Current practices and challenges of registered dietitians in the nutritional management of children with cerebral palsy in South Africa

Figures & data

Table 1: Summary of personal information of South African registered dietitians with an interest in paediatrics (N = 87).

Variable	N = 87 n (%)
Gender:
Female	84 (96.6)
Male	3 (3.4)
Number of SA RDs per sector:
Public sector	40 (51.0)
Private sector	38 (49.0)
Number of SA RDs who received CP training:
Yes	62 (71.3)
No	25 (28.7)
Number of SA RDs who were satisfied with training received:
Yes	20 (32.3)
No	42 (67.7)

Table 2: Provinces where South African registered dietitians reside and universities attended (N = 87)

Province/university	n (%)
Province:
Eastern Cape	8 (9.2)
Gauteng	33 (37.9)
KwaZulu-Natal	15 (17.3)
Limpopo	2 (2.3)
North-West	3 (3.4)
Northern Cape	2 (2.3)
Western Cape	24 (27.6)
University:
Pretoria University	19 (21.8)
Stellenbosch University	18 (20.7)
University of Cape Town	6 (6.9)
University of KwaZulu-Natal	13 (14.9)
University of Limpopo	5 (5.7)
University of North-West	16 (18.4)
University of the Free State	4 (4.6)
University of Western Cape	6 (6.9)

Table 3: Achievement of the selected ESPGHAN## guidelines by South African registered dietitians, public-sector and private-sector dietitians and p-values of the tests# comparing the two sectors

Guideline	Total dietitians (N = 78) n (%)	Public sector (N = 40) n (%)	Private sector (N = 38) n (%)	p-value^#
1. Nutritional management is provided while consulting as part of a multidisciplinary team	66 (84.6)	38 (95.0)	28 (73.7)	0.009*
2. Using additional types of anthropometry than weight and height when assessing patients	52 (66.7)	30 (75.0)	22 (57.9)	0.109
3. Knee height or tibial length is used routinely when linear height is not easily measured	25 (32.1)	11 (27.5)	14 (36.8)	0.377
4. Fat mass by triceps skinfold thickness (TST) is routinely measured to assess patients	4 (5.1)	2 (5.0)	2 (5.3)	1.000
5. The use of follow-up anthropometry (weight, length, fat mass) at least six monthly	4 (5.1)	2 (5.0)	2 (5.3)	1.000
6. Undernutrition is identified based on anthropometry	73 (93.6)	36 (90.0)	37 (97.4)	0.184
7. The use of one or more red flags to identify undernutrition: physical signs of undernutrition weight-for-age z score < 2 TST < 10th centile for age and sex Mid-upper arm fat or muscle area < 10th centile Faltering weight	73 (93.6)	36 (90.0)	37 (97.4)	0.359
8. Regular monitoring of bodyweight and fat mass to estimate energy requirements	18 (23.1)	7 (17.5)	11 (28.9)	0.230
9. Include feeding history starting from early infancy to assess patients	74 (94.9)	38 (95.0)	36 (94.7)	0.958
10. Cerebral palsy-specific growth charts are not used to identify undernutrition	31 (39.7)	16 (40.0)	15 (39.5)	0.962
11. Micronutrient status is determined annually	17 (21.80)	3 (7.5)	14 (36.8)	0.002*
12. The use of dietary reference standards in typically developing children to estimate energy requirements	44 (56.4)	17 (42.5)	27 (71.1)	0.011*
13. Using dietary reference intake (DRI) in typically developing children to estimate protein requirements	46 (59.0)	25 (62.5)	21 (55.3)	0.422
14. Using DRI in typically developing children to estimate micronutrient requirements	36 (46.2)	14 (35.0)	22 (57.9)	0.043*
15. Prescribe supplementary protein in specific clinical situations like pressure ulcers or with low calorie requirement	30 (38.5)	9 (22.5)	21 (55.3)	0.003*
16. Paying attention to hydration status	63 (80.8)	31 (77.5)	32 (84.2)	0.452
17. Paying attention to non-nutritional problems as these may contribute to feeding difficulties	59 (75.6)	30 (75.0)	29 (76.3)	0.892
18. Referral to speech therapist when there is oropharyngeal dysfunction	69 (88.5)	35 (87.5)	34 (89.5)	0.785
19. Consider the presence of oropharyngeal dysfunction in all patients with cerebral palsy even in absence of clinical signs	42 (53.8)	22 (55.0)	20 (52.6)	0.834
20. Modifying enteral nutrition and other therapeutic options when gastro-oesophageal reflux is present	32 (41.0)	16 (40.0)	16 (42.1)	0.850
21. Trial use of whey-based formula in gastro-oesophageal reflux	9 (11.5)	0 (0.0)	9 (23.7)	0.001*
22. Increase fluid and fibre intake when constipated	65 (83.3)	33 (82.5)	32 (84.2)	0.839
23. Use of enteral feeding if it is nutritionally sufficient, safe, stress free and not prolonged	66 (84.6)	33 (82.5)	33 (86.8)	0.595
24. Recommend breast milk, standard infant formula or nutrient-dense formula in infants	67 (85.9)	34 (85.0)	33 (86.8)	0.815
25. Prescribe standard polymeric feeds with fibre in children > one year old	50 (64.1)	24 (60.0)	26 (68.4)	0.438
26. Use high-energy dense feeds with fibre, micronutrient replete formula for volume-restricted children	55 (70.5)	28 (70.0)	27 (71.1)	0.919
27. Prescribe low-fat, low-calorie, high-fibre, micronutrient replete formula for immobile children	14 (17.9)	6 (15.0)	8 (21.1)	0.486
28. Always involve parents and or caregivers in decision-making especially around gastrostomy feeding	66 (84.6)	33 (82.5)	33 (86.8)	0.595

#Pearson’s chi-square test or Fisher’s exact test.

##ESPGHAN: European Society for Paediatric Gastroenterology, Hepatology and Nutrition.

*Significant difference (p < 0.05).

Table 4: Percentage of registered dietitians (n = 78) who perform nutritional assessments of children with cerebral palsy at various intervals

Method of nutritional assessment according to ESPGHAN^# guidelines	Frequency of evaluations
	First evaluation n (%)	After 1 month n (%)	After 3 months n (%)	After 6 months n (%)	After 12 months n (%)
Weight	71 (91.0)	51 (65.3)	47 (60.2)	44 (56.4)	44 (56.4)
Height	66 (84.6)	24 (30.8)	38 (48.7)	37 (47.4)	34 (43.6)
Knee height if linear length not accessible	38 (48.7)	11 (14.1)	16 (20.5)	19 (24.3)	17 (21.8)
Body mass index	54 (69.2)	28 (36.0)	31 (39.7)	27 (34.6)	26 (33.3)
Mid-upper arm circumference	56 (71.8)	27 (34.6)	30 (38.5)	31 (39.7)	27 (34.6)
Triceps skinfold thickness	7 (9.0)	2 (2.6)	3 (3.8)	2 (2.6)	1 (1.3)
Micronutrient blood status	29 (37.2)	4 (5.1)	13 (16.7)	8 (10.3)	15 (19.2)
Clinical signs of malnutrition	67 (86.0)	45 (57.7)	42 (53.8)	39 (50.0)	40 (51.3)
Feeding history	72 (92.3)	22 (28.2)	20 (25.6)	19 (24.3)	17 (21.8)
Do not determine anthropometry	0 (0.0)	1 (1.3)	2 (2.6)	1 (1.3)	1 (1.3)

^# ESPGHAN: European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines.

Figure 1: Challenges registered dietitians (n = 78) face when managing children with cerebral palsy.

Note: # Health care professional; ## Percutaneous endoscopic gastrostomy

Figure 2: Challenges registered dietitians (n = 78) perceive caregivers face when supporting their children with cerebral palsy nutritionally.

Note: # Health care professional; ## Percutaneous endoscopic gastrostomy