Acta Paediatr 84: 689-92.

1995

Positioning improves the oral and pharyngeal swallowing function in

children with cerebral palsy
G Larnert and 0 Ekberg'
Departmen1 of Paedialric Rehabilitation Center, Lund, and Department of Radiology' University of Lund, Malmo General Hospital, Malmo,
I

Sweden

Larnert G, Ekberg 0. Positioning improves the oral and pharyngeal swallowing function in children
with cerebral palsy. Acta Padiatr 1995;84:689-92. Stockholm. ISSN 0803-5253
Many children with cerebral palsy have feeding difficulties. The aim of this study was to investigate if
trunk and neck positioning influenced oral and pharyngeal swallow. Five children with feeding
problem aged 3-10 years with cerebral palsy were examined using videofluoroscopy. All children
had tetraplegia with dystonia, i.e. poor head control and poor trunk stability. All children had gross
aspiration and posterior oral leak. The pharyngeal phase was delayed in relation to the oral phase. Two
children had pharyngeal retention. The children were positioned with both an extended and flexed
neck. The flexed neck position was combined with a 30" reclined sitting position. In both positions they
were given purCe with barium and liquid barium during video recording. In the reclined position with
the neck flexed, aspiration decreased in all five children, oral leak diminished in two children and
retention improved in one child. 0 Cerebralpalsy, neck extension, neckflexion, positioning, swallowing,
videofluoroscopy
0 Ekberg, Department of Radiology, Malmo General Hospital, S-214 01 Malmo, Sweden

Many children with cerebral palsy have feeding difficul-
ties in the neonatal period. Neurological lesions cause
abnormalities in oral motor activity and defective co-
ordination of swallowing (1 -3). Several studies have
shown that feeding a child with cerebral palsy is a
substantial problem both for the child and parents.
Feeding can take up to 7 h per day and 15 times
longer than for neurologically normal children (4-6).
Even if feeding takes an extremely long time, the chil-
dren do not receive enough nourishment and this may
be the reason why they show failure to thrive (7). In a
study by Bax, 19 of 100 children with cerebral palsy were
found to be underweight or badly nourished due to
feeding problems (8).
Physiotherapy of these children is symptomatic and
aims at changing motor behaviour, for example by
adopting a suitable body position. Many of these chil-
dren are hypotonic in the trunk. In an upright sitting
position, therefore, the thoracic columna becomes
kyphotic and the cervical spine lordotic (9). Also the
children usually have poor lip control and inadequate
posterior transport of the bolus in the oral cavity. This
leads to the oral contents leaking out of the mouth
anteriorly (1, 9). Due to this the head is often tilted
backwards. The children therefore become lordotic in
the cervical spine which has a negative influence on the
function of the pharynx during swallowing. A prior
study showed that neck extension, for example, ham-
pered closure of the laryngeal vestibule (10).
The aim of this study was to evaluate if neck extension
and neck flexion combined with a reclining sitting
position influenced pharyngeal function in children
with severe cerebral palsy and feeding difficulties.
Patients and methods
Six children (4M, 2F), aged 3-10 years, with tetraplegia
and dystonia were included. All had severe cerebral
palsy (Table 1). They were not chosen at random. All
had had feeding problems from the neonatal period and
all had signs of aspiration and recurrent pneumonia.
Therefore, there was a clinical indication for the swal-
lowing study. All parents agreed to the study.
Before the radiological examination, the physical
therapist (GL) visited the child's home or day-care
centre for evaluation of the child's sitting position and
the degree of problems during feeding.
Videoradiographic study
Patients were given a puree mixed with barium
powder. The puree was given with a spoon in amounts
of about 3 ml. The liquid bolus consisted of 60% wjv
barium suspension. The liquid was administered via a
cup and without control of volume. The barium swal-
low was recorded on a video (S-VHS). The children
were examined only in lateral projection, with a field of
view including the oral cavity, pharynx and cervical
oesophagus.
690 G Larnert and 0 Ekberg ACTA PRDIATR 84 (1995)

First the child was positioned in the seater in an Results

upright position. This position corresponded to the
regular eating position of the child. Thereafter the seat
was reclined 30” backwards on the X-ray table and the
child’s neck was flexed. The neck was supported by a
pillow. The positioning was controlled and adjusted if
necessary during intermittent fluoroscopy. None of the
children showed any asymmetric tonic neck reflex or
extension synergy, which could not be inhibited.
During both positions the child was given puree and
liquid, and oropharyngeal function was recorded on
video (Table 2).
Swallowing was assessed according to the following
protocol. (i) The chdd’s ability to control the oral
content. Oral leak was defined as leakage over the
tongue base into the pharynx without elicitation of the
pharyngeal swallow. (ii) Pharyngeal swallow was said to
have occurred when the hyoid bone moved forward. (iii)
The position of the apex of the bolus was registered when
the anterior movement of the hyoid bone occurred. (iv)
Assessment of amount of aspiration was divided into
small, medium and gross. Aspiration was assessed as
small if bolus penetrated only into the laryngeal vesti-
bule in less than half of the swallows, as medium if bolus
penetrated into the laryngeal vestibule regularly but only
infrequently to the trachea, and as gross if the bolus
reached into the trachea on every swallow. (v) The time
of aspiration was categorized according to when aspira-
tion occurred: before, during or after swallowing. It was
also noted whether or not the patient coughed. (vi)
Retention of contrast medium in the pharynx was
registered. (vii) Opening of the pharyngeal oesophageal
segment was registered. (viii) The range of movement of
the hyoid bone was registered and divided into normal or
restricted.
All children had oral motor dysfunction with posterior
leak and gross aspiration while the pharyngeal stage was
otherwise normal. Three children showed oral leak while
eating puree, while all five children had leak when
drinking liquids. Oral leak decreased when neck flexion
was applied in two children. Aspiration occurred before,
during and after swallowing. All children had normal
opening of the pharyngo-oesophageal segment (POS)
and normal range of movements of the hyoid bone.
Pharyngeal swallow was elicited from the fauceal
isthmus in two children when swallowing puree. Puree
in the other three children, as well as liquid in all
children, elicited swallowing when the apex of the
bolus was in the vallecula or the piriform sinus. This
did not change when the head was flexed.
Oral dysfunction was most pronounced on liquid
swallow. Both oral leak and aspiration increased.
When the neck was flexed, aspiration decreased in all
five children on swallowing liquid and in four of five
children when swallowing puree. Three children coughed
sometimes during aspiration episodes. However, on 13
occasions aspiration did not cause any cough.
Retention of puree in the pharynx was seen in one
child and retention of liquid in another child. This did
not lead to aspiration.
Discussion
In a normal child, the airways, including the laryngeal
vestibule are closed during swallowing and no part of
the bolus passes through (1 1- 14). This is in contrast to
bolus penetration in the children in this study who had
abnormal closure of the airways. Such aspiration may

Tuhle 1. Characteristics of the children in the study.

Age Failure Meal-time Chest

Child (years) Diagnosis to thrive observations infections Cough

1 10 Tetraplegia, + Hypersensib, 1-2 t/year After

dystonia, oral region, meal time
ep. hypotonia tongue protrusion
2 6 Tetraplegia, + Bite reflex, 3-4 t/year After
dystonia, gag reflex, meal time
ep. ATNR tongue protrusion
3 10 Tetraplegia, + Bad oral function, 1-2 t/year After
dystonia, hypokinetic meal time
hypotonia
4 4 Tetraplegia, + Tongue protrusion, 3-4 t/year After
hypertonia, lip pursing, meal time
ATNR bite reflex
5 3 Tetraplegia, ~ Hypotonic oral regulation, 1-2 t/year After
hypotonia, oral loss of food meal time
eP.

Failure to thrive = low weight and/or length for age. ATNR = Asymmetric tonic neck reflex. Tongue protrusion = maintains the flow of
movement seen in the normal suckle pattern (1). Lip pursing = when the child tries to close the lips from a retracted position and the lip muscles
are drawn closed in a puckered way, as when a laundry bag is pulled closed by a drawstring (1).
ACTA PEDIATR 84 (1995) Oral andpharyngeal swaNowing in CP 691

Table 2. Videofluoroscopic findings.

Position Aspiration
Neck bolus before, during or
Child position Oral leak apex after swallowing Coughing Retention

Puree swallowing
1 Ext 0 Vallec During + + +
Flex 0 Vallec During O/ + 0
2 Ext + Sin pir Before + + 0
During +
Flex + Sin pir 0 0
3 Ext 0 fi Before + 0
Flex 0 fi 0 0
4 Ext 0 fi 0 0
Flex 0 fi 0 0
5 Ext i -++ Vallec + 0
Flex ++ Vallec 0 0
Liquid swallowing
1 Ext + Vallec During + + 0
Flex + Vallec During + 0
2 Ext + Sin pir Before + + 0
During + +
Flex + Sin pir During O/ + 0
3 Ext + Sin pir Before + + + Vallec
Flex + Sin pir Before + Vallec
4 Ext + Sin pir Before + + 0
Flex 0 Sin pir Before + 0
5 Ext ++ Sin pir Before + + + 0
Flex + Vallec o/ + 0

Abbreviations: Ext = neck extension, Flex = neck flexion, Oral leak = bolus leakage over the tongue base without elicitation of the
pharyngeal swallow, Position bolus apex = the position of the apex of the bolus when swallowing was elicited. Vallec = Vallecula, Sin
pir = sinus piriformis, f i = fauceal isthmus, + = minimal, + + = moderate, + + + = severe aspiration. Retention = retention of the bolus
in the pharynx after swallowing.

cause pneumonia and if severe enough may lead to
chronic pulmonary fibrosis (6). Aspiration does not
usually lead to a cough reflex even when the bolus
reaches into the trachea. This has been called silent
aspiration. Arvedson and Brodsky found that 26% of
186 children with cerebral palsy aspirated (15). Of those
who aspirated 98% did not cough. Children with cere-
bral palsy also frequently have gastro-oesophageal
reflux. Aspiration of acid material may also lead to
chronic pulmonary disease (6, 16).
Poor oral transfer of the bolus, together with increas-
ing neck extension (from 0 to 45"), causes deterioration
in co-ordination between the pharyngeal contraction
and the POS opening (17). During neck extension the
POS is less relaxed over a shorter period. These authors
also showed that there is narrowing of the pharynx
during neck extension. Protection of the airways is
improved when the cervical spine is held in flexion
(17). This was verified in our study in which the sitting
position with the neck flexed and 30" reclined seating
diminished the tendency to aspirate during swallowing
in all five children. This is in line with previous reports
by Ekberg (lo), and Castell et al. (17). Elicitation of
pharyngeal swallow, i.e. the beginning of the anterior
movement of the hyoid bone, did not change during
positioning. Neither did dissociation between the oral
and pharyngeal phases. Chin tuck is a useful technique
to improve closure of the airways. The tilting down of
the epiglottis seems to be facilitated and this gives some
protection to the laryngeal vestibule even if the vestibule
is not completely closed. Also, the sagittal diameter of
the pharynx widens, including the vallecula. Thereby
the bolus is retained within the vallecula for a varying
period of time and this may actually increase the time
for elicitation of pharyngeal swallow.
Extension of the neck can cause extension synergy (9).
This has a negative influence on the oral motor pattern
and the oral tonus (1, 18). With neck flexion some
inhibition of this can be achieved. This also improves
the training condition for oral motor function. Swallow-
ing with extended neck causes the tongue to fall back-
wards into the pharynx due to gravity. This may
decrease the volume of the vallecula (19). The open
vallecula forms a barrier for inflow of bolus into the
laryngeal vestibule.
Three children in our study had severe epilepsy and
were on medication. The medications, such as pheno-
barbital, phenytoin and carbamazepine may lead to
hypotonia and a hyporeaction in the oral cavity (1, 9).
In two children it was difficult to position them due to
high tonus. They also showed abnormal reactions when
the spoon approached the mouth, for example both had
a strong asymmetric tonic neck reflex (ATNR), lip
pursing, hyperreactive gag reflex and tongue thrust.
692 G Larnert and 0 Ekberg
During corrected positioning these adverse effects were
normalized.
The radiographical examination made it possible to
determine immediately if the positioning was adequate.
In some patients we noted that while the positioning
might look adequate by observing the patient exteriorly,
fluoroscopy revealed that it was inadequate. This could
then be adjusted immediately. This also made it possible
to plan and assess different treatment and positioning
strategies (20). Therefore, radiographical examination
is crucial in the treatment of these patients. It is impor-
tant to have the patient positioned in a straight lateral
position, as otherwise the oropharyngeal swallow is
difficult to assess. However, it is obvious that the few
boluses which are observed during fluoroscopy give
only a glimpse of that particular patient's swallowing
function. However, videofluoroscopy is the best method
of routinely assessing these patients (21, 22). The
amount of bolus that is aspirated is, however, difficult
to assess quantitatively during barium swallow. In
nuclear medicine studies it has been shown that in
those with the most severe aspiration, only 10% of the
bolus passed into the airways.
We found that positioning our patients with tetraple-
gia and dystonia in a reclined 30" position and with the
neck flexed, diminished the tendency to aspirate during
swallowing and made feeding easier.
References
1. Morris SE, Klein MD. Pre-feeding skills. A comprehensive
resourse for feeding development. Tucson, Arizona: Therapy
Skill Builders, 1987
2. Griggs CA, Jones PM, Lee RE. Videofluoroscopic investigation
of feeding disorders of children with multiple handicap. Dev Med
Child Neurol 1989;31:303-8
3. Matthiesen B, Skuse D, Wolke D, Reilly S. Oral motor dysfunc-
tion and failure to thrive among inner-city infants. Dev Med Child
Neurol 1989;31:293-302
4. Johnson CB, Deits JC. Time use of mothers with preschool
children: a pilot study. Am J Occup Ther 1985;39:578-83
5. Gisel EG, Patrick J. Identification of children with cerebral palsy
ACTA PEDIATR 84 (1995)
unable to maintain a normal nutritional state. Lancet 1988;l:
283-6.
6 . Jones PM. Feeding disorders in children with multiple handicaps.
Dev Med Child Neurol 1989;31:404-6
7. Shapiro BK, Green K, Krick J, Allen D, Capute AJ. Growth of
severely impaired children: neurological versus nutritional fac-
tors. Dev Med Child Neurol 1986;28:229-33
8. Bax M. Eating is important [editorial]. Dev Med Child Neurol
1989;31:285-6
9. Bobath B, Bobath K. Motor development in the different types of
cerebral palsy. London: Heinemann, 1975
10. Ekberg 0. Posture of the head and pharyngeal swallowing. Acta
Radio1 Diagn 1986;27:691-6
11. Arvedson J, Rogers B, Brodsky L. Anatomy, embryology and
physiology. In: Arvedson JC, Brodsky L, editors. Pediatric swal-
lowing and feeding, San Diego, CA: Singular Publishing Group
Inc, 1992:5-51
12. Bosma JF. Development and impairments of feeding in infancy
and childhood. In: Groher ME, editor. Dysphagia, 2nd ed.
Oxford: Butterworth-Heinemann, 1992:107-41
13. Kramer SS. Swallowing in children. In: Jones B, Donner MW,
editors. Normal and abnormal swallowing. Imaging in diagnosis
and therapy. New York: Springer Verlag, 1990:173-88
14. Kramer SS. Radiologic examination of the swallowing impaired
child. Dysphagia 1989;3:117-25
15. Arvedson J, Brodsky L. Pediatric swallowing and feeding. Asess-
ment and management. San Diego, CA: Singular Publishing
Group, Inc., 1993
16. Loughlin GM. Respiratory consequences of dysfunctional swal-
lowing and aspiration. Dysphagia 1989;3:126-30
17. Castell JA, Castell DO, Schultz AR, Georgeson S. Effect of head
position on the dynamics of the upper esophageal sphincter and
pharynx. Dysphagia 1993;8:1-6
18. Mueller H. Facilitating feeding and prespeech. In: Pearson PH,
Williams CE editors. Physical therapy services in the develop-
mental disabilities. Springfield: Charles C Thomas, 1972
19. Logemann JA. Evaluation and treatment of swallowingdisorders.
San Diego: College Hill Press, 1983:114-15
20. Helfrich-Miller KR, Rector KL, Straka JA. Dysphagia: its treat-
ment in the profoundly retarded patient with cerebral palsy. Arch
Phys Med Rehabil 1986;67:520-5
21. Langmore S, Logemann JA. After the clinical bedside swallowing
examination: what next? Am J Speech Language Pathol
1991;1:I: 13-20
22. Sonies BC. A model for differential diagnosis for adults and
children. Prepared for: Clinical management of dysphagia. Sten-
sil presenterad vid kurs: Diagnostik och behandling av dysfagi.
Goteborg Universitet, 1993
Received July 14, 1994. Accepted Jan. 17, 1995