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Nutrition
FEEDING DIFFICULTIES

Nutrition – Feeding Difficulties

Feeding difficulties need to be addressed in order to reduce the risk of undernutrition, growth failure, micronutrient deficiencies, osteopenia and nutritional comorbidities.1

Asking the caregiver the following questions may help you better evaluate the situation2:

  • Does feeding time take longer than 30 minutes?
  • Are mealtimes stressful for you and your child?
  • Have you observed a lack of weight gain for the past 2-3 months, especially in the first 2 years of life?
  • Does your child have a history of respiratory illnesses?
  • Have you observed an increased nasal congestion at meal times?
  • Have you noticed a change in voice quality during meal times?

If possible, in order to help you identify the specific feeding issues of your patient with CP, you may observe how your patient eats.

If you suspect the presence of a swallowing disorder, it would be preferable to have an assessment under taken by a speech and language therapist (SLT). The SLT may refer them for further evaluation with a video fluoroscopic swallow study, also known as modified barium swallow.2,3

 

References:

  1. Romano C et al. European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Neurological Impairment. J Pediatr Gastroenterol Nutr. 2017;65(2):242-264.
  2. Scarpato E et al. Nutritional assessment and intervention in children with cerebral palsy: a practical approach. Int J Food Sci Nutr. 2017;68(6):763-770.
  3. National Institute for Health and Care Excellence. Cerebral palsy in under 25s: assessment and management. Full Guideline. NG62. 2017. Available at:https://www.nice.org.uk/guidance/ng62/evidence/full-guideline-pdf-4357166226

Dysphagia, also called swallowing difficulties, is by far the most common feeding issue in children with moderate to severe cases of cerebral palsy.1

Typically, a child with dysphagia has trouble swallowing food and/or fluids. Greater swallowing difficulties are observed in children with spastic quadriplegia.2

A number of signs could indicate that the child has dysphagia. Here is a partial list of possible signs:2,3

  • Coughing and/or chocking during feeding
  • Changes in facial colour during feeding
  • Fatigue/sweating during feeding
  • Difficulty in retaining food in the mouth
  • Prolonged time for feeding
  • A chronic cough
  • Poor weight gain
  • Recurrent chest infections
  • Altered breathing patterns
Diagnosis Tools in Dysphagia Evaluation
Careful feeding history
Physical examination (especially neurological examination)
Barium swallow
Modified barium swallow (videoftuoroscopy)
Oesophageal manometry
Oesophageal pH monitoring
Endoscopic evaluation (hypopharynx or oesophageal)

 

Diagnostic tool table Source: DeLegge MH. Enteral nutrition and the neurologic diseases. In: Rolandelli RH. Enteral and Tube Feeding, eds. 4th ed. Elsevier, Inc., 2005, p. 410.

 

Dysphagia can not only lead to malnutrition, but can also cause a number of respiratory problems, such as pneumonia, due to recurrent aspirations (when food or liquid enters the airway or lungs due to swallowing problems).4 Aspiration is a dangerous side effect that requires close monitoring and careful interventions to prevent. In certain circumstances, it can be silent, so careful and early diagnosis may therefore be life-changing to the patient.

Major risk factors for aspiration include:5

  • Decreased level of consciousness
  • Neuromuscular diseases and structural abnormalities of the aero-digestive tract
  • Endotracheal intubation
  • Vomiting
  • Persistently elevated gastric residual volumes
  • Need for prolonged supine positioning of the patient
  • Previous episodes of aspiration

 

The effective management of dysphagia needs the collaboration of a multidisciplinary team. Indeed, gastrointestinal issues, pulmonary status, nutrition/hydration, oral sensorimotor skills, behavioural issues and family interactions all need to be managed in parallel.5

Adapting the texture and consistency of your patient’s meals and ensuring a correct posture during the feeding process are possible ways to address dysphagia.

→For more details on how to adapt texture and consistency, refer to the section related to nutritional solutions

 

References:

  1. Penagini F et al. Dietary Intakes and Nutritional Issues in Neurologically Impaired Children. Nutrients.2015;7(11):9400-15.
  2. Arvedson JC. Feeding children with cerebral palsy and swallowing difficulties. Eur J Clin Nutr. 2013;67 Suppl 2:S9-12.
  3. Nice Guidelines: National Institute for Health and Care Excellence. Cerebral palsy in under 25s: Assessment and management. Full Guideline. NG62. 2017. Available at: https://www.nice.org.uk/guidance/ng62/evidence/full-guideline-pdf-4357166226
  4. Garcia-Peris P et al. Management of patients with dysphagia: Update on chronic patients in need of nutritional support. Nutr Hosp Supl. 2012; 5(1): 33–40.
  5. DeLegge MH. Enteral nutrition and the neurologic diseases. In: Rolandelli RH. Enteral and Tube Feeding, eds. 4th ed. Elsevier, Inc., 2005, p. 410.

Gastro-oesophageal reflux, also known as GORD, is another very common feeding difficulty.1,2 It happens when stomach content rises back up in the oesophagus. GORD can cause pain, vomiting and harm to the oesophagus, because the liquid that comes back up contains acid from the stomach, as well as enzymes and bile. GORD can be controlled through nutritional strategies and specific medications that can be prescribed.

Lifestyle recommendations can also help in alleviating the condition, such as correct positioning of the child and refraining from laying the child down directly after meal times.

Recurrent episodes of GORD can be very harmful for children, and nutritional strategies should be adapted accordingly. Children with CP are at an increased risk of developing GORD, due to complications such as decreased lower oesophageal sphincter tone, delayed gastric emptying, impaired oesophageal motility, poor posture, recurrent seizures, scoliosis, and various medications.3

 


References:

  1. 1. Penagini F et al. Dietary Intakes and Nutritional Issues in Neurologically Impaired Children. Nutrients.2015;7(11):9400-15.
  2. Sullivan PB. Gastrointestinal disorders in children with neurodevelopmental disabilities. Dev Disabil Res Rev. 2008; 14(2):128-36.
  3. Kim S et al. Gastroesophageal Reflux in Neurologically Impaired Children: What Are the Risk Factors? Gut Liver. 2017 Mar 15;11(2):232-36.

A child with cerebral palsy may also be suffering from associated conditions, such as:

Constipation

Up to 74% of children with severe disabilities suffer from constipation.1
Contributing factors are:1

  • Reduced fluid and fibre intake
  • Abnormal bowel mobility
  • Prolonged immobility
  • Skeletal abnormalities
  • Generalised hypotonia (decreased muscle tone)

Recurrent episodes of constipation can lead to chronic nausea, recurrent vomiting, abdominal pain and, ultimately, reduced food intake.1 A child suffering from constipation might refuse to eat due to pain in his/her tummy, and thus may not get the required nutrition for proper growth and development.1

Obesity

In certain cases of very limited mobility, children are at an increased risk of suffering from obesity.

Overweight children that have a BMI (Body Mass Index) >95th percentile are at an increased risk of obesity and need to follow an individualised nutritional plan.

It is important to diagnose and treat these associated conditions while managing CP related challenges. Specific nutritional solutions are an essential part of an overall holistic treatment plan.

→Click here to take a look at our dedicated section related to nutritional solutions

References:

  1. Penagini F et al. Dietary Intakes and Nutritional Issues in Neurologically Impaired Children. Nutrients.2015;7(11):9400-15.