Feeding and Eating Considerations in Cerebral Palsy

Original Editor - Teona Darchia

Top Contributors - Ewa Jaraczewska, Jess Bell, Tarina van der Stockt and Kim Jackson  

Introduction

Feeding is a vital process in everyday life. It is important for the development of the motor and cognitive functions of the child because healthy and nutritious food is essential for normal brain development. Children with cerebral palsy are often diagnosed with poor nutritional status due to their feeding and swallowing problems. When untreated, difficulties with feeding and eating may lead to growth failure, chronic aspiration, esophagitis, and respiratory infections. It can also impact the child's social, emotional, and cognitive function and significantly increase caregiver stress. This article overviews problems and solutions in feeding children with cerebral palsy who experience eating and swallowing difficulties.

Feeding and Swallowing Disorders

Paediatric Feeding Disorder is "an impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction."

Dysphagia is a swallowing problem that places the child at risk for aspiration with oral feeding. Aspiration may lead to life-threatening pulmonary consequences.

Mechanics of Feeding and Swallowing

Feeding

The feeding and eating process takes place in the following four phases:

Phase 1: Opening the mouth

Phase 2: Using utensils and placing the food and liquid in the mouth

Phase 3: Closing the mouth to prevent food or liquid from spilling out

Phase 4: Chewing the food and moving it around to prepare to swallow

Swallowing phases

Swallowing

Swallowing (deglutition) is the process by which food passes from the mouth through the pharynx and into the oesophagus. It requires breathing coordination because both processes share the same entrance to the pharynx. Failure in coordination would result in choking or pulmonary aspiration.

Swallowing occurs in three phases:

Phase 1: Oral phase

Phase 2: Pharyngeal Phase

Phase 3: Oesophageal Phase

Learn about each swallowing phase here.

Feeding and Swallowing Challenges in Cerebral Palsy

Feeding Challenges

The child's feeding and eating skills may be affected by motor or sensory challenges:

Motor Challenges

• Poor head and/or trunk alignment in midline. The posture can be either too flexed or hyperextended
• Increased muscle tone and involuntary body movements
• Unable to close the mouth due to an increased or decreased resting tone of the jaw muscles
• Unable to open the mouth due to jaw flexion pattern
• Uncoordinated, non-graded, or limited movements of the jaw leading to lack of jaw rotation movement and limited or lack of ability to chew
• Passive lips, lack of lip closure and spoon clearance
• Difficulty forming food in the mouth
• Food accumulation in the mouth
• Poor saliva control

Sensory Challenges

• Hypersensitivity to certain textures or stimuli ( taste, smell, temperature, visual aspect of food)
• Difficulty discriminating tactile sensations (preference for crunchy, chewy foods)
• Difficulty in the perception of gustatory and olfactory stimuli (preference for sour and spicy food and refusal to eat balanced or mild tastes)
• Difficulty accepting new food experiences
• Avoiding behaviour towards a primary caregiver

Swallowing Challenges

The challenges of the swallowing skills may include the following:

• Lack of stability of the lower jaw, not providing a base of support for the selective tongue movements in all directions. Poor tongue control affects bolus transport, delayed initiation of swallowing, and reduced pharyngeal motility
• Irregular swallow
• Needing extra work or time to chew or swallow
• Having food or liquid leak from the mouth
• Food getting stuck in the mouth

Clinical Signs of Feeding and Swallowing Problems

The child may display the following signs of feeding and swallowing difficulties:

• Difficulties with breastfeeding or bottle feeding
• Crying, worrying, and excited or agitated during feeding
• Does not follow the feeding developmental milestones

• Coughing during or right after eating or drinking
• Clearing the throat often
• Often vomiting or signs of vomiting while eating
• During feeding, food flows from the mouth or nose
• Poor food ration
• Long duration of feeding
• Having a wet or gurgly voice during or after eating or drinking
• Feeling like something is stuck in the throat or chest
• Challenges with drinking from a cup
• Having problems with breathing after meals
• Difficulty gaining weight or weight loss
• Behavioural challenges

Factors Influencing Child's Feeding and Eating Skills

Environmental factors: Environmental distractions decrease concentration on feeding and eating. These distractions include watching television, looking at the computer, bringing toys along during mealtime, and having meals in chaotic, crowded environments with people having loud conversations.

Physical difficulties: the child's oral motor difficulties may prevent the child from eating independently and increase the time and energy spent feeding and eating.

Behavioural factors: caregiver stress and child's negative mood affect feeding and eating. Caregiver calmness and emotional control positively affect a child's behaviour.

Healthcare Team Responsibilities

An interdisciplinary team is needed to treat the child with feeding and eating difficulties because different areas of the child's life can be impacted.

Speech-Language Pathologist

Communication, speech and language pathologist is responsible for the following:

• Assessing the function of feeding
• Contributing to the diagnosis and aetiology of dysphagia
• Assessing the protective capacity of the respiratory system
• Indicating alternative ways of eating
• Providing direct and indirect intervention with the patient, which includes strengthening facial muscles, teaching different strategies to develop sucking, chewing, and drinking skills, tasting new food and drink with rich flavours and aromas, and modifying food liquid to improve swallowing
• Guiding staff and caregivers in better management of feeding difficulties

Occupational Therapist

The occupational therapy assessment of the child with cerebral palsy's feeding and eating needs, independence and safety should include the following:

• Motor and sensory skills assessment
• Muscle strength
• Behaviour and environmental factors surrounding mealtimes

The occupational therapist's intervention focuses on the following:

• Improving oral motor skills
• Sensory processing
• Promoting correct posture
• Selecting adaptive devices and choosing strategies to use them functionally
• Adjusting and adapting the environment to promote independent eating
• Working with parents and caregivers on using different feeding methods or techniques

Physical Therapist

Physical therapy interventions are part of oral motor therapy (OMT). OMT can improve a child's functional independence and quality of life. Protocols for OMT vary and may include the following:

• Passive range of motion exercises
• Active-assistive range of motion exercises
• The oral motor facilitation technique (OMFT)
• Passive sensory stimulation of the muscles of the face and mouth with different textures and therapeutic devices
• Relaxation techniques for muscles responsible for sucking, swallowing, and chewing using the strain-counterstrain (SCS) technique and the NeuroDevelopmental Treatment-Bobath (NDT-Bobath) method
• Strain-counter strain technique to relax the tensed muscles, including the masseter muscle and the sternocleidomastoid muscle

Feeding and Eating Management Strategies

Goals and Outcomes

General goal: "to improve the quality of life for both the child and family, through interventions that maximise independence in activities of daily living, mobility, and nutrition".

The outcome measures will vary and depend on the following:

• Type of cerebral palsy: spastic vs nonspastic
• Location of motor involvement: diplegia, quadriplegia, etc.
• The child's functional status, including the ability to walk or sit and the degree of head and trunk control

Incorrect sitting posture in the wheelchair

Treatment Strategies

• Establish feeding routine
• Promote correct posture during meal times and beyond
  • Use of adequate seating equipment and/or handling techniques to maintain head/trunk aligned and upright
  • Facilitate chin tuck and elongation of the back of the neck in a midline neutral position
  • Provide adequate symmetric postural stability
    • stable base of support for the trunk, hips, knees and feet
    • 

      Correct sitting posture in the wheelchair
      hip symmetrically flexed at around 90°,
    • tray to support arms
    • headrest to support the head and the neck

• • Maintain the child's correct posture outside of mealtime
  • Oral appliances to help stabilising the jaw, improving sucking, tongue coordination, lip control, and chewing

This video offers parenting strategies to promote the child's correct posture during meal time:

• Promote eating independence
  • The food quantity on the spoon or fork should be enough for the child to handle it
  • Provide hand-over-hand assistance and gradually decrease the assistance provided as the child's motor control improves
  • Introduce assisted eating for part of the meal or snack

Watch this video to learn about general strategies to promote a child's eating independence:

• Increase food acceptability trough sensory stimuli
  • Allow the child to touch the food and smell it before trying to eat it
• Use adaptive equipment as needed
  • Children with difficulties in sucking may benefit from the introduction of a drinking cup
  • 

    U-shaped cup
    U-shaped cut-out cup for drinking the liquid limits the child's need to pull the neck or head while drinking
  • A shallow-bowled spoon can help the child remove the food from the spoon through lip closure
  • Angled spoon will require less wrist movement to bring food to the mouth
  • Universal cuff with attached fork or spoon will help to hold the utensils for the child with a weak grasp
  • Scoop plates and plates with a silicone base to help with scooping the food off the plate
  • A feeding chair with a tray attached to the front helps to maintain posture alignment

This video demonstrates examples of adaptive feeding equipment:

• Consider 'play elements to support the child's willingness and enjoyment during the feeding process
• Introduce a variety of foods to play with
  • Changing the viscosity of liquids
  • Increasing or decreasing the consistency of solids offered
  • Adding supplemental feedings when needed
• Organise the environment
  • Create a quiet environment
  • Slowly introduce an element of distraction when the child’s ability progresses
  • Start with background sounds like radio
  • The caregiver/the person feeding or assisting with eating should be in front of the child, in midline, to facilitate communication with the child

Resources

• Module 6. Feeding Your Child. In: GETTING TO KNOW CEREBRAL PALSY