Feeding disorders in the Child with Cerebral Palsy

Dr Owen HenseyCentral Remedial Clinic

Dublin

Environment

Behaviour Physical

Factors influencing feeding

Normal swallow

Trachea

Epiglottis

Pharynx

Bolus

Epiglottis

Normal swallow

Trachea

Epiglottis

Pharynx

Bolus

Epiglottis

Neurological coordination

Normal Gastrointestinal Tract Anatomy

Growth and Health in Children with Moderate to Severe Cerebral Palsy

GMFCS III, IV and V

Richard D Stevenson et al, Pediatrics 2006;118:1010

Weight Centiles

Cause of Inadequate Nutritional Intake

• Inability to self feed• Increased length of time taken to feed• Poor fluid intake• Inability to communicate• Inability to forage• Increased calorie use in dyskinetic

cerebral palsy

Clinical consequences of nutritional deficiencies

• Mild to severe undernutrition• Poor growth• Functional immune deficiency• Behavioural/learning effects• Quality of life • Survival• Osteoporosis/ rickets

Osteoporosis/rickets

Risk factors:• Low vitamin D• Immobility (GMFC level)• Altered muscle tone• Low sun exposure• Anti convulsants

Longer Term Consequences of Feeding Disorders

• Gastrooesophageal reflux• Aspiration • Unsafe to orally feed

Normal Stomach

Gastro-oesophageal reflux

acid reflux

diaphragm

oesophagus

lower oesophageal sphincter

stomach

Reflux in Cerebral Palsy

• Chronic recumbent posture• Increased muscle tone• Oral motor dysfunction• Delayed gastric emptying• Musculoskeletal deformity• Constipation • Behavioural

20-30% of developmentally disabled children have reflux

Symptoms of Gastrooesophageal Reflux

• Vomiting• Abdominal pain/colic• Reluctance to feed• Poor sleeping habits• Respiratory complaints

Effects of Gastrooesophageal Reflux

• Anaemia due to bleeding• Food refusal• Failure to thrive• Poor sleep pattern• Abnormal posturing

(Sandifer syndrome)• Parental anxiety• Aspiration with respiratory infection

Aspiration Pneumonia

Bronchiectasis

Clinical suspicion of aspiration:

• Recurrent respiratory infections

• Coughing during feeds

• Apnoeic spells during feeds

Diagnosis of feeding disorders

• Clinical history• Barium swallow• pH studies• Endoscopy and biopsy• Feeding studies

Barium Swallow

Effects of Gastrooesophageal Reflux on Oesophagus

• Oesophagitis • Stricture • Hernia

Oesophageal Stricture

pH studies

NormalSevere reflux (pH<4)

Indications for a feeding study

• Clinical suspicion of aspiration

• Prolonged feeding time

• Inability to cope with solids or

lumpy foods

• Difficulties with bottle feeding

Abnormal findings

Preoral - extensor spasm as food approaches mouth

Oral - abnormalities of lip closureTongue - abnormal tongue movementPharyngeal - abnormalities of swallow

Focus on findings that affect management

Aspiration

• Before during or after swallow ?

• Cough ?

• Cleared ?

• Silent ?

Useful Findings

Aspiration excluded:

– allows resumption / continuation of

feeding

– improves confidence of parents/carers

Aspiration present:

– consider gastrostomy

Other Useful Findings

• No suck ability – needs tube/PEG feed

• Swallows best when food put further in mouth – adjust feeding style

• Can only swallow with neck extension – adjust feeding posture

Medical management of feeding disorders

Management of Gastrooesophageal Reflux

Conservative:

Eliminate constipationPositioning Solid foodsThickened fluids

Management of Gastrooesophageal Reflux

Medical:Thickening agentsGavisconErythromycinAntacids – Cimetidine(Tagamet)

Ranitidine(Zantac)

Omeprazole(Losec)Lansoprazole(Zoton)

Management of Gastrooesophageal Reflux/ Aspiration

Medical: Nasogastric tube

Surgical:PEG feedingFundoplication

NG tube feeding

• Sucking partly a learned response• NG tube further reduces function• Inevitable reflux ± aspiration• ? no longer that 2 months

PEG tube

Mickey button

Mickey button

Nissan fundoplication

Nissen fundoplication

Efficacy:• 90% success in stopping GOR• ? stops respiratory symptoms

Nissen fundoplication

Complications:• 15% perioperative or surgery failure• Postoperative retching/burping• Dumping syndrome (10 – 15%)

– Failure to thrive – Frequent loose stools– Postprandial pallor, sweating and lethargy– Feeding difficulties– Absolute refusal to feed

Jejunal Feeding

Naso-Jejunal Tube

Gastro-Jejunal Tube

Gastrostomy tube feeding in children with cerebral palsy: a prospective,

constitutional study

Sullivan P. et al, DMCN 2005, 47: 77-85

• Oxford/Manchester/Watford• 57 children with CP• Median age 4.33yrs

(Range 5mths-17.25yrs) • Outcome measures:

– Nutritional intake– General health– Complications – Growth/anthropometry

Results

• Weight and subcutaneous fat deposition increased significantly over study period

• Almost all parents reported a significant improvement in their child’s health

• Decreased incidence of respiratory tract infection and hospital admissions

• Decreased feeding time

• Serious complications rare

Complications

Complication %Minor site infection 59Granulation tissue 42Leakage 30Tube blockage 19Tube migration 7Child pulled tube out 4Peritonitis 2

Quality of life of carers

6 months:• Mental health• Role limitation due to

emotional problems• Physical and social

functioning• Energy/vitality

12 months:• Further statistically

significant increase in all parameters

• Reduction in feeding time

• Ease of drug administration

• Reduced concern re nutritional status

Improved survival

Respiratory careGastrostomy feedingEpilepsy control

Improved nutritionImmunizationImproved social and living

standards