risks including hypertension, diabetes, and cardiovascular disease. Obesity can also significantly decrease independence. In overweight and obese children, transfers may become increasingly more difficult, and may cause damage to skin by shearing as they move across surfaces. They may be less likely to perform pressure relief and may be at risk for skin breakdown from ill-fitting braces and wheelchairs. Obese individuals are less likely to use standing devices or braces, which can increase weight- bearing forces necessary for optimum bone density development. Obesity can make self-catheterization and independent bowel management difficult or impossible.
Underweight
Underweight or low weight for height status can be as problematic as obesity. Lack of skeletal muscle and fat pads causes increased risk of skin breakdown due to pressure on bony prominences. Children and teens with SCI may experience a decrease in appetite from depression or immobility and may not feel the internal cues for hunger and satiety. Low weight individuals may report nausea. Bracing following spine surgery and abdominal binders increase external pressure on the abdomen and can cause fullness with small volumes of food. Individuals who lose significant weight after their injury (10 % or more of pre- injury body weight) are more likely to develop complications than those with a historically low weight for height status (Klawitter, 2003).
Small, frequent meals of calorie dense foods are good options for underweight children and teens with SCI. High calorie, high protein nutritional supplements may be included in the early post-injury dietary plan. The Recommended Daily Allowance (RDA) for age can be used as a guide for protein and calorie requirements (Queen & Lang, 1993). Exceptions may include those who have undergone recent major surgeries, newly acquired injuries, urinary tract infections, or pressure ulcers. These individuals often require more than the RDA for protein and calories. High fat foods should be limited to control nausea. Whenever possible meals should contain a mixture of substrates for consistency in blood sugar and energy level. The standard recommendations for dietary composition include 50-60 % total calories from carbohydrates, 20 % total calories from protein, and 30 % or less of total calories from fat (Jeffcoat & Lindsey, 1996).
Pressure Ulcers
Skin breakdown and pressure ulcers can increase calorie needs by at least 20% and protein needs to 1.5 to 2.0 grams/kg of current body weight (Novartis Nutrition Corporation, n.d.). If the individual has experienced significant weight loss following injury or was very thin prior to injury, using ideal body weight or usual body weight as reported by the individual may be the best option. If the individual is obese, ideal body weight should be used for both the calorie and protein calculations to prevent over feeding and more closely match lean tissue needs. Over feeding in obese individuals causes undesired weight gain and increased glucose levels that may further increase the risk of infection. A standard multivitamin and mineral supplement should be adequate to meet nutritional needs. If the patient is malnourished, however, or has an extremely poor appetite, additional vitamin C and zinc may be necessary to promote healing (Fuhrman, 2003).
Supplements
Adequate vitamin and mineral intake can be achieved with a varied diet. Children with SCI and their families should be educated in diet requirements based on the food guide pyramid (US Department of Agriculture, Food and Nutrition Information Center, 1996). For patients who are unwilling or unable to consume an adequate variety of foods, a multivitamin may be recommended to provide zinc, vitamins C, D, K, and iron for skin maintenance and healing. Many children and adolescents fail to consume adequate calcium and vitamin D. Children with SCI subsequently become more immobile and may lack the weight bearing forces needed to increase and maintain bone density. Adequate calcium and vitamin D intake will optimize this process. Children and teens 9 to 17 years of age have the greatest need for calcium. Skeletal bones are in the process of linear growth while still accruing mass and strength. Unless hypercalcemia is a concern, a calcium supplement with vitamin D should be recommended for any child not consuming 1,300 mg calcium/day (American Academy of Pediatrics Committee on Nutrition, 1999). Calcium carbonate or calcium citrate supplements are recommended because they are most easily absorbed. Many calcium supplements can be found that include vitamin D for increased absorption. It is important to be aware that some supplements may also include vitamin K because it is a factor in bone matrix formation. Vitamin K also impacts blood coagulation and should be monitored for those individuals requiring anticoagulant therapy.
Bowel Management
Bowel management can be a challenge for children and teens with SCI. Constipation may occur from decreased muscle tone and immobility. Nutritional issues can have a profound impact on bowel management and continence. Continence is essential for children and teens to make social connections and move on with their lives. Achieving continence and planned bowel elimination can significantly improve quality of life.
Inadequate fluid intake and lack of fiber in the diet will result in hard stool. Foods with high fat content may result in soft and/or liquid stool. Encouraging high fiber breads and cereals, fresh fruits, vegetables, and adequate fluid intake, especially water, is essential. Chocolate, refined sugar, bananas, rice, cheese, and excessive milk can all cause constipation (Queen & Lang, 1993).
For children over three years, it is recommended that they consume their age plus 5 grams of fiber daily. For example, a 3-year-old child requires 8g of fiber/day (Aiello, 2003). Fluid needs can be calculated using 1ml/calorie for normal weight individuals or any of the other standard fluid calculations available. Bowel patterns vary greatly and any dietary changes must be tailored to current diet habits and bowel patterns. Patients and families need to know that bowel management can be more than just a nuisance. Bowel impaction can result in hospitalization and bowel rupture.
Urinary Tract Infections
Ensuring the child receives adequate hydration (preferably water) is essential. The use of cranberry juice, cranberry tablets, and the avoidance of certain caffeinated, carbonated beverages may help to acidify the urine and limit bacterial growth, but not all experts agree. Also, adequate hydration is essential. Recommendations include 1 liter of fluid for those weighing 20 pounds, 1.5 liters for those weighing 45 pounds, and 2 liters for those weighing over 100 pounds (Foulkes, 2002). Copious water intake must be coupled with frequent, complete bladder emptying.
Conclusion
It is essential to look ahead to future stages of growth and development when caring for children and teens with SCI. Nutritional education and interventions need to be adapted and reinforced as children transition into adulthood. For very young children with SCI, adult caregivers make nutritional choices. As children grow and develop, they assume increasing control over food choices, and ultimately food procurement. These developmental considerations can have a profound impact on overall, long-term health and life satisfaction.
Nutritional considerations in pediatric SCI include encouraging healthy eating habits and preventing complications. Good nutrition is the basis for long-term health for all individuals, especially for children and teens with SCI.
References:
Aiello, A. (2003). High-fiber diet. In N. Nevin-Folino, (Ed.), Pediatric manual of clinical dietetics (2nd ed.). Chicago: The Pediatric Nutrition Practice Group, American Dietetic Association.
American Academy of Pediatric Committee on Nutrition. (1999). Calcium requirements of infants, children, and adolescents. Pediatrics, 104 (5), 1152-1157.
Foulkes, D. (2002). Fluids and electrolytes. In V. Gunn & C. Nechyba (Eds.), The Harriet Lane handbook (16th ed.) (pp. 233-234). Philadelphia: Mosby.
Fuhrman, M. (2003). Wound healing: A nutritional enigma. In M. Kalista-Richards, & M. Marian (Eds.), Dietitians in nutrition support: Sharpening your skills as a nutrition support dietitian (pp. 200-201). Presented at instructional symposium, Sharpening Your Skills as a Nutrition Support Dietitian, New Orleans, Louisiana.
Jeffcoat, M., & Lindsey, L. (1996, January). Spinal cord injury information network: Nutrition-SCI infosheet #8. Retrieved October 11, 2004, from: http://www.spinalcord. uab.edu.
Klawitter, B. (2003). Nutritional assessment of infants and children. In N. Nevin-Folino, (Ed.), Pediatric manual of clinical dietetics (2nd ed.). Chicago: The Pediatric Nutrition Practice Group, American Dietetic Association.
Kocina, P. (1997). Body composition of spinal cord injured adults. Sports Medicine, 23(1), 48.
Novartis Nutritional Corporation. (n.d.). Nutritional support in wound care. Retrieved October 15, 2004 from: http://www.novartisnutrition.com.
Queen, P. M., & Lang, C. E. (Eds.). (1993). Handbook of pediatric nutrition. Gaithersburg, MD: Aspen.
US Department of Agriculture, Food and Nutrition Information Center. (1996). The food guide pyramid. Retrieved December 30, 2004 from: http://www.pueblo. gsa.gov/cic_text/food/food-pyramid/main.htm
Pamela Patt, RD, LD, CNSD, is a Clinical Dietitian and the Manager of Nutritional Services at Shriners Hospitals for Children, Chicago, Illinois.
Kathyrn Hickey, BA, RN, is SCI Care coordinator at Shriners Hospitals for Children, Chicago, Illinois.
The editor of Pediatric Perspectives welcomes your input. Please contact Kathryn Hickey at khickey@shrinernet.org with comments, questions and suggestions.