Feeding problems in children

with cerebral palsy

Luh Karunia Wahyuni
 Cerebral Palsy Disorder of
posture and movement
• Loss of selective muscle control
• Dependence on primitive reflex
patterns
• Abnormal muscle tone
• Imbalance between agonist and
antagonists muscles
• Permanent
Deficient equilibrium reactions
Unchanging
• a lesion in the
immature brain
• non-progressive
• static encephalopathy
CP Child CP Adult
Feeding problems ..........????
 Communication
Visual Dental problems
difficulty
Auditif GER
impairment Constipation

Dysruption
of learning
Recurrent
period aspiration

Cognitive
Disorder of Behavioral
Immobility movement problem
and posture
The suck/swallow/breathe synchrony

The synchrony available at

birth develops into strong
synergistic relationships with
repeated use which leads to
modification and increased
complexity as development
progresses
 Craniocervical Relationship

• Muscular attachments to the hyoid provide an anatomic link between the structures of
sucking, swallowing, and breathing and craniocervical posture
• The muscles used in swallowing include some of the same musculature that stabilizes the
head and jaw. This musculature is strengthened by sucking in the infant and additional
oral activity in the older child and adult
• e.g bite, crunch, chew, lick
Tahap perkembangan oromotor

Head from Body, Jaw from Head, Lips-Eyes-Jaw-Face, Tongue from Jaw

Kontrol leher ( postur )

Rahang

Bibir

Lidah
 Complication

• Aspiration
is a common complication of dysphagia and is usually silent
• Malnutrition
• Behavioral problem
• Speech problem
 Children with cerebral palsy

High risk for feeding and swallowing disorders that can have
significant health implications, including limited caloric intake
and acute and chronic malnutrition

Rogers B. Feeding Method and Health Outcomes of Children with Cerebral Palsy.
The Journal of Pediatrics 2004;145:S28–S32
 Feeding problems in cerebral palsy
• Oral-motor involvement was clinically observable in 78% of
children with CP (Wilson EM, Hustad KC. J Med Speech Lang Pathol. 2009)
• A London-based population survey revealed that 56% children
with CP (12-72 months of age) demonstrated difficulty with
sucking for breast and/or bottle feeding) and 52% of children
had difficulty with solid foods (Reilly et al., 1996).
• The average age at introduction to solids in the current
investigation was 10.83 months of age; approximately 4-6
months later than children without CP (Evans-Morris and Klein, 2000).
• Children with more severe oral-motor involvement may actually
demonstrate shorter feeding times than children without or
with minimal oral-motor involvement (Reilly et al., 1996)
 Cerebral palsy spastic

• Difficulty moving head independently from shoulders

• Often hypersensitivity
• Retracted jaw leading to swallowing difficulties
• Flexion-bite response
• Tight mouth limits range of movement options
• Prefers soft food as easier to suck
 Cerebral palsy hypotonia
• Open jaw
• No or poor lip closure
• Very limited tongue movement
• May retract tongue, associated with holding head back
• Lack of facial expression which may be interpreted as a lack
of awareness or learning difficulties
• May appear hyposensitive because lack of movement prevent
child from showing reaction
 Cerebral palsy athetoid
• Excessive jaw opening or deviation
• Tongue thrust with extension
• Grimacing, facial twitches caused by involuntary movements
of the jaw, lips and tongue
• Extend away from food
• Most problems with speech and group most likely to have
intact intellect
• Often hyperextends with an increased risk of aspiration
 Assessment of feeding and swallowing
• Seating and positioning
• Muscle tone and movement patterns
• Oral reflexes
• Movement of oral structures
• Food choices
• Respiration during feeding
• Evidence of aspiration
• Evidence of oral hypersensitivity or hyposensitivity
• Evidence of reflux
• Appropriateness of utensils
• Presentation of food/liquid boluses
• Drooling
• Communication and behavior during feeding
 Instrumentral Assessment

• If aspiration is suspected
• If the child is having difficulty in managing some
consistency of food that he/she would be expected
to managed based on developmental level and
motor ability
 Considerations for oral feeding
of children with cerebral palsy

• Feeding interruptions, duration of individual feedings, and

consumed food textures are useful historical estimates of
feeding efficiency
• Weight gain is a good measure of oral feeding efficiency
• Even though oral feedings may be difficult, they are
important to children and families
• Malnutrition usually presents in early infancy and is rarely
resolved by continued oral feedings
• Gastro-esophageal reflux is very common and can complicate
oral feeding, appetite, growth, and respiratory status
 Treatment principles
• Determine the optimal position .... Align head, trunk and
limbs/symmetry.
• Treatment must be individualized to maximize posture, tone,
and positioning for feeding hypertonic or hypotonic
• Organize the infants for oral feeding
• Utilize a behavioral management program
• Establish an optimal infant state: alter environment,
alerting/calming cues.
• Maintain and promote the development of normal feeding skills
• Reduce oral aversion to feeding
• Alter consistency, temperature, and presenta