Question 1. What is cerebral palsy?

Cerebral palsy (CP) is an umbrella term used to describe a permanent non-progressive condition in which dysfunction of the brain affects movement, posture, and co-ordination.

The condition can arise before, during, or after birth. The severity and effects of the condition are wide ranging and less severe cases may not be detected until early childhood. Approximately 1 in every 400 children is diagnosed in the UK each year (SCOPE UK 2020) and the condition can affect individuals from any social background or ethnic group. There is a higher prevalence in children born prematurely (Sadowska et al. 2020).

The damage to the brain may occur prenatally between conception and birth, during birth or during early childhood. Prenatal causes include: inefficient placenta, genetic disorders, infections, maternal high blood pressure, or premature birth. Birth trauma may be due to prolonged labour, oxygen deficit or occasionally forceps delivery. Damage in the neonatal period may be caused by hypoglycaemia, respiratory problems, convulsions, blood group incompatibility, or infection (Sadowska et al. 2020).

There are four main classifications of cerebral palsy: spastic, when the child’s movement is difficult or stiff; ataxic, where there is loss of depth perception and balance; athetoid or dyskinetic, where movement is uncontrolled or involuntary; or the condition may be a mixture of any or all of these. Half of children born with cerebral palsy have an intelligence quotient within normal range; others will have some learning difficulties. Many children with cerebral palsy have swallowing problems due to poor tongue control.

Question 2. Discuss the rationale for enteral feeding

Poor nutrition is a complication of many childhood diseases which can affect the child’s health by impairing immunity, delaying wound healing, reducing muscle strength, and impairing psychological drive (Kim et al. 2018). There are a number of reasons why illness may interfere with eating, digestion, and absorption. The desire to eat can be affected by many things such as: lack of appetite, nausea, vomiting, dysphasia, pain on swallowing, altered taste due to medications, and psychological factors. Ability to eat can be affected by impaired sucking, chewing, and swallowing mechanisms and respiratory or cardiac conditions leading to breathlessness when feeding (Nur et al. 2019). Digestion and absorption can be affected by altered pathophysiology of the gut, for example short-term conditions such as severe acute diarrhoea or long-term conditions including coeliac disease or short bowel syndrome.

When a child is at risk of suffering from under nutrition, enteral feeding can be considered, providing they have a functioning gastro-intestinal tract (Serjeant & Tighe 2021).

There are four main groups of children that may require enteral feeding. These include children with:

• Neurological disorders, such as cerebral palsy (Hopwood et al. 2021).
  
• Chronic conditions, such as cystic fibrosis, renal failure, and bowel disorders.
  
• Short-term feeding problems, including prematurity, cancer, and severe burns.
  
• Some miscellaneous conditions, such as anorexia nervosa (Falcoski et al. 2021). Refer to Box 29.1.

Question 3. What is enteral feeding?

Enteral feeding refers to the delivery of a nutritionally complete feed containing protein, carbohydrate, fat, water, minerals, and vitamins directly into the stomach, duodenum, or jejunum (NICE 2020).

Enteral feeding is an artificial method of providing nutrition to a child. There are three main routes for administration: orogastric, nasogastric, and gastrostomy.

• Orogastric feeding involves a tube passing through the mouth and oral cavity down the back of the throat, into the oesophagus and then into the stomach.
  
• Nasogastric feeding is when a tube is passed through the nostril, down the back of the throat, into the oesophagus and then into the stomach.
  
• Gastrostomy feeding is performed through a tube surgically placed through the skin of the abdomen into the stomach.

Nasogastric feeding is usually considered for the child requiring short-term nutritional support and can be used for anything between 6 weeks and 12 months depending on circumstances (Abdelhadi et al. 2020). Furthermore, it is suitable for those children unable to feed orally in acute or chronic illness. This is the most common method of enteral feeding, with nutrients being delivered directly into the gastrointestinal tract through a nasogastric tube. Although there is no direct guidance from NICE on enteral feeding specifically for children and young people, the Guidelines and Audit Implementation Network published guidelines in 2015 which recognised this deficit (GAIN 2015). Refer to Box 29.2.

Question 4. Using the nursing process and a model of care, how would the children’s nurse prepare Colin and his family for the insertion of a naso-gastric tube?

Activity of living: communication (Roper et al. 2000).

Best practice involves making sure Colin and his parents are fully informed regarding the benefits of inserting a nasogastric tube in order to meet Colin’s nutritional needs. Information should be given verbally and when necessary supported by written information to meet the child and family’s needs (National Institute of Clinical Excellence (NICE) 2021b). The individual’s ability to understand must be considered when providing information with regard to language, culture, physical, sensory, or learning disabilities. Effective communication will need to take into consideration Colin’s age, cognitive ability, personality, and coping skills. Misunderstandings can cause the child to become distressed; for a child there is no such thing as a minor procedure and often the severity of pain or discomfort does not correlate accurately with what the child feels they experience, as pain is personal, subjective, and complex (Pope et al. 2017). Children in hospital have described procedures as causing them fear and sadness (Clarke 2021) which is why effective communication is important.

The procedure should be explained to both the Colin and his parents and they should be encouraged to ask questions.

Goal: Colin and his parents will understand the need to commence enteral feeding. They will be fully informed regarding the procedure for passing a nasogastric tube.

Implement and evaluate:

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