Support and Interventions for Managing Feeding Issues in Cerebral Palsy Dr Nadeem Ghayas
July 20, 2024
Difficulty with feeding is a common issue with children who have cerebral palsy (CP); a group of long-term disabilities caused by brain injury which affects muscle strength, coordination, and posture. Feeding difficulties can have many negative impacts on a child’s nutritional status, respiratory health, and overall quality of life.
The importance of early diagnosis and consistent support cannot be overstated; if left unmanaged, feeding issues can lead to serious complications like malnutrition, aspiration pneumonia, and poor growth.
What Are Feeding Difficulties in Children with Cerebral Palsy?
Oropharyngeal dysphagia (swallowing and feeding disorders) occur when a child has trouble coordinating their muscles used to chew and swallow, which results from impaired muscle control, spasticity, and poor coordination of the oral and pharyngeal muscles (Benfer et al., 2017).
Types of Feeding Problems in Cerebral Palsy
Children with cerebral palsy will often experience varying levels of feeding and swallowing difficulties based upon their level of physical impairment.
Common Feeding Problems in Cerebral Palsy
- Oral Motor Dysfunction
Many children with cerebral palsy have difficulties with oral motor function, which includes:
Sucking
Chewing
Tongue movement
Coordinating the act of swallowing
Impaired oral motor function causes difficulty with managing food safely; weak facial and jaw muscles make it hard to use utensils or manipulate food properly, causing food to spill out of the mouth and prolong meal times (Arvedson, 2013).
- Delays or Weakness of the Swallowing Reflex
When the swallowing reflex occurs too slowly, there is an increased risk of choking and aspiration (when food or liquids enter the airway instead of the esophagus). Aspiration can cause repeated episodes of respiratory infection and pneumonia.
To evaluate safe feeding methods, clinical feeding evaluations and instrumental studies are usually necessary (Benfer et al., 2017).
- Gastroesophageal Reflux Disease (GERD)
GERD is much more prevalent in children with cerebral palsy due to the atypical muscle tone and decreased GI motility.
Symptoms of GERD can include:
Vomiting
Irritability while eating
Arching of the back
Poor weight gain
If left untreated, GERD can cause feeding refusal and esophageal pain. Medical and nutritional management is usually needed to treat symptoms (Romano et al., 2017).
- Drooling (Sialorrhea)
Children with cerebral palsy will often exhibit excessive drooling due to poor oral motor control (i.e., they do not have enough control over their tongues and lips).
Excessive drooling can:
Result in skin irritation
Increase risk of dehydration
Impact social participation
Decrease mealtime confidence
Therapy options include oral motor exercises, behavioral interventions and/or medical treatments.
- Aversions to Textures and Sensory Sensitivities
Due to the possible presence of sensory processing disorder, children may display aversions to certain food textures such as:
Lumpy
Crunchy
Mixed textures
Texture aversion may limit the variety of food consumed and lead to nutritional deficiencies. Through gradual exposure and feeding therapy, children can learn to accept a wider variety of food.
- Reduced Mobility and Postural Instability
Posture is a major contributor to feeding safely. Many children with cerebral palsy have poor postural stability; this can be due to a lack of trunk control, spasticity, and/or reduced ability to sit upright (Arvedson, 2013).
Positioning the child improperly increases the risk of aspiration and increases the likelihood of feeding fatigue. Using proper seating systems and providing supportive positioning during meals helps improve the child’s ability to feed independently and safely.
- Poor Appetite and Fatigue
For children with cerebral palsy, feeding is energetically expensive. It can be physically tiring to chew and swallow, resulting in:
Inadequate food consumption
Reduced calorie intake
Delayed growth
Strategies to manage feeding fatigue may include reducing the amount of time spent at the table and having smaller, more frequent meals (e.g., six small meals per day vs. three large meals per day) (Weinberger, 1998).
- Behavioral Feeding Challenges
Behavioral feeding challenges can be exhibited as:
Refusal to eat
Tantrums during meals
Eating-related anxiety
These behaviors are often the result of the child being uncomfortable or fearful of choking during feeding; they may also be the result of sensory overload during feeding. Behavioral interventions combined with medical and therapeutic management should be implemented.
- The Use of Adaptive Feeding Equipment
Some children with cerebral palsy may need special assistive devices to facilitate independent feeding; these devices include:
Angled utensils
Suction-based plates
Modified cups
Specialized feeding chairs
Use of specialized equipment can enhance a child’s independence during meals and improve feeding safety.
H2: Evidence-Based Interventions for Managing Feeding Issues in Children with Cerebral Palsy
There are several evidence-based approaches to managing feeding issues in children with cerebral palsy. A multi-disciplinary team of professionals, including a speech-language pathologist (SLP), registered dietitian (RD), occupational therapist (OT), physiotherapist (PT), and pediatrician (MD) should work together to develop a plan to address the child’s specific needs.
H3: 1. Speech-Language Pathology Services
Speech-language pathologists (SLPs) assess the child’s oral motor skills and provide therapies designed to strengthen oral muscles, improve chewing skills, and create safe swallowing patterns (Benfer et al., 2017).
Early initiation of feeding therapy can improve nutritional status and reduce the risk of aspiration.
- Registered Dietitian Services
Registered dietitians (RDs) conduct nutritional assessments to determine the child’s total daily calorie and nutrient requirements. Depending on the child’s nutritional assessment, the RD may recommend the following interventions:
High-calorie meal plans
Modifying the texture of food
Supplementary nutrition
Tube feeding (in severe cases)
Appropriate nutritional management can help prevent malnutrition and growth failure (Romano et al., 2017).
- Medical Management
Pediatricians (MDs) may prescribe medications to alleviate the symptoms of GERD and may monitor and manage other complications arising from aspiration. If severe, surgery (such as the placement of a gastrostomy tube) may be recommended (Weinberger, 1998).
- Occupational Therapist/Physiotherapist Support
Occupational therapists (OTs) and physiotherapists (PTs) help children develop better postural control, upper limb coordination, and positioning during meals.
By improving a child’s postural control and upper limb coordination, the OT and PT can help reduce the child’s fatigue and improve the child’s ability to safely swallow.
- Parent/Caregiver Education and Mealtime Strategies
Parents/caregivers play a key role in implementing feeding strategies in the home setting. Parents/caregivers may receive training and education regarding:
Optimal feeding positions
Identifying signs of aspiration
Pacing techniques for meals
Creating a peaceful environment for meals
Using the same feeding strategies consistently at home can significantly improve outcomes.
Importance of Interdisciplinary Care
Interdisciplinary care refers to the collaborative efforts of multiple healthcare professionals working together to assess and manage a child’s unique needs.
Pediatricians (MDs)
Speech-Language Pathologists (SLPs)
Registered Dietitians (RDs)
Occupational Therapists (OTs)
Physiotherapists (PTs)
Parents/Caregivers
Collaborative interdisciplinary care provides for a comprehensive evaluation and coordinated interventions, as well as ongoing monitoring and evaluation of the effectiveness of the plan (Benfer et al., 2017).
Conclusion
Cerebral palsy can present many challenges to a child’s development and daily functioning. The combination of oral motor dysfunction, delayed swallowing reflex, GERD, drooling, sensory sensitivities, and fatigue can cause significant feeding challenges.
Early recognition and interdisciplinary intervention, along with caregiver education and support, are key components of helping children with cerebral palsy overcome the challenges of feeding and achieve safe and successful feeding experiences.
References
Arvedson, J. C. (2013). Feeding children with cerebral palsy and swallowing difficulties. European Journal of Clinical Nutrition, 67(S2), S9-S12.
Benfer, K. A., Weir, K. A., & Boyd, R. N. (2017). Clinimetrics of measures of oropharyngeal dysphagia in children with cerebral palsy. Developmental Medicine & Child Neurology, 59(6), 618-624.
Romano, C., van Wynckel, M., Hulst, J., Broekaert, I., Bronsky, J., Dall’Oglio, L., … Gottrand, F. (2017). European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines for the evaluation and treatment of gastrointestinal and nutritional complications in children with neurological impairment. Journal of Pediatric Gastroenterology and Nutrition, 65(2), 242-264.*