WIC 348 Central Nervous System Disease

Conditions which affect energy requirements, ability to feed self, or alter nutritional status metabolically, mechanically, or both. These include, but are not limited to:

Central Nervous System Disorders

• Epilepsy
• Cerebral palsy (CP)
• Neutral tube defects (NTDs), such as spina bifida
• Parkinson’s disease
• Multiple sclerosis (MS)

Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician’s orders, or as self reported by applicant/participant/caregiver. See Clarification for more information about self-reporting a diagnosis.

Epileptics are at nutrition risk due to alterations in nutritional status from prolonged anti-convulsion therapy, inadequate growth, and physical injuries from seizures (1). The ketogenic diet has been used for the treatment of refractory epilepsy in children (2). However, children on a ketogenic diet for six months or more have been observed to have slower gain in weight and height (3, 4). Growth monitoring and nutrition counseling to increase energy and protein intakes while maintaining the ketogenic status are recommended (4). In some cases, formula specifically prepared for children on a ketogenic diet is necessary. Women on antiepileptic drugs (AEDs) present a special challenge. Most AEDs have been associated with the risk of neural tube defects on the developing fetus. Although it is unclear whether folic acid supplementation protects against the embryotoxic and teratogenic effects of AEDs, folic acid is recommended for women with epilepsy as it is for other women of childbearing age (5-7).

Oral motor dysfunction is associated with infants and children with cerebral palsy (CP). These infants and children often have poor growth due to eating impairment, such as difficulty in spoon feeding, biting, chewing, sucking, drinking from a cup and swallowing. Rejection of solid foods, choking, coughing, and spillage during eating are common among these children (8, 9). Growth monitoring and nutrition counseling to modify food consistency and increase energy and nutrient intakes are recommended. Some children may require tube feeding and referral to feeding clinics, where available.

Limited mobility or paralysis, hydrocephalus, limited feeding skills, and genitourinary problems put children with neural tube defects (NTDs) at increased risk of abnormal growth and development. Ambulatory disability, atrophy of the lower extremities, and short stature place NTDs affected children at high risk for increased body mass index (10). Growth monitoring and nutrition counseling for appropriate feeding practices are suggested.

In some cases, participants with Parkinson’s disease require protein redistribution diets to increase the efficacy of the medication used to treat the disease (11). Participants treated with levodopa-carbidopa may also need to increase the intake of B vitamins (12). Participants with Parkinson’s disease will benefit from nutrition education/counseling on dietary protein modification, which emphasizes adequate nutrition and meeting minimum protein requirements. Additionally, since people with Parkinson’s often experience unintended weight loss (13), it is important to monitor for adequate maternal weight gain.

Individuals with multiple sclerosis (MS) may experience difficulties with chewing and swallowing that require changes in food texture in order to achieve a nutritionally adequate diet (14). Obesity and malnutrition are frequent nutrition problems observed in individuals with MS. Immobility and the use of steroids and anti-depressants are contributing factors for obesity. Dysphagia, adynamia, and drug therapy potentially contribute to malnutrition. Both obesity and malnutrition have detrimental effects on the course of the disease. Adequate intakes of polyunsaturated fatty acids, vitamin D, vitamin B12 and a diet low in animal fat have been suggested to have beneficial effects in relapsing-remitting MS (15-17). Breastfeeding advice to mothers with MS has been controversial. However, there is no evidence to indicate that breastfeeding has any deleterious effect on women with MS. In fact, breastfeeding should be encouraged for the health benefits to the infant (18). In addition, mothers who choose to breastfeed should receive the necessary support to enhance breastfeeding duration.

As a public health nutrition program, WIC plays a key role in health promotion and disease prevention. As such, the nutrition intervention for participants with medical conditions should focus on supporting, to the extent possible, the medical treatment and/or medical/nutrition therapy a participant may be receiving. Such support may include: investigating potential drug-nutrient interactions; inquiring about the participant’s understanding of a prescribed special diet; encouraging the participant to keep medical appointments; tailoring the food package to accommodate the medical condition; and referring the participant to other health and social services.

1. Institute of Medicine. Food and Nutrition Board. WIC nutrition risk criteria: A scientific assessment. Washington, DC: National Academy Press; 1996.

2. Nelson JK, Mayo C. Mayo clinic diet manual a handbook of nutrition practices. St. Louis: Mosby; 1994.

3. Peterson SJ, Tangney CC, Pimentel-Zablah EM, Hjelmgren B, Booth F, Berry-Kravis E. Changes in growth and seizure reduction in children on the ketogenic diet as a treatment for intractable epilepsy. JADA. 2005 May; 105(5):718-724.

4. Santoro KB, O’Flaherty T. Children and the ketogenic diet. JADA. 2005 May; 105(5):725-726.

5. Yerby MS. Management issues for women with epilepsy: neural tube defects and folic acid supplementation. Neurology. 2003 Sep; 1:61 (6 Suppl 2): S23-6.

6. Champel V, Radal M, Moulin-Vallez M, Jonville-Bera AP, Autret-Leca E. Should folic acid be given to women treated with valproic acid and/or carbamazepine? Folic acid and pregnancy in epilepsy. (Abstract) Rev Neurol (Paris). 1999 Mar; 155(3): 220-4.

7. Yerby MS. Clinical care of pregnant women with epilepsy: neural tube defects and folic acid supplementation. Epilepsia. 2003; 44 Suppl 3:33-40.

8. Fung EB, Samson-Fang L, Stallings VA, Conaway M, Liptak G, Henderson RC, Worley G, O’Donnell M, Calvert R, Rosenbaum P, Chumlea W, Stevenson RD. Feeding dysfunction is associated with poor growth and health status in children with cerebral palsy. JADA. 2002; 102(3):361-373.

9. Yilmaz S, Basar P, Gisel EG. Assessment of feeding performance in patients with cerebral palsy. Int J Rehabil Res. 2004 Dec; 27(4):325-329.

10. Ekvall SW. Pediatric nutrition in chronic diseases and developmental disorders: prevention, assessment, and treatment. New York Oxford University Press; 1993.

11. Karstaedt PJ, Pincus JH. Protein redistribution diet remains effective in patients with fluctuating parkinsonism. Arch Neurol. 1992 Feb; 49(2):149-151.

12. Valkovic P, Benetin J, Blazicek P, Valkovicova L, Gmitterova K, Kukumberg P. Reduced plasma homocysteine levels in levodopa/entacapone treated Parkinson patients. Parkinsonism Relat Disord. 2005 Jun; 11(4):253-6. Epub 2005 Apr 20.

13. Chen H, Zhang SM, Heman MA, Willett WC, Ascherio A. Weight loss in Parkinson’s disease. Ann Neurol. 2003 May; 53(5):676-9.

14. Schapiro R. Managing the symptoms of multiple sclerosis. 4th Ed. New York: Demos Medical Publishing; 2003. Ch.13 Swallowing Difficulties.

15. Payne A. Nutrition and diet in the clinical management of multiple sclerosis. J Hum Nutr Dietet. 2001; 14:349-357.

16. Schwarz S, Leweling H. Multiple sclerosis and nutrition. Multiple Sclerosis. 2005; 11:24-32. 17. Mark BL, Carson JS. Vitamin D and autoimmune Disease-Implications for practice from the multiple sclerosis literature. JADA. 2006 Mar; 106(3): 418-424.

18. Gulick EE, Johnson S. Infant health of mothers with multiple sclerosis. West J Nurs Res. 2004 Oct; 26(6): 632-49.

Self-reporting of a diagnosis by a medical professional should not be confused with self-diagnosis, where a person simply claims to have or to have had a medical condition without any reference to professional diagnosis. A self-reported medical diagnosis (“My doctor says that I have/my son or daughter has…”) should prompt the CPA to validate the presence of the condition by asking more pointed questions related to that diagnosis.