Nutritional Management

Very early after severe TBI, it is important for the primary team to place emphasis on the child's nutritional status. Guidelines have been established for achieving adequate nutritional management in this population (175).

These guidelines are mostly from the adult TBI literature, as there is quite limited pediatric research regarding nutrition after TBI. Metabolism is reported to be increased after severe TBI in children, causing increased nutritional requirement. Phillips et al. (176) studied pediatric TBI survivors who had initial GCS between 3 and 8. Overall, the energy expenditure in those patients was 130% of their expected metabolism. Phillips also found that weight loss ranged between 2 and 26 pounds during their two-week post-injury evaluation despite aggressive nutritional support. Moore et al. (177) identified metabolic profiles of pediatric TBI survivors who had initial GCS of less than 7. They found that the increased energy expenditure in that group averaged 180%. In adult literature, hypermetabolism in TBI survivors is well established. The guidelines for the adult population include the following recommendations: (a) Full nutritional replacement should be initiated by day 7 post injury; (b) enteral nutrition should be started no later than 72 hours post injury; and (c) tight control of serum glucose is necessary to avoid hyperglycemia, which is associated with worsening ischemic injury and worse outcome. Parenteral nutrition should be started if enteral nutrition is not full and complete by day 7.

Tube Feedings

Typically, enteral support of nutrition begins with nasal jejunal or nasal gastric feedings. Jejunal tube feedings are often tolerated better due to delayed gastric emptying (172), but the goal is to move to gastric feeds with boluses of nutritional formula for more typical meal feedings to decrease the complexity of equipment needs and to more approximate the typical physiology of enteral feedings.

Percutaneous gastronomy (PEG) tubes are often placed at the time tracheostomies are placed, with the presumption that the patient who requires the tracheostomy will require tube feedings for longer than an acceptable time to leave a nasal tube in place. Nasal gastric and nasal jejunal tubes are associated with an increased risk of sinusitis, and the presence of the tubes in the posterior pharynx may be a source of irritation for the restless and the agitated child with TBI. If the child's cognitive status improves and they achieve full nutrition by mouth with no risk for aspiration, the PEG tube can be discontinued as early as two to six weeks after it was placed once the cutaneous-gastric fistula has matured (178). Janik et al. (179) found that gastrostomy tubes that remained in place in the pediatric patient for greater than 8 months required surgical closure of the fistula in 92% of the patients studied.

Gastroesophageal Reflux Disease

Prior to placing a gastrostomy tube, consideration should be given to the child's likelihood of having gastroesophageal reflux disease. This can be evaluated with an upper gastrointestinal radiologic study, a pH probe study, or a milk scan. Occasionally, a Nissen fundoplication will be done in conjunction with the placement of a gastrostomy tube to avoid reflux and the risk for aspiration and its associated morbidity. Children with gastrostomy tubes in place should usually be placed on an H2 receptor blocker or proton pump inhibitor to decrease risk for acid reflux as well as gastrointestinal bleeding (180).

Transition to Oral Feedings

Evaluation of the child with TBI at bedside by speech and language pathologists and/or occupational therapists is usually the first step in determining whether to begin transitioning to oral feeding. Studies show that dysphagia, oral motor impairment, and cognitive impairment are all highly correlated in the child with TBI; therefore, evaluation at the bedside of oral motor control as well as cognitive impairment helps to determine the degree to which dysphagia is present (181).

The incidence of dysphagia in this population varies by severity of the brain injury. Overall incidence is reported to be 5.3%. Children with mild brain injuries have an incidence of dysphagia of 1%, moderate brain injuries demonstrating a 15% incidence, and severe brain injuries 68% (182). The strongest factor predicting whether dysphagia will be present in a pediatric patient is the GCS. If the GCS is less than 9 (representing a severe TBI), the child is more likely to have dysphagia. These children tend to exhibit both oral and pharyngeal deficits with reduced lingual control and a delayed swallow reflex in the majority (181). Most dysphagia in this population resolves about 12 weeks post injury and a normal diet is resumed. Once a child is evaluated by modified barium swallow and no silent aspiration is identified, the rehabilitation team can begin oral feeding in a stepwise fashion. Typically, the team will begin with tastes of pureed foods and thickened liquids, with progression over time, as tolerated, to solid foods and thin liquids.

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Source: Alexander M.A., Matthews D.J.. Pediatric Rehabilitation: Principles and Practice. 4 th. еd. — New York: Demos Medical Publishing,2010. — 540 р.. 2010

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