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Influence of proteins in meals on rate of
gastric emptying, gastrointestinal symptoms
and gastric myoelectrical activity in children
with cerebral palsy (CP)
Anne Charlotte Brun
15.09.2015
Presentation outline
• Background
– definition and prevalence of CP
– feeding problems/malnutrition
– gastrostomy feeding
– Nissen fundoplication
– fast and slow protein concept
• Aims of the project
• Material and methods
• Paper I-III
• Conclusion
Definition and prevalence of CP
• Definition
– umbrella term
– permanent disorder
– impaired muscle control
movement and posture
– early insult to developing
brain
• Prevalence in Norway: 2.1 per
1000 live births
Istockphoto.com
Rosenbaum P et al. Dev Med Child Neurol 2007
Andersen GL et al. Eur J Paediatr Neurol 2008
“Feeding skills and sufficient growth
are among the most powerful
prognostic factors for survival”
Strauss DJ et al. Pediatr Neurol 1998
Severe CP- more feeding problems
• Poor oral motor function
• 1 in 5 children with CP:
completely dependent on
help or need tube feeding
• Severe CP: 1 in 4
undernourished
Photo approved by parents
Samson-Fang L et al. J Pediatr 2002
Sullivan PB et al. Dev Med Child Neurol 2000
Dahl M et al. Acta Paediatr 1996
Dahlseng MO et al. Acta Paedtr 2012
Vomiting
• Gastrooesophageal reflux disease (GORD)
• Abnormal gastric motility
Gastric myoelectrical activity (GMA)
Ravelli AM, Milla PJ. J Pediatr Gastroenterol Nutr ,1998
Handbook of electrogastrography, Koch KL, Stern RM, 2004
Consequences malnutrition
Increased risk of death!
Sullivan PB et al. Dev Med Child Neurol, 2000
Stallings VA et al.Dev Med Child Neurol, 1993
Grantham-McGregor SM et al. Lancet, 1991
Samson-Fang L et al. J Pediatr, 2002
Brooks J et al. Pediatrics, 2011
Gastrostomy tube feeding (GTF)
Gastrostomy (GTF) when?
• Malnutrition
• Difficulties with fluids and
medication
• Respiratory complications
• Stressful/time consuming
meals
Sullivan PB Bail Clin Gastro, 1997
Samson-Fang L Dev Med Child Neurol, 2003
Bankhead RR Nutr Clin Pract, 2005
Grant JP Ann Surg, 1988
Treatment of GORD
Medication
Nissen fundoplication
Best treatment option? UNKNOWN
No relevant RCT’s –no conclusions
Vernon-Roberts A, Sullivan PB Cochrane Database, 2013
Current status
• Improved survival with gastrostomies, better understanding of their
requirements
• GTF in Norway has increased, but still undernourished children with
CP
• Many continue to vomit after NF: AM Ravelli, PJ Milla, JPGN 1998:
“Children with CNS disorders who vomit have abnormal gastric
motility as often as GORD”
Samson-Fang L et al. Dev Med Child Neurol, 2003
Sullivan BP et l. Dev Med Child Neur, 2005
Sleigh G et al. Arch Dis Child, 2004
Dahlseng MO et al. Acta Paediatr, 2012
Vik T et al.Tidsskr Nor Legefor, 2001
Fast and slow proteins
-time required for digestion and absorbtion of protein
Cows milk
80% Casein -> slow absorption
20% Whey -> fast absorption
Rate limiting step - gastric emptying?
Boirie Y et al. Proc Natl Acad Sci USA, 1997
Fried MD et al. J Pediatr, 1992
Billeaud C et al.Eur J Clin Nutr, 1990
Savage K et al. JPEN, 2012
Clinical experience
• Change in formula
symptom relief
• Protein?
• Gastric emptying?
Aims
• Additional aims:
• Main aim: Study the
effect of protein
source in liquid
feeding formulas on
rate of gastric
NF: GE, GI symp, GMA
emptying (GE) and
gastrointestinal (GI)
symptoms in children
with CP and
gastrostomy
GMA: influenced by protein? Correlations to GE?
Specific findings in children with CP?
Material and methods
Material
• Patients with CP
– Risk malnutrition
– Gastrostomy
– Could benefit from results
• Test meals
–
–
–
–
Identical in context, except protein
4 different proteins
Fast and slow proteins
Commercially available
Method
• Gastric emptying rate (T1/2)
– 13C octanoic acid breath test
– stable isotope added to each meal
– exhaled 13C measured as a fraction of CO2
Method - EGG
• Myoelectrical activity of
the stomach
– Electrogastrography, noninvasive recording via
electrodes
– Measures slow waves (SW),
rythmic electrical
depolarizations, 3cpm,
normogastria
– SW-determines frequency
and propagation of gastric
contractions
Electrogastrography analysis
• Running spectrum
analysis (RSA)
– graphic representation of the
frequency and power
distribution of the recorded
signal on a min-by-min basis
– each line, 1 min of data
Beautiful 
– Overall spectrum analysis
graph(OSA): calculated
average of power and
frequency in a given periode
Method GI-symptoms
• Symptoms recorded
– Before
– During
– After
Papers I-III
Paper I
• Randomised, double
blinded, crossover
study
– 15 children tested 4
different meals
– Proteins
•
•
•
•
100% casein
hydrolyzed whey
amino acids
40% casein & 60% whey
Results gastric emptying, T ½ (min)
Minutes 160
153,9
140
120
P=0.08
100
82
80
P=0.07
74,4
P<0.001
63,3
60
40
20
0
Casein
H.whey
A.a.
40/60
Wilcoxon test
Too fast for some patients?
Paper II
• Randomised and
double blinded study
– 10 children with CP
and NF were
compared to 10
without NF for 2 meals
– Proteins
• 100% casein
• 40% casein & 60% whey
Results gastric emptying, T ½ (min)
NF + fast meal = GI-symptoms
Paper III
• Myoelectrical pattern
related to fast and slow GE
• Comparison of two
methods
– EGG - 13C octanoic acid
breath test: correlations?
– EGG – GI symptoms:
correlations?
• 20 children, 2 meals:
• 100% casein
• 40% casein & 60% whey
Pathological response to fast and
slow emptying
• Decrease in %
normogastria after
meal, sig. after fast
meal
• Majority with lack of
power increase
• No sig. difference
between NF vs non-NF
groups
Correlations?
• Yes, EGG variables vs GE variables of
40/60% mix, uncertain value
• None EGG vs GE variables of casein
• None EGG vs GI symptoms
• Subanalyses: none
Major conclusions papers I-III
• Gastric emptying is influenced by type of protein in the
meal. 40% casein and 60% whey empties significantly
faster than 100% casein
• Children with CP and Nissen fundoplication, significantly
more symptoms to the fast emptying meal
• Children with CP, abnormal postprandial EGG response to
both fast- and slow-emptying meals
Clinical implication
• ”Right meal for the
right patient”
• Extra caution with CP
& NF
• Applicable methods
• EGG- adjunct
information, uncertain
clinical role
Acknowledgements
• Parents and patients for their participation in the study
• Oslo University Hospital, Ullevål, Akershus University Hospital,
Østfold Hospital Trust, Vestfold Hospital Trust and Innlandet
Hospital Trust
• Collaborating supervisors and authors: Asle Medhus, Ketil
Størdal, Beint Bentsen, Groa Johannesdottir, Edda Olafsdottir
and Vibeke Fossum
• Funding was obtained from the Norwegian Extra Foundation
for Health and Rehabilitation via Knappenforeningen, ESPEN
Nutricia Research Fellowship Award and Vestfold Hospital Trust