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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