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1
Department of Paediatrics, John
Radcliffe Hospital, University of
Oxford, Oxford, UK
2
Institute of Neurosciences,
Newcastle University, Newcastle
Upon Tyne, UK
Correspondence to
Morag J Andrew, Department of
Paediatrics, University of Oxford,
John Radcliffe Hospital, Level 2,
Children’s Hospital, OX3 9DU,
UK;
morag.andrew@paediatrics.
ox.ac.uk
Received 23 August 2011
Accepted 12 December 2011
222 Arch Dis Child Educ Pract Ed 2012;97:222–229. doi:10.1136/archdischild-2011-300914
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Feeding difficulties in children with
cerebral palsy
Morag J Andrew,1 Jeremy R Parr,2 Peter B Sullivan1
ABSTRACT
Feeding difficulties are common in children with
cerebral palsy and have an effect on growth,
nutritional state, general health, social interaction
and behaviour and developmental outcomes.
Many factors have an effect on feeding ability.
Identification of these factors and amelioration of
their impact on feeding difficulties is essential to
promote adequate growth and nutrition. Appropriate
assessment and management is best achieved by a
multiprofessional team skilled in the care of children
with cerebral palsy and feeding impairments.
Feeding difficulties must be considered within the
wider context of family and social circumstance.
Introduction
Feeding difficulties are common among
children with cerebral palsy (CP).
Problems with feeding may result from
oromotor impairment, dysphagia, sen-
sory impairment with or without behav-
ioural difficulties, and be associated with
specific medical problems such as aspira-
tion, chest infections, gastro-oesophageal
reflux (GOR) and constipation. Feeding
difficulties may cause inadequate fluid
intake resulting in dehydration, subopti-
mal calorie intake and inadequate growth.
Feeding problems may also have signifi-
cant psychosocial impact, quality of life
(QoL) and participation implications for
the child, carer and wider family. Early
involvement of a skilled multiprofessional
team is essential to reduce the impact of
feeding difficulties, and improve a range
of outcomes, including nutritional intake
and growth.1
Prevalence of feeding difficulties in children
with CP
Feeding difficulties occur in 30–40% of
children with CP,2 3 and are the common-
est among children with severe motor
impairment.2 In 2000, the Oxford Feeding
Study evaluated 271 children with CP
and feeding problems. Common feeding
problems were need for help with feeding
(89%), choking with food (56%), feeding
time greater than 3 h per day (28%), con-
stipation (26%) and frequent vomiting
(22%).3 Inadequate nutrition caused by
feeding difficulties may be further exacer-
bated by excessive losses caused by vomit-
ing and GOR. The study also highlighted
inadequacies in appropriate professional
involvement to this group of children;
two-thirds of children had never had a
feeding or a nutritional assessment, and
only 17% had received input from a dieti-
cian in the preceding 12 months.
Aetiology
Feeding difficulties in children with CP
result from damage and disruption to the
central nervous system (CNS) and enteric
nervous system (ENS).
CNS control of feeding and swallow-
ing is mediated via pathways involving
cranial nerve nuclei, the brainstem and
cortex. Sensory (afferent) input from cra-
nial nerves V, VII, IX and X is relayed
to the nucleus tractus solitarius (NTS)
and then to specific regions of the brain-
stem known as central pattern generators
(CPGs). Motor (efferent) signals from the
CPG travel via the nucleus ambiguous and
cranial nerve nuclei V, VII, IX, X and XII,
and upper cervical nerves (C1–C3), con-
trolling the movements of mastication,
respiration and swallowing necessary to
safe, effective feeding. Descending corti-
cal pathways mediate the output from the
NTS and CPG.4
The ENS comprises around 1 billion
neurons and functions partly independ-
ently of the CNS. The ENS controls
important functions such as motility,
secretion and gastrointestinal blood flow.
The CNS modulates the ENS. In children
with neurological disorders, this interac-
tion is disordered5 resulting in enteric
dysfunction. This manifests primarily as
foregut dysfunction. The foregut begins
at the mouth and ends in the second part
of the duodenum. The foregut is densely
innervated by neurons of the ENS, making
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Figure 1 Causal relationships between factors contributing to feeding difficulties and growth and general health in children with cerebral
palsy.
it vulnerable to abnormal efferent control, leading to
electromechanical dissociation and associated dysmo-
tility and symptoms.
These underlying problems may be further compli-
cated by many other factors, some of which interact,
and are shown in figure 1.
Consequences of impaired feeding
Inadequate growth and nutrition
Historically, poor nutritional status was believed to be
unavoidable in children with severe neurodisability. We
now understand that chronic feeding problems may
cause malnutrition, dehydration and poor growth.
When necessary, these can be avoided through appro-
priate intervention with dietetic input, with or with-
out gastrostomy insertion. The contribution of specific
brain injury does not adequately explain growth fal-
tering in children with neurodisability. Equally, under-
nutrition does not explain all of the growth failure,
especially linear growth failure, in children with CP.6
However, the pattern of early growth failure seen in
children with CP reflects chronic undernutrition; poor
weight gain is followed by suboptimal linear growth
and eventual drop-off in head growth.7 Body mass
index is a poor measure of body fat in children with
CP.8 Skinfold thickness acts as a proxy estimate of
body fat. Triceps skinfold thickness (TST) is relatively
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easy to perform; TST below the 10th percentile is a
strong indicator of low body fat stores and therefore
of undernutrition in children with CP.8
Neurodevelopmental outcome
It is possible that nutritional deficits may exacerbate
the effects of primary brain injury in very young chil-
dren with CP. Head circumference trajectory reflects
brain growth. The positive relationship between head
circumference and developmental outcome is widely
acknowledged.9 Brain growth occurs most rapidly dur-
ing the third trimester of pregnancy and the first 2 years
of life, during which explosive neuronal growth and
synaptogenesis occur. Postnatal rather than intrauter-
ine head growth determines neurodevelopmental out-
come.10 11 Poor postnatal head growth in ex-preterm
infants aged 2 years, but not at term, is strongly associ-
ated with neurodevelopmental problems10 12 and CP.12
One small randomised double-blind control study of
neonates with perinatal brain injury showed improved
head growth and increased corticospinal axon dia-
meter in those fed a high-energy and high-protein diet
(120% of recommended average intake (RAI)) com-
pared with those fed a standard energy and protein
diet (100% RAI).13 The developmental outcome of
this group of children has not yet been reported. Data
223
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Table 1 Clinical symptoms and signs of aspiration
Clinical symptoms and signs of aspiration
Blinking, eye watering
Throat clearing, grimacing, head tilting
Difficulty handling oral secretions
Poor oral motor co-ordination
Limited endurance/increasing fatigue during feeding
Delayed swallow reflex
Multiple swallows to clear single bolus
Wet voice quality during or after feeding
Increased congestion during feeds
Noisy/wet upper airway sounds associated with feeding
Coughing or choking during/after feeds
Change in breathing rhythm or apnoea
Recurrent wheeze
Recurrent respiratory infection
from a small study of children with CP demonstrated
improved gross motor skills following 6 months of
nutritional rehabilitation.14 Studies of whether or not
nutritional supplementation with macronutrients and
micronutrients improves neurodevelopmental out-
come in children with CP are underway.
Nutritional support of children with CP and dys-
phagia is essential during this 2-year formative period.
However, this is also the period in which the parents
of children with neurodisability are experiencing con-
siderable challenges in ensuring their child receives
appropriate calories.
General health
The North American Growth in Cerebral Palsy Project2
correlated feeding difficulties with adverse general
health outcomes. Recurrent aspiration is a recognised
consequence of dysphagia, and may lead to recurrent
chest infections and chronic lung disease. Aspiration
may result in recurrent respiratory infections, recur-
rent wheezing, intermittent stridor, atelectasis or
desaturation requiring oxygen therapy. Acute aspira-
tion pneumonia can be life threatening, and children
may need expert management in intensive care.
Children with CP also experience gastrointestinal
problems caused by disruption of the CNS-ENS axis.
Foregut dysmotility resulting from transient relaxa-
tions of the lower oesophageal sphincter, delayed
gastric emptying and abnormalities of oesophageal
peristalsis result in GOR, affecting 15–75% of chil-
dren with CP.15–17 Severe scoliosis may also contribute
to GOR by causing raised intra-abdominal pressure.
GOR commonly manifests as pain caused by resultant
oesophagitis and recurrent vomiting, further compro-
mising the nutritional intake in children with feeding
difficulty. Chronic constipation occurs in 26–57%
of children with severe disability.18–20 Factors such as
prolonged immobility, skeletal abnormalities, exten-
sor spasm, hypotonia and altered bowel motility are
risk factors for constipation. Inadequate fluid and
fibre intake also contribute. Opioids, anticonvulsants,
antispasmodics, antihistamines and aluminium antacid
preparations can further exacerbate problems.21 In
224 Arch Dis Child Educ Pract Ed 2012;97:222–229. doi:10.1136/archdischild-2011-300914
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addition to causing pain and discomfort, constipation
may worsen feeding problems by causing recurrent
vomiting, chronic nausea and early satiety.22 As stool
softeners work by increasing the amount of fluid in the
bowel, their effectiveness is often reduced in children
with inadequate liquid intake.
Psychosocial impact and QoL
Feeding difficulties can have psychosocial impact for
child and carer. Mealtimes provide potential opportu-
nities for social interaction with family and friends. For
the parents of a child with severe disability, feeding is
usually an important part of parent-child social inter-
action. Dependence on a carer for feeding, prolonged
feeding times, feeding-related behavioural difficulties,
messy feeding and limited communication abilities all
contribute to reduced opportunities for participation
in feeding in the usual groups and settings (eg, peers at
lunchtimes, and with the family in restaurants).
Twenty per cent of parents participating in the
Oxford Feeding Study3 found mealtimes stressful.
These findings are mirrored by a recent study exam-
ining feeding-related QoL in children with spastic
quadriplegic CP.23 Parental stress resulting from ade-
quately feeding their child was a prominent nega-
tive feature of focus group responses. Parents also
reported that time spent preparing food and feeding
their child, plus the preparation required for visits
and trips limited the time available for other activi-
ties for the whole family.23 If oral feeding cannot
support adequate growth, some parents may feel a
sense of failure despite tremendous efforts to nour-
ish their child. This may be compounded by negative
interactions with health professionals. The majority
of parents participating in the study of Morrow et al
reported negative experiences when communicating
with professionals regarding feeding issues. Parental
responses indicated that they thought profession-
als did not consider their opinions to be important,
that there was a general lack of information regard-
ing treatment options and that they were made to
feel guilty or ashamed, particularly with regard to
their child’s nutritional status.23 Parents also felt that
healthcare staff took a very clinical approach, placing
too much emphasis on weight.
Feeding dependence may have an impact on parents
and other family members in other ways. For instance,
particular ways of feeding are often considered essential
for safe feeding by parents. This may make it difficult
to leave their child in someone else’s care, fearing that
they are unequipped to deal with mealtime challenges,
placing severe restrictions on parental and other family
members’ employment and social opportunities.
Assessment of children with neurodisability and feeding
difficulties
The increased risk of nutrition and feeding-related
morbidity warrants careful assessment and appropri-
ate intervention in children with CP. The importance
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Figure 2 Assessment and management of feeding difficulties in a
child with cerebral palsy.
of effective multidisciplinary team (MDT) working
cannot be overemphasised. The MDT should include,
as appropriate, a paediatric gastroenterologist, paedi-
atric surgeon, neurodisability or community paediatri-
cian, or paediatric neurologist, paediatric radiologist,
speech and language therapist (SLT), dietician, clinical
nurse specialist, occupational therapist (OT), physio-
therapist, psychologist and social worker. Open chan-
nels of communication with the child’s family doctor,
school, health visitor and community nurse facilitate
appropriate exchange of information between all
professionals around the child. Clinicians in regional
services value close liaison with the child’s local pro-
fessionals. Figure 2 provides a summary illustration of
the assessment and management of feeding difficulties
in a child with CP.
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Medical and developmental history
Information relating to the aetiology of the child’s
condition, severity of impairment, developmental
progress, co-morbid conditions and drug therapies
should be collected. A clear picture of the child’s level
of receptive language ability and overall cognitive abil-
ity, social communication skills, functional vision and
motor ability is necessary to place the child’s feeding
ability and difficulties in a developmental context.
Communication and cognitive impairments may reduce
the child’s ability to convey hunger, satiety, food pref-
erences or discomfort during feeding. Children with
visual impairment may be unable to anticipate food or
drink approaching. Concurrently evaluating parental
understanding of their child’s ability is essential, as
this helps clinicians understand parents’ expectations
about feeding. This information becomes very useful
at the time of management formulation. A drug his-
tory may reveal that the child is on antiepileptic or
antidrooling medications. These may reduce alertness,
appetite and cause dryness of the mouth. Antiepileptic
medications can be associated with increased risk of
osteopenia. Nevertheless, suboptimal dosing and fre-
quent seizures will interfere with feeding.
Feeding history
A detailed feeding history is essential. Current feeding
should be placed in the context of the previous feed-
ing history, and significant events. Thus, a feeding his-
tory starts with feeding ability and progress following
birth, including any need for nasogastric tube feeding.
The feeding trajectory of infants born preterm must be
considered within the context of their corrected age
appropriate gross and fine motor, cognitive and speech
and language skills. Progress during significant events
(such as hospital admissions due to illness and surgery)
and times of change in feeding (eg, weaning) should
be specifically enquired about. Any history suggestive
of non-developmental, progressive feeding difficulty is
a cause for concern, and warrants consideration and
investigation of acquired disorders. Regarding current
feeding, typical nutritional intake should be recorded,
with details of quantities and consistencies of food
ingested at snacks and mealtimes, and details of spill-
age or food vomited. The quantity of fluid ingested
per day should be calculated in millilitres per kilogram
body weight per day (50–100 ml/kg/day are adequate
in temperate climates). Time taken to feed and feeding
method are important. Other people involved in feed-
ing the child (eg, carers, nursery or school staff) may
give valuable perspectives on feeding. Involvement
of a dietician in assessing the adequacy of the diet
is extremely helpful. It is helpful for feeding to be
observed by the MDT. Twenty-four hour food recall
or a 3-day food diary is often used to provide nutri-
tional information. Food diaries are a burden for fami-
lies to complete and compliance is variable. Caution in
interpretation is required as families may overestimate
225
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amounts consumed by overlooking spillage or vomit-
ing. However, food diaries can be used to record food
preferences for incorporation into dietary plans.
Growth history
The child health record, hospital, community or
school records should be used to obtain a longitudi-
nal record of weight and head circumference. Accurate
height measurements are difficult to obtain in children
unable to stand; it may not be possible to obtain previ-
ous accurate height recordings.
Physical examination
The purpose of examination is to identify the cause
of feeding difficulties and factors which may interfere
with feeding ability, complications of feeding difficul-
ties and evidence of malnutrition. Muscle tone, trun-
cal stability and head control, contractures, spasms
and abnormal movements all impact on feeding abil-
ity. Evidence of chronic lung disease resulting from
chronic aspiration may exist. Skin condition and
examination of peripheral circulation provides infor-
mation on nutritional status and helps identify those
at risk of micronutrient deficiencies. Poorly nourished,
poorly hydrated children often have prolonged capil-
lary refill time and cold extremities.
Gross motor skills
Feeding and nutritional problems are more likely to
occur in children with severe motor disability.3 Muscle
tone, control of movements, degree of independence
and persistence of reflexes which may interfere with
feeding ability (eg, asymmetrical tonic neck reflex)
should be assessed. Many children with CP have an
element of dystonia. This is likely to further interfere
with feeding ability and a trial of L-dopa may be appro-
priate. Mobility level is relevant to assessing energy
requirements and dietary intake should be appropriate
to energy expenditure.
Oral motor skills
Full assessment necessitates evaluation of oral motor
skills at rest and during feeding. Assessment of jaw
stability, movement and tone of the lips, cheeks
and tongue is important. Significant overbites are
common in children with CP and affect biting and
chewing. Tonic biting may also be problematic. Jaw
instability limits graded opening and closure, impair-
ing manipulation of food in the mouth and leading to
poor bolus formation and swallowing difficulty. Jaw
thrusting and retraction may cause difficulties taking
food from a spoon, drinking, retaining and manipu-
lating food within the mouth, bolus formation and
safe and effective swallowing. Consideration and
management of mouth and jaw movements are cen-
tral to any feeding plan.
The lips also play an important role in effective feed-
ing. The lips may be hypotonic, hypertonic or have a
226 Arch Dis Child Educ Pract Ed 2012;97:222–229. doi:10.1136/archdischild-2011-300914
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mixed tone with constant movement at rest. Poor lip
control can cause leakage of food and fluids, resulting
in decreased intake and contributing to poor nutrition
and dehydration. Normal cheek tone allows food to
be contained within the mouth and supports lip and
tongue movement. Poor cheek tone results in collec-
tion of food in the lateral sulci preventing formation
of a cohesive food bolus.
By around 9 months, typically developing children
have developed horizontal, vertical and lateral tongue
movements. Children with neurological problems
may never develop lateral tongue movements, com-
promising bolus formation, effective chewing and
limiting the child’s ability to manage age appropriate
food textures. SLT assessment of tongue movement
is an important component of oromotor skill assess-
ment. Tongue thrusting causes food loss and difficul-
ties in bolus formation and control. Tongue thrusting
also makes spoon and cup placement difficult. Limited
tongue movements also cause poor food control, slow
or ineffective bolus formation and transit prior to
swallowing and an inability to chew. Children with
Worster–Drought syndrome have particular difficulty
with oromotor and lip movements (including speech and
blowing). Oromotor difficulties are often more severe
than gross motor difficulties in this group of children.24
Swallowing
Careful assessment of swallowing is indicated in chil-
dren with significant feeding difficulties. Ideally, clini-
cians should see the child eat and drink their usual food
and fluid in the usual way in clinic. Safe and effective
swallowing necessitates effective oral preparation of
food, formation of a food bolus, oral transit and then
propulsion of the bolus through the pharynx with the
airway protected. Aspiration occurs when this proc-
ess fails, allowing materials to pass below the vocal
cords into the trachea and lungs. Aspiration occurs in
as many as 68–70% of children with severe motor dis-
ability.25 26 Aspiration may be associated with specific
clinical signs (table 1), or may occur silently.
As well as identifying aspiration, videofluoroscopy
provides useful information on optimum feeding
position, rate of feeding and appropriate textures.
Identification of the phase during which aspiration
occurs informs decisions about whether or not a child
can eat and drink safely. For some children, oral feed-
ing will not be a safe option, leading to recommenda-
tion of gastrostomy insertion. The reasons for doing
the videofluoroscopy and possible outcomes should be
clear to parents in advance of the assessment.
Seating/positioning
An assessment of the child’s usual seating arrangement
for feeding is helpful. This can often be carried out
in clinics where the relevant equipment is available.
Parents’ mobile telephone video clips are useful for
this purpose. Home and school visits by an OT are
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helpful to evaluate seating and the feeding environ-
ment. Head position affects the ability to swallow and
maintain a safe airway. Minor alterations to the posi-
tion of the head and body during feeding can improve
feeding safety and ability. Ideally, the hips and knees
should be at right angles to the body, and the feet sup-
ported or on a firm surface. This relies on some flex-
ibility at the hips, knees, ankles, shoulders and spine.
A midline head position should be maintained, with a
slight chin tuck, avoiding neck extension. Depending
on local set-up, an OT or a PT can advise on suitable
specialist seating options. Seating suitability requires
regular re-assessment as the child grows.
Management
Feeding intervention should aim to achieve appropri-
ate nutrition and growth within the limits of the child’s
neurological condition. Intervention becomes neces-
sary when there is evidence of potentially unsafe feed-
ing, initial evidence of poor nutrition with or without
growth failure. This may involve dietetic monitoring
of the use of feeding intervention strategies which sup-
plement the normal diet with glucose polymers with
or without long-chain triglycerides to increase calorie
intake, the use of hypercaloric or high-energy-density
feeds, or gastrostomy tube (GT) insertion.
Feeding intervention strategies
Evidence to support the use of feeding intervention
strategies for children with CP is limited, but suggests
potential benefits from interventions including individ-
ualised positioning for feeding,27–29 alteration of food
consistency30 and use of oral appliances.31–34 Evidence
is conflicting concerning the use of oral sensorimotor
treatment programmes. The only randomised con-
trol trial did not suggest benefit35 but included only
20 children. One small study employing less robust
methodology33and two case series36 37 reported some
benefits, while a larger study found no improvements
following use.38 Feeding devices (an electric feeder) are
unlikely to be helpful in enhancing feeding efficien-
cy.39 40 Most of the available studies use comparison or
control groups and include relatively small numbers of
children. There is an urgent need for adequately pow-
ered randomised control trials offering definitive guid-
ance on best management.
Indications for gastrostomy feeding
GT feeding is indicated if oral feeding is unsafe, when
nutrition cannot be maintained orally or daily feeding
time is prolonged. What parents regard as a prolonged
feeding time varies depending on parental opinion, but
a definition of feeding time greater than 3 h per day is
commonly used in clinical practice. Before GT inser-
tion, a number of assessments are advisable. These
include a contrast study to exclude hiatus hernia,
assessment of respiratory function to determine the
need for preoperative physiotherapy and antibiotics,
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lower oesophageal pH monitoring to identify sig-
nificant GOR and videofluoroscopy to assess risk of
aspiration. A simultaneous antireflux procedure, for
example, fundoplication, may be indicated in children
with significant GOR. Complications of gastrostomy
feeding include anaesthetic complications, oesophageal
laceration, pneumoperitoneum, peritonitis, colonic
perforation and cologastric fistula formation. Later
complications include stoma leakage, cellulitis, gran-
ulation tissue formation around the gastrostomy site
and displacement. Gastrostomy insertion may worsen
GOR, necessitating the use of antireflux medication or
surgery. Further trials evaluating the efficacy of medical
versus surgical management of GOR in children with
gastrostomies are needed to establish best practice.41
An immobile child with low-energy requirements may
be overfed via their GT. Close monitoring is essential
to prevent excessive weight gain. One study examin-
ing body composition and total energy expenditure in
40 gastrostomy-fed children with spastic quadriplegic
CP demonstrated significantly higher body fat content
and lower lean body mass than a reference population
of neurologically normal children.42 Commercially
available enteral formulae developed for neurologi-
cally normal children may be associated with increased
risk of overfeeding in immobile children with CP. A
follow-on study of children with severe spastic quad-
riplegic CP and oral motor dysfunction examined the
effects of a low-energy-dense, micronutrient-complete,
high-fibre feed on growth and body composition.
Appropriate growth was maintained without dispro-
portionate rise in fat mass or fat percentage among
trial participants.43
The use of gastrostomy feeding for children with CP
has provoked some controversy. One study reported
a negative impact of GT feeding on the survival of
children with disabilities.44 A prospective longitudinal
study showed no increase in respiratory morbidity or
mortality in children with CP fed by GT.45 A parallel
study demonstrated significant improvements in paren-
tal QoL following institution of GT feeding.46 These
findings were not upheld by a prospective longitudinal
study examining the impact of GT insertion on global
and health-related QoL (HR-QoL) at 6 and 12 months
following GT insertion.47 However, parents reported
a positive impact of GT insertion on ease of feeding
and medication administration, and felt that GT inser-
tion had a positive impact on their child’s health.47 In a
further study, the majority of parents of children with
gastrostomies reported benefits secondary to reduced
feeding time, improved physical comfort and decreased
burden of care. Reduced anxieties related to safety of
feeding, nutritional status, adequate hydration and
reduced dependence on one carer also contributed to
positive views towards gastrostomies. Negative opin-
ions resulted from complications of GT insertion, inad-
equate follow-up post insertion and a feeling of having
been pressured into agreeing GT insertion.23
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Sensitivity to the complex issues surrounding GT
insertion is important when approaching the subject
of GT feeding. Inclusion of the family in the decision-
making process is vital. The MDT around the child
must be made fully aware of the potential benefits
and disadvantages to the child in order to support the
family through the process. Disagreements between
parents, carers (eg, those feeding the child at school
or in respite care) and clinicians about the safety of
oral feeding, and the need for GT insertion do occur.
Clinicians should seek the advice of colleagues when
necessary; referral to a regional feeding clinic or to a
neurodisability specialist may be helpful. Very occasion-
ally, it becomes necessary to consider whether the oral
feeding desired by parents or carers or both is harmful
for the child and in their best interests. Once again,
discussion with colleagues and referral to a specialist
clinic becomes helpful in helping parents see poten-
tial dangers for their child. When absolutely necessary,
managing issues through child protection routes may
require consideration.
The feeding environment
The mealtime environment may impact on the suc-
cessfulness of feeding. Distracting visual or auditory
stimuli can impair the child’s ability to attend to
feeding. Sudden noise may provoke muscle spasm or
extension, increasing the risk of aspiration. Creation
of a safe and comfortable feeding environment with
plentiful interaction and communication opportunities
helps to achieve a more enjoyable feeding experience
for child and carer. The child’s preferred commu-
nication method should be used during mealtimes.
Augmentative communication aids may help the child
to indicate choices, readiness for feeding, satiety or
discomfort with feeding.
Behaviour
Children with CP have a higher incidence of behav-
ioural and emotional problems than their normally
developing peers.48 49 Consideration of the causes of
any feeding-related behavioural difficulties is impor-
tant, as factors such as pain, GOR, fear, sensory issues
or past unpleasant feeding experiences may underlie
aversive feeding behaviours. Avoidance of force feed-
ing, waiting for the child’s cues and increasing oppor-
tunities for interaction and encouragement are also
important. An SLT can help implement good feeding
practice. If these measures are unsuccessful, referral to
a clinical psychologist may be appropriate. However,
behavioural feeding difficulties can be challenging to
ameliorate or eradicate; therefore, managing parental
expectation is important.
Conclusion
Management of complex feeding difficulties requires
careful and co-ordinated planning by all involved
professionals. Any management plan must take into
228 Arch Dis Child Educ Pract Ed 2012;97:222–229. doi:10.1136/archdischild-2011-300914
edpract-2011-300914.indd 7
account the child’s nutritional status, feeding abili-
ties, medical condition and associated gastrointesti-
nal problems, drug therapies, cognitive level, activity
level and family members’ opinions and circumstances.
Careful multidisciplinary assessment and management
of feeding difficulties is important in order to achieve
appropriate growth and nutrition in children with neu-
rodevelopmental disability. Failure to do so may result
in inadequate growth, suboptimal neurodevelopmental
outcome and poor general health. Management plans
should be sensitive to individual family circumstances
and priorities, while keeping child welfare paramount.
Funding This article received no specific funding;
however, Dr Morag Andrew’s salary is provided
by the Oxford Biomedical Research Centre.
Competing interests None.
Provenance and peer review Commissioned;
externally peer reviewed.
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Feeding difficulties in children with cerebral

palsy
Morag J Andrew, Jeremy R Parr and Peter B Sullivan

Arch Dis Child Educ Pract Ed 2012 97: 222-229 originally published
online January 31, 2012
doi: 10.1136/archdischild-2011-300914

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