Oropharyngeal Dysphagia and Cerebral Palsy

Is Chewing Performance Related to Dietary Intake in Children with Cerebral Palsy?

To examine the relationship between chewing performance and dietary intakes in children with Cerebral Palsy (CP). Forty children with CP aged between 2 and 6 years were included. The Karaduman Chewing Performance Scale (KCPS) and the Mastication Observation and Evaluation (T-MOE) instruments were used to evaluate chewing performance. Daily dietary intakes were measured from a 24-h food record with digital photographs including the amount and textures of all foods consumed during the meal. Chewing function was impaired in 70% of children. There was a negative low-to-moderate correlation between KCPS scores and daily protein intake (r = -0.32, p = 0.04), but not with energy and other macronutrients. The percentage of daily dietary intakes from 'liquid-blenderized' foods were positively correlated with KCPS, and negatively correlated with T-MOE scores (p < 0.001). There was a significant negative association between the percentage of daily dietary intakes from 'easy to chew & regular solid' foods and KCPS scores, and a significant positive association was found with T-MOE scores. In conclusion, the amount of daily protein intake decreased, and daily intake ratios of energy and macronutrients from liquid-blenderized foods increased as chewing performance decreased in children with CP. Timely diagnosis and treatment of chewing dysfunction can serve as a useful treatment option to ensure adequate dietary intake in children with CP, and also to decrease the burden of their parents and improve their quality of life.

Pediatric Dysphagia

Pediatric dysphagia is a common condition encountered in clinical practice. We review the physiology and development of swallow, presentation, epidemiology, and etiology of dysphagia. Additionally, comorbidities, associated conditions, and medical management of dysphagia are discussed.

Global State of the Art and Science of Childhood Dysphagia: Similarities and Disparities in Burden

Feeding/swallowing and airway protection are complex functions, essential for survival, and continue to evolve throughout the lifetime. Medical and surgical advances across the globe have improved the long-term survival of medically complex children at the cost of increasing comorbidities, including dysfunctional swallowing (dysphagia). Dysphagia is prominent in children with histories of preterm birth, neurologic and neuromuscular diagnoses, developmental delays, and aerodigestive disorders; and is associated with medical, health, and neurodevelopmental problems; and long-term socioeconomic, caregiver, health system, and social burdens. Despite these survival and population trends, data on global prevalence of childhood dysphagia and associated burdens are limited, and practice variations are common. This article reviews current global population and resource-dependent influences on current trends for children with dysphagia, disparities in the availability and access to specialized multidisciplinary care, and potential impacts on burdens. A patient example will illustrate some questions to be considered and decision-making options in relation to age and development, availability and accessibility to resources, as well as diverse cultures and family values. Precise recognition of feeding/swallowing disorders and follow-up intervention are enhanced by awareness and knowledge of global disparities in resources. Initiatives are needed, which address geographic and economic barriers to providing optimal care to children with dysphagia.

A comparative analysis of oropharyngeal functions in preterm and term children with cerebral palsy

This study aims to compare term and preterm children with Cerebral Palsy (CP) in terms of their oropharyngeal functions. A total of 50 children with CP participated in the study, and were divided into two groups according to their birth history including preterm group (gestational age below 37 weeks; 60 % female; mean age = 6.86 ± 4.35 years) and term group (gestational age between 37 and 41 weeks; 60 % female; mean age = 6.48 ± 4.86 years). Chewing and swallowing functions were evaluated in terms of oropharyngeal functions. Chewing evaluation was performed by using the Karaduman Chewing Performance Scale (KCPS) and the Turkish version of the Mastication Observation and Evaluation Instrument (T-MOE). The pediatric version of the Eating Assessment Tool (PEDI-EAT-10) was used to evaluate swallowing performance of children. In addition, the Behavioral Pediatric Feeding Assessment Scale (BPFAS) was used to assess feeding behaviors of children. There were significant differences between groups in terms of KCPS (p = 0.03), T-MOE (p = 0.01), and PEDI-EAT-10 scores (p = 0.04). There was a significant difference between groups in terms of the parental frequency score from the BPFAS (p = 0.04). Oropharyngeal functions of preterm children with CP were more adversely affected than term children with CP. Clinicians working with children with CP should be aware of the risks of preterm birth on oropharyngeal functions, and take precautions for oropharyngeal dysfunction in the early period in preterm children with CP.

Effectiveness of kinesiotape and sham kinesiotape application in children with cerebral palsy with dysphagia: A randomized controlled study

Objectives

This study aimed to investigate the short- and long-term effects of kinesiotaping (KT) on dysphagia in children with cerebral palsy (CP).

Patients and methods

One hundred one CP patients (59 males, 42 females; mean age: 49.3±18.8 years; range, 2 to 6 years) with dysphagia referred between October 2017 and January 2020 were enrolled in the randomized controlled study. Children who met the study criteria were randomly assigned to the kinesiotape group (n=54) or the sham group (n=47). Specific swallowing evaluations were performed on all patients before the therapy. The KT or sham application protocole combined with conventional rehabilitaion therapy was conducted for six weeks. Evaluation parameters were repeated at 6 and 18 weeks. The evaluated parameters were compared within and between groups.

Results

Drooling, weak tongue movement, chewing difficulty, coughing/choking and retching/vomiting during/after feeding, functional oral intake score, and meal time were found to be significantly improved at six weeks in the kinesiotape group compared to the sham group, and the clinical improvements were present at 18 weeks (p<0.05). There was no statistically significant difference in any parameter in the sham group at 6 and 18 weeks compared to the pretreatment (p>0.05).

Conclusion

The addition of KT to a home exercise program is an effective method for dysphagia in CP.

Neuromuscular adaptations of swallowing and speech in unilateral cerebral palsy: shared and distinctive traits

Our aims were to 1) examine the neuromuscular control of swallowing and speech in children with unilateral cerebral palsy (UCP) compared with typically developing children (TDC), 2) determine shared and separate neuromuscular underpinnings of the two functions, and 3) explore the relationship between this control and behavioral outcomes in UCP. Surface electromyography (sEMG) was used to record muscle activity from the submental and superior and inferior orbicularis oris muscles during standardized swallowing and speech tasks. The variables examined were normalized mean amplitude, time to peak amplitude, and bilateral synchrony. Swallowing and speech were evaluated using standard clinical measures. Sixteen children with UCP and 16 TDC participated (7-12 yr). Children with UCP demonstrated higher normalized mean amplitude and longer time to peak amplitude across tasks than TDC (P < 0.01; and P < 0.02) and decreased bilateral synchrony than TDC for swallows (P < 0.01). Both shared and distinctive neuromuscular patterns were observed between swallowing and speech. In UCP, higher upper lip amplitude during swallows was associated with shorter normalized mealtime durations, whereas higher submental bilateral synchrony was related to longer mealtime durations. Children with UCP demonstrate neuromuscular adaptations for swallowing and speech, which should be further evaluated for potential treatment targets. Furthermore, both shared and distinctive neuromuscular underpinnings between the two functions are documented.NEW & NOTEWORTHY Systematically studying the swallowing and speech of children with UCP is new and noteworthy. We found that they demonstrate neuromuscular adaptations for swallowing and speech compared with typically developing peers. We examined swallowing and speech using carefully designed tasks, similar in motor complexity, which allowed us to directly compare patterns. We found shared and distinctive neuromuscular patterns between swallowing and speech.

Motor deficits are associated with increased glial cell activation in the hypothalamus and cerebellum of young rats subjected to cerebral palsy

Cerebral palsy (CP) is a syndrome characterized by a wide range of sensory and motor damage, associated with behavioral and cognitive deficits. The aim of the present study was to investigate the potential of a model of CP using a combination of perinatal anoxia and sensorimotor restriction of hind paws to replicate motor, behavioral and neural deficits. A total of 30 of male Wistar rats were divided into Control (C, n = 15), and CP (CP, n = 15) groups. The potential of the CP model was assessed by evaluating food intake, the behavioral satiety sequence, performance on the CatWalk and parallel bars, muscle strength, and locomotor activity. The weight of the encephalon, soleus, and extensor digitorum longus (EDL) muscles, and the activation of glial cells (microglia and astrocytes) were also measured. The CP animals showed delayed satiety, impaired locomotion on the CatWalk and open field test, reduced muscle strength, and reduced motor coordination. CP also reduced the weight of the soleus and muscles, brain weight, liver weight, and quantity of fat in various parts of the body. There was also found to be an increase in astrocyte and microglia activation in the cerebellum and hypothalamus (arcuate nucleus, ARC) of animals subjected to CP.

andomised to early neuroprotection and neurorehabilitation: protocol for a follow-up study of participants from four randomised clinical trials

INTRODUCTION

School readiness includes cognitive, socio-emotional, language and physical growth and development domains which share strong associations with life-course opportunities. Children with cerebral palsy (CP) are at increased risk of poor school readiness compared with their typically developing peers. Recently, earlier diagnosis of CP has allowed interventions to commence sooner, harnessing neuroplasticity. First, we hypothesise that early referral to intervention for children at-risk of CP will lead to improved school readiness at 4-6 years relative to placebo or care as usual. Second, we hypothesise that receipt of early diagnosis and early intervention will lead to cost-savings in the form of reduced healthcare utilisation.

METHODS AND ANALYSIS

Infants identified as at-risk of CP ≤6 months corrected age (n=425) recruited to four randomised trials of neuroprotectants (n=1), early neurorehabilitation (n=2) or early parenting support (n=1) will be re-recruited to one overarching follow-up study at age 4-6 years 3 months. A comprehensive battery of standardised assessments and questionnaires will be administered to assess all domains of school readiness and associated risk factors. Participants will be compared with a historical control group of children (n=245) who were diagnosed with CP in their second year of life. Mixed-effects regression models will be used to compare school readiness outcomes between those referred for early intervention versus placebo/care-as-usual. We will also compare health-resource use associated with early diagnosis and intervention versus later diagnosis and intervention.

ETHICS AND DISSEMINATION

The Children's Health Queensland Hospital and Health Service, The University of Queensland, University of Sydney, Monash University and Curtin University Human Research Ethics Committees have approved this study. Informed consent will be sought from the parent or legal guardian of every child invited to participate. Results will be disseminated in peer-reviewed journals, scientific conferences and professional organisations, and to people with lived experience of CP and their families.

TRIAL REGISTRATION NUMBER

ACTRN12621001253897.

Tutorial on Clinical Practice for Use of the Fiberoptic Endoscopic Evaluation of Swallowing Procedure With Pediatric Populations: Part 2

PURPOSE

This is Part 2 of a two-part tutorial series establishing clinical guidelines pertaining to the administration of fiberoptic endoscopic evaluation of swallowing (FEES) developed by representatives of the American Board of Swallowing and Swallowing Disorders, all of whom are members of Special Interest Group 13. Whereas Part 1 focused on use of FEES with adults and included general information common to using FEES in any population, the purpose of this tutorial is to provide clinicians with updated best practice clinical guidelines for performing, interpreting, and documenting outcomes when using FEES with the pediatric population. This document has two main sections. The first section discusses the history of pediatric FEES, needed knowledge and skill pertaining to all elements of performing and interpreting the examination including detailed information related to indications and contraindications, developmental anatomical and physiological changes across childhood, preparing for and conducting the examination, medical collaboration, and patient safety. The second section provides detailed guidelines for clinicians who require training for use of FEES with the pediatric population.

CONCLUSIONS

This first of its kind tutorial offers guidelines for clinicians who perform, interpret, and/or want to train to perform FEES in the pediatric population. Important clinical distinctions exist when using FEES with the pediatric population versus with the adult population. Developmental changes, pediatric medical frailty, provider-parent/caregiver interaction, collaboration with physician colleagues, and patient safety are representative of key areas highlighted in this document.

Day-to-Day Variability of Clinical Feeding and Swallowing Performance in School-Age Self-Feeding Children With Cerebral Palsy

PURPOSE

We aimed to examine the day-to-day variability of feeding and swallowing performance and mealtime duration in school-age self-feeding children with spastic cerebral palsy (SCP) across 15 days.

METHOD

Thirteen children with SCP (ages 5;10 [years;months]-17;6) participated. Children were divided into unilateral (UCP, n = 6) and bilateral (BCP, n = 7) SCP groups. Feeding/swallowing assessments using the Dysphagia Disorder Survey (DDS) were conducted and total mealtime durations (TMDs) were calculated for all days. DDS Part 1 (factors related to feeding) and DDS Part 2 (signs of oropharyngeal difficulties) components were rated. Mixed-effects models were used to compare group means and estimate between- and within-subject variances in each group. Likelihood ratio tests were used to determine best covariance structure and compare variance types across groups.

RESULTS

Within-subject variance for all three variables, DDS Part 1, 2, and TMD, across days was larger in the BCP group than the UCP group (Part 1: p = .0036, Part 2: p = .0002, and TMD: p = .0005) and the between-subject variance was larger in the BCP group for DDS Part 2 (p = .0362). The UCP group presented with lower (milder) DDS scores (Part 1: p = .0160; Part 2: p = .0141) and shorter TMD (p = .0077) than the BCP group across days. Furthermore, both groups exhibited greater variability in DDS Part 2 than 1 (p < .0001).

CONCLUSION

These preliminary results emphasize the need to account for day-to-day variability when evaluating swallowing especially in children with BCP and provide preliminary ranges of performance that could be useful for clinical prognosis and future treatment research.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21669611.

Neurological impairment and malnutrition in children: The role of home enteral nutrition in real life

Objective

Recent decades have brought an increased survival of children with Neurologic Impairment (NI) but malnutrition and digestive comorbidity remain important challenges to face. We designed the present study to assess the course of nutritional status following standardized Home Enteral Nutrition (HEN) program and to evaluate impact of changing mode of feeding, as a part of overall multidisciplinary management, on digestive co-morbidity as Gastro-Esophageal Reflux Disease (GERD), Oropharyngeal Dysphagia (OPD), constipation and airway aspiration.

Methods

We performed a retrospective analysis on NI children entered into Institutional HEN program due to NI disorders between January 2011 and 2019. Demographic, anthropometric characteristics (BMI z-score and weight for age z-score) and symptoms (GERD, OPD constipation and airway aspiration) were collected at the enrolment and during the follow up.

Results

We enrolled 402 patients (median age: 39 months); overall survival was 97%. Nutritional status was significantly improved by HEN; in particular growth profile significantly changed within the first 2 years following HEN beginning; GERD and airways aspirations decreased after HEN beginning. Constipation and OPD remained unchanged over time.

Conclusions

Malnutrition and digestive complaints are distinctive features of NI children. Nutritional status improve after 2 years from the beginning of standardized nutritional interventions. Overall multidisciplinary care, including standardized HEN protocols, seems to also impact on GERD and airway aspirations, which can decrease over time. It is possible that constipation and OPD, unchanged over time, are more dependent on underlying diseases than on overall treatments.

Laboratory indicators of nutritional status in children with cerebral palsy

Children with cerebral palsy are at high risk of developing nutritional disorders: malnutrition, osteopenia, micronutrient deficiency. This is facilitated by motor disorders, restriction of actual nutrition, the presence of concomitant drug therapy, and metabolic features.

Purpose. The study aims at evaluation of laboratory markers of nutritional status in children with cerebral palsy.

Material and methods: for a comprehensive assessment of nutritional status disorders, a cross-sectional analytical study of 175 children with cerebral palsy was carried out. Laboratory studies included the determination in blood of: total protein, glucose, ALT, AST, total and direct bilirubin, cholesterol, creatinine, urea, vitamins A, E, B12, folic acid, magnesium, phosphorus, calcium, serum iron, zinc, total iron-binding ability, ferritin, 25-OH vitamin D, parathyroid hormone.

Results. Only in 5 (3%) children all the studied laboratory parameters were within the reference values. The most frequently observed in children with cerebral palsy were: 25-OH vitamin D insufficiency/deficiency in 68% of children, a decrease in folic acid levels in 32%, an increase in vitamin B12 in 32%, a decrease in cholesterol in 26% and creatinine in 16.6%, a decrease in phosphorus in 14.5%, serum iron in 12.4% and an increase in magnesium in 10.3%.

Conclusion. The detected deficiency of some indicators is most likely associated with an unbalanced actual diet of patients with cerebral palsy, although the reduced intake of certain vitamins and microelements was not always reflected in their blood concentrations (vitamin A, E, magnesium, calcium). The levels of zinc, vitamin B12 and A did not decrease in any of the examined children, which casts doubt on the recommendations of ESPGHAN experts in terms of prescribing them to all children with cerebral palsy in routine clinical practice. 

Swallowing and Motor Speech Skills in Unilateral Cerebral Palsy: Novel Findings From a Preliminary Cross-Sectional Study

PURPOSE

Our purpose was to start examining clinical swallowing and motor speech skills of school-age children with unilateral cerebral palsy (UCP) compared to typically developing children (TDC), how these skills relate to each other, and whether they are predicted by clinical/demographic data (age, birth history, lesion type, etc.).

METHOD

Seventeen children with UCP and 17 TDC (7-12 years old) participated in this cross-sectional study. Feeding/swallowing skills were evaluated using the Dysphagia Disorder Survey (DDS) and a normalized measure of mealtime efficiency (normalized mealtime duration, i.e., nMD). Motor speech was assessed via speech intelligibility and speech rate measures using the Test of Children's Speech Plus. Analyses included nonparametric bootstrapping, correlation analysis, and multiple regression.

RESULTS

Children with UCP exhibited more severe (higher) DDS scores (p = .0096, Part 1; p = .0132, Part 2) and reduced speech rate than TDC (p = .0120). Furthermore, in children with UCP, total DDS scores were moderately negatively correlated with speech intelligibility (words: r = -.6162, p = .0086; sentences: r = -.60792, p = .0096). Expressive language scores were the only significant predictor of feeding and swallowing performance, and receptive language scores were the only significant predictor of motor speech skills.

CONCLUSIONS

Swallowing and motor speech skills can be affected in school-age children with UCP, with wide variability of performance also noted. Preliminary cross-system interactions between swallowing, speech, and language are observed and might support the complex relationships between these domains. Further understanding these relationships in this population could have prognostic and/or therapeutic value and warrants further study.

The global prevalence of oropharyngeal dysphagia in different populations: a systematic review and meta-analysis

Background

Oropharyngeal dysphagia (OD) refers to any abnormality in the physiology of swallowing in the upper gastrointestinal tract, which leads to the related clinical complications, such as malnutrition, dehydration, and sever complication, such as aspiration pneumonia, suffocation, and eventually, premature death. The previous studies indicated a various range of prevalence of OD. The present systematic review and meta-analysis aimed to standardize the global prevalence of OD in different populations.

Methods

A systematic literature review was conducted using Embase, Scopus, PubMed, Web of Science (WoS) databases, and Google Scholar motor engine using related MeSH/Emtree and Free Text words, with no time limitation until November 2021. The heterogeneity among studies was quantified using I² index and the random effects model was used, due to the high heterogeneity among the results of studies included in the meta-analysis.

Results

The systematic literature search retrieved 2092 studies. After excluding the irrelevant studies, ultimately 27 articles with a sample size of 9841 were included in the meta-analysis. After combining the studies, the overall estimate of the global prevalence rate of OD was 43.8% (95% CI 33.3–54.9%) and the highest prevalence rate was estimated in Africa with 64.2% (95% CI 53.2–73.9%). Given the subgroup analysis based on the study population, the highest prevalence of OD was related to Dementia with 72.4% (95% CI 26.7–95.0%). The results of meta-regression indicated that the prevalence of OD has an increasing trend with the enhancement of year of publication and mean age.

Conclusion

The results of the present systematic review and meta-analysis revealed that the prevalence of OD is high in different populations and its trend has been increasing in recent years. Therefore, the appropriate strategies should be applied to reduce the prevalence of OD by finding its causation and monitoring at all levels, as well as providing feedback to hospitals.

Lung ultrasound in young children with neurological impairment: A proposed integrative clinical tool for deaeration-detection related to feeding

Infants and children with neurological impairment, such as cerebral palsy (CP), often experience abnormal ingestion functions, including oropharyngeal dysphagia and gastroesophageal reflux disease, which led to aspiration-related respiratory complications, morbidity, hospitalization, or death. There is a lack of evidence-based, repeatable, infant-friendly instrumental procedures to assess aspiration-risk in infants with CP or other neurological disorders, with also a lack of clinical assessment measures to support the use of more invasive diagnostic techniques. To this purpose, in the current study we explore the feasibility of lung ultrasound (LUS), to assess lung deaeration possibly related to aspiration during meal, in a cohort of 35 subjects affected by CP or other encephalopathies, and 10 controls in the same age-range. We coupled LUS procedure with meal caregiver administration for each child. Our results support the feasibility of this innovative approach in the clinical setting. Exploratory findings revealed a number of lung abnormalities likely related to abnormal ingestion function in subjects. Subgroup analyses revealed possible differences in LUS abnormalities between CP and other encephalopathies, possibly related to different mechanism of disease or dysfunction. Also, some evidences arose about the possible relationship between such LUS abnormalities and feeding and swallowing abilities in CP or other encephalopathies. LUS showed preliminarily feasibility and effectiveness in detecting meal-related LUS abnormalities in a dynamic manner in the clinical setting. This approach demonstrated usefulness as a potential tool for improving assessment and management in complex care of infants and young children with severe neurological disorders.

Aspiration of an exfoliated primary molar in a child with cerebral palsy: A case report

Foreign body aspiration is a concern in children which may occur with anything introduced to the oral cavity and can result in significant morbidity and mortality. Food and foreign objects are the most commonly aspirated objects in young children. Aspiration of a normally exfoliated primary tooth is thought to be extremely rare, if not unheard-of. The purpose of this case report is to describe the events occurring to a 10-year-old child with a cerebral palsy presenting with signs and symptoms of respiratory distress due to aspiration of a naturally exfoliated primary molar. Recommendations are provided for delivery of appropriate anticipatory guidance, management of exfoliating primary teeth, and safe clinical practice.

Spontaneous Swallowing Frequency, Dysphagia, and Drooling in Children With Cerebral Palsy

OBJECTIVE

To evaluate relationships between spontaneous swallowing frequency, dysphagia, and drooling in children with cerebral palsy. Spontaneous swallowing frequency was predicted to be inversely related to both dysphagia and drooling among children with cerebral palsy. A secondary objective compared patterns among spontaneous swallowing frequency, drooling, and age in healthy children vs children presenting with cerebral palsy.

DESIGN

Cross sectional study.

SETTING

Children with cerebral palsy were tested at a Cerebral Palsy Reference Center in a university hospital. Healthy children were tested in their home setting.

PARTICIPANTS

Twenty children with cerebral palsy were recruited from the local registry for cerebral palsy children and purposive sampling among parents. A group of 30 healthy children was recruited by purposive sampling among family, friends, and the local community. Children below 1 year of age up to 5 years of age were included in the healthy group. This age range was targeted to maximize the potential for drooling in this group.

MAIN OUTCOME MEASURES

Both groups provided data on spontaneous swallowing frequency (swallows per minute, or SPM), dysphagia, and drooling. Motor impairment was documented in the children with cerebral palsy.

RESULTS

SPM was significantly lower in children with cerebral palsy. Among children with cerebral palsy, SPM correlated significantly with dysphagia severity and trended toward a significant correlation with drooling at rest. In this subgroup, SPM was not correlated with age or degree of motor impairment. Dysphagia was significantly correlated with drooling at rest and both dysphagia and drooling at rest were correlated with degree of motor impairment. The 2 groups did not differ in the degree of drooling at rest. Among healthy children, age but not SPM demonstrated a significant inverse correlation with drooling quotient at rest.

CONCLUSIONS

Spontaneous swallowing frequency is related to dysphagia and drooling in children with cerebral palsy. The pattern of relationships among spontaneous swallowing frequency and drooling is different between children with cerebral palsy and younger healthy children.

Foreign Body Ingestion in Neurologically Impaired Children: A Challenging Diagnosis and Management in Pediatric Surgery

Children with intellectual disability/neurodevelopmental delay (ID-ND) commonly ingest foreign bodies (FB) and often present complications due to peculiar aspects of their condition. The aim of this paper is to report the experience of two centers in the management of ID-ND patients after FB ingestion and to discuss a possible algorithm for clinical practice. We retrospectively evaluated data of patients managed for FB ingestion (period: 2017–2021), focusing on those with ID-ND, specifically demographics and baseline diagnosis, elements related to the event, symptoms, time to endoscopy, FB location, endoscopic details, and follow-up. A total of 457 patients were managed in the study period and 19 had ID-ND (mean age 9.8 ± 3.5 years, 15 males). A total of 16/19 (84.2%) were symptomatic and required an operative approach. Recurrent ingestions and multiple FB were found in 2 and 11 patients, respectively. Endoscopy (mean time 65.6 ± 41 min) was effective in 14 cases (73.6%) and 6 patients (31.6%) developed a complication. FB ingestion in ID-ND patients represents a challenging condition for the clinician and a potentially dangerous situation. It should be addressed specifically by a multidisciplinary team considering a tailored diagnostic and management protocol.

Hyoid bone movement during swallowing and mechanism of pharyngeal residue in patients with profound intellectual and multiple disabilities

OBJECTIVES

Dysphagia is linked to mortality risk among patients with profound intellectual and multiple disabilities (PIMD); the present study therefore aimed to clarify the characteristics of hyoid movements during swallowing and to examine the mechanism of dysphagia in patients with PIMD.

METHODS

A retrospective video fluoroscopic swallowing study was conducted on 43 patients with PIMD (mean age = 25.4; 25 males, 18 females) and 24 healthy adults (mean age = 44.3; 16 males, 8 females). The movements of the hyoid bone and mandible were tracked frame by frame in the video footage, and their range of movements and trajectories were analyzed.

RESULTS

Most patients showed atypical movement trajectories of the hyoid, such as insufficient anterior movement and increased range of mandibular downward movement, compared with normal adults. Moreover, the mechanism of dysphagia was revealed by structural equation modeling, indicating that insufficient anterior movement could lead to pharyngeal residue in the pyriform sinus.

CONCLUSION

The insufficient anterior movement of the hyoid could be caused by weak ventral suprahyoid muscles and atypical head and neck posture characteristic of patients with PIMD. It may be useful to predict pharyngeal residue from the range of hyoid movements and trajectories for the prevention of aspiration.

Videofluoroscopic Swallow Study Findings and Correlations in Infancy of Children with Cerebral Palsy

OBJECTIVES

Cerebral palsy (CP) in infants can affect global motor function and lead to swallowing difficulties. This study aims to characterize oral and pharyngeal swallowing dynamics in infancy of patients later diagnosed with CP and to determine if swallow study performance in early infancy is associated with later CP severity and characteristics.

METHODS

This is a retrospective chart review of infants who underwent videofluoroscopic swallow studies (VFSS) between 6/2008 and 10/2018 at a tertiary children's hospital, and were later diagnosed with CP. Demographic data, CP characteristics and metrics, and VFSS findings were collected and analyzed.

RESULTS

There were 66 patients included in this study. The average age at the time of VFSS was 4 months (range: 0.3-12 months), 42% of patients were female, and 50% of patients were born premature. In our sample, 86% of patients presented with oral dysphagia, and 76% with pharyngeal dysphagia. Laryngeal penetration in isolation was seen in 39% of patients, and tracheal aspiration was seen in 38% of patients. Of these tracheal aspiration events, 64% were silent. At the time of VFSS, 58% of patients had a nasogastric tube, 12% had a gastrostomy tube, and 3% had a prior hospitalization for pneumonia. Rates of penetration and aspiration in early infancy did not consistently correlate with prematurity, type of CP (spastic, non-spastic, or mixed), degree of paralysis (quadriplegic, hemiplegic, or diplegic), or severity of Gross Motor Function Classification System (GMFCS) score.

CONCLUSION

While there was not a consistent correlation of swallowing dynamics in infancy with later gross motor categorizations of CP, the results of this retrospective review highlight the essential role of early clinical and videofluoroscopic swallowing evaluations to identify oral and pharyngeal swallowing dysfunction in this patient population.

Effect of oral sensorimotor stimulation on oropharyngeal dysphagia in children with spastic cerebral palsy: a randomized controlled trial

BACKGROUND

Children with cerebral palsy show various degrees of dysphagia causing late development of oral motor skills.

AIM

To investigate effect of oral sensorimotor stimulation on oropharyngeal dysphagia in children with spastic quadriplegia.

DESIGN

This was a double-masked, randomized controlled clinical trial.

SETTING

Out-patient Clinics of Faculty of Physical Therapy, Cairo University and Modern University of Technology and information.

POPULATION

A convenient sample of 71 children age ranged from 12 to 48 months diagnosed with spastic quadriplegia, were randomly assigned into two groups.

METHODS

Children in the control group received 90 minutes conventional physical therapy training five times/week for 4 successive months while those in the experimental group received 20 minutes of oral sensorimotor stimulation before the same program as in control group for 60 minutes. Oral motor function, body weight, segmental trunk control and gross motor function were assessed at base-line and after completing treatment.

RESULTS

In total, 64 (experimental n=32, control n=32) children completed treatment and data collection. The baseline assessment showed non-significant difference regarding all measured variables while with-in group comparison showed significant improvement in the two groups. The post-treatment comparisons revealed significant difference the oral motor function and physical growth in favor of the experimental group (p < 0.05). Finally, there was non-significant difference regarding segmental trunk control and gross motor function (p > 0.05).

CONCLUSIONS

Oral sensorimotor stimulation has the capability to improve feeding in children with spastic cerebral palsy diagnosed with oropharyngeal dysphagia.

CLINICAL REHABILITAYION IMPACT

OSMS has effect on some of the essential oral motor skills that contribute toward the improvement of feeding performance in children with spastic CP. The results of our study offer remarkable clinical importance for the children and their families.

Is sensory-level electrical stimulation effective in cerebral palsy children with dysphagia? A randomized controlled clinical trial

Dysphagia is one of the common findings in children with cerebral palsy (CP). Electrical stimulation (ES) has been demonstrated to positively contribute to swallowing functions, particularly in adult patients with various neurological disorders. Therefore, the objective of this study was to assess the effects of sensory-level ES treatment combined with conventional dysphagia rehabilitation in pediatric age group CP patients who had any oropharyngeal dysphagia symptoms and/or findings. Participants were randomly assigned to either the experimental group (Group 1, n = 52) who underwent intermittent galvanic stimulation to bilateral masseter muscles for 5 days/week, for 4 weeks combined with conventional dysphagia rehabilitation or the control group (Group 2, n = 50) who received sham stimulation with conventional dysphagia rehabilitation. The experimental group achieved significantly more improvement in swallowing functions including drooling, tongue movements, chewing, eating large food ability, feeding duration, as well as dysphagia screen test and dysphagia level, compared to control group. This study suggested that sensory-level ES might be a useful and safe therapeutic modality to improve oropharyngeal symptoms, symptom severity and dysphagia level in children with CP and dysphagia. Further research is needed to determine the long-term effects of ES on dysphagia, especially in different neurological disorders such as CP.

A Quality Improvement Initiative to Reduce Gastrostomy Tube Placement in Aspirating Patients

OBJECTIVES

Oropharyngeal dysphagia and aspiration may occur in infants and children. Currently, there is wide practice variation regarding when to feed children orally or place more permanent gastrostomy tube placement. Through implementation of an evidence-based guideline (EBG), we aimed to standardize the approach to these patients and reduce the rates of gastrostomy tube placement.

METHODS

Between January 2014 and December 2018, we designed and implemented a quality improvement intervention creating an EBG to be used by gastroenterologists evaluating patients ≤2 years of age with respiratory symptoms who were found to aspirate on videofluoroscopic swallow study (VFSS). Our primary aim was to encourage oral feeding and decrease the use of gastrostomy tube placement by 10% within 1 year of EBG initiation; balancing measures included total hospital readmissions or emergency department (ED) visits within 6 months of the abnormal VFSS.

RESULTS

A total of 1668 patients (27.2%) were found to have aspiration or penetration noted on an initial VFSS during our initiative. Mean gastrostomy tube placement in these patients was 10.9% at the start of our EBG implementation and fell to 5.2% approximately 1 year after EBG initiation; this improvement was sustained throughout the next 3 years. Our balancing measures of ED visits and hospital readmissions also did not change during this time period.

CONCLUSIONS

Through implementation of this EBG, we reduced gastrostomy tube placement by 50% in patients presenting with oropharyngeal dysphagia and aspiration, without increasing subsequent hospital admissions or ED visits.

Cerebral Palsy: Current Opinions on Definition, Epidemiology, Risk Factors, Classification and Treatment Options

Cerebral palsy (CP) is one of the most frequent causes of motor disability in children. According to the up-to-date definition, CP is a group of permanent disorders of the development of movement and posture, causing activity limitations that are attributed to non-progressive disturbances that occurred in the developing foetal or infant brain. The CP definition has evolved over time; the problem is aetiologically and clinically very heterogeneous. According to European data, the average frequency of CP is 2.08 per 1000 live births, but in the group of children born with a body weight below 1500 g, the frequency is 70 times higher when compared with the group of children with a body weight over 2500 g at birth. The risk factors for CP can be divided into pre-conception, prenatal, perinatal and postnatal ones. CP commonly co-exists with epilepsy, in particular drug-resistant epilepsy, but also with mental retardation, visual and hearing impairment, as well as feeding and behavioral disorders. The degree of motor problem varies from mild to very severe making the child totally dependent on caregivers. Cerebral palsy is divided into forms depending on the type of motor disorders which dominate the clinical presentation; the traditional classifications by Ingram and Hagberg have now been replaced by the Surveillance of Cerebral Palsy in Europe classification which divides CP into spastic, dyskinetic and ataxic forms. Although cerebral palsy is a clinical diagnosis, modern diagnostic imaging provides information that allows the division of the results of magnetic resonance imaging in children with cerebral palsy into five groups according to the magnetic resonance imaging classification system. Just as the clinical presentation and the factors predisposing for CP are very diverse, treatment is also a very complex problem. Modern treatment of spasticity includes both botulinum toxin therapies and surgical techniques, eg, rhizotomy. The authors present current views on definitions, risk factors, diagnostics and treatment of CP as well as comorbid problems, eg, drug-resistant epilepsy.

Evaluation and Management of Respiratory Illness in Children With Cerebral Palsy

Cerebral palsy (CP) is the most common cause of disability in childhood. Respiratory illness is the most common cause of mortality, morbidity, and poor quality of life in the most severely affected children. Respiratory illness is caused by multiple and combined factors. This review describes these factors and discusses assessments and treatments. Oropharyngeal dysphagia causes pulmonary aspiration of food, drink, and saliva. Speech pathology assessments evaluate safety and adequacy of nutritional intake. Management is holistic and may include dental care, and interventions to improve nutritional intake, and ease, and efficiency of feeding. Behavioral, medical, and surgical approaches to drooling aim to reduce salivary aspiration. Gastrointestinal dysfunction, leading to aspiration from reflux, should be assessed objectively, and may be managed by lifestyle changes, medications, or surgical interventions. The motor disorder that defines cerebral palsy may impair fitness, breathing mechanics, effective coughing, and cause scoliosis in individuals with severe impairments; therefore, interventions should maximize physical, musculoskeletal functions. Airway clearance techniques help to clear secretions. Upper airway obstruction may be treated with medications and/or surgery. Malnutrition leads to poor general health and susceptibility to infection, and improved nutritional intake may improve not only respiratory health but also constipation, gastroesophageal reflux, and participation in activities. There is some evidence that children with CP carry pathogenic bacteria. Prophylactic antibiotics may be considered for children with recurrent exacerbations. Uncontrolled seizures place children with CP at risk of respiratory illness by increasing their risk of salivary aspiration; therefore optimal control of epilepsy may reduce respiratory illness. Respiratory illnesses in children with CP are sometimes diagnosed as asthma; a short trial of asthma medications may be considered, but should be discontinued if ineffective. Overall, management of respiratory illness in children with CP is complex and needs well-coordinated multidisciplinary teams who communicate clearly with families. Regular immunizations, including annual influenza vaccination, should be encouraged, as well as good oral hygiene. Treatments should aim to improve quality of life for children and families and reduce burden of care for carers.

Prevalence of drooling, swallowing, and feeding problems in cerebral palsy across the lifespan: a systematic review and meta-analyses

AIM

To determine the prevalence of drooling, swallowing, and feeding problems in persons with cerebral palsy (CP) across the lifespan.

METHOD

A systematic review was conducted using five different databases (AMED, CINAHL, Embase, MEDLINE, and PubMed). The selection process was completed by two independent researchers and the methodological quality of included studies was assessed using the STROBE and AXIS guidelines. Meta-analyses were conducted to determine pooled prevalence estimates of drooling, swallowing, and feeding problems with stratified group analyses by type of assessment and Gross Motor Function Classification System level.

RESULTS

A total of 42 studies were included. Substantial variations in selected outcome measures and variables were observed, and data on adults were limited. Pooled prevalence estimates determined by meta-analyses were as high as 44.0% (95% confidence interval [CI] 35.6-52.7) for drooling, 50.4% (95% CI 36.0-64.8) for swallowing problems, and 53.5% (95% CI 40.7-65.9) for feeding problems. Group analyses for type of assessments were non-significant; however, more severely impaired functioning in CP was associated with concomitant problems of increased drooling, swallowing, and feeding.

INTERPRETATION

Drooling, swallowing, and feeding problems are very common in people with CP. Consequently, they experience increased risks of malnutrition and dehydration, aspiration pneumonia, and poor quality of life.

WHAT THIS PAPER ADDS

Drooling, swallowing, and feeding problems are very common in persons with cerebral palsy (CP). The prevalence of drooling, swallowing, and feeding problems is 44.0%, 50.4%, and 53.5% respectively. There are limited data on the prevalence of drooling, swallowing, and feeding problems in adults. Higher Gross Motor Function Classification System levels are associated with higher prevalence of drooling, swallowing, and feeding problems. There is increased risk for malnutrition, dehydration, aspiration pneumonia, and poor quality of life in CP.

Survival and mortality in cerebral palsy: observations to the sixth decade from a data linkage study of a total population register and National Death Index

Background

Likely duration of survival of children described as having cerebral palsy is of considerable interest to individuals with cerebral palsy, their families, carers, health professionals, health economists and insurers. The aim of this paper is to describe patterns of survival and mortality to the sixth decade in a geographically defined population of people with cerebral palsy stratified according to the clinical description of their impairments in early childhood.

Methods

Identifiers of persons born in Western Australia 1956–2011, registered with cerebral palsy on the Western Australian Register of Developmental Anomalies and surviving at least 12 months, were linked to the Australian National Death Index in December 2014. Patterns of mortality were investigated using survival analysis methods.

Results

Of 3185 eligible persons, 436 (13.7%) had died. Of that sample the 22% with the mildest impairment had survival patterns similar to the general population. Mortality increased with increasing severity of impairment. Of 349 (75%) with available cause of death data, 58.6% were attributed to respiratory causes, including 171 (49%) to pneumonia at a mean age of 14.6 (sd 13.4) years of which 77 (45%) were attributed to aspiration.

For the most severely impaired, early childhood mortality increased in succeeding decades of birth cohorts from 1950s to 1990 with 20% dying by 4 years of age in the 1981–1990 birth cohort; it then decreased for subsequent birth cohorts, 20% mortality not being attained until 15 years of age. However by 20 years of age mortality of the most severely impaired born in the 1991–2000 birth cohort exceeded that of all other birth cohorts.

Remaining life expectancies by age to 50 years have been estimated for two strata with more severe impairments.

Conclusion

For 22% of individuals with cerebral palsy with mild impairment survival to 58 years is similar to that of the general population. Since 1990 mortality for those with severe cerebral palsy in Western Australia has tended to shift from childhood to early adulthood.

Evaluation and Treatment of Malnutrition and Associated Gastrointestinal Complications in Children with Cerebral Palsy

The majority of children with cerebral palsy (CP) have feeding difficulties and are especially prone to malnutrition. The early involvement of a multidisciplinary team should aim to prevent malnutrition and provide adequate nutritional support. Thorough nutritional assessment, including body composition, should be a prerequisite for the nutritional intervention. As in typically-developed children nutritional support should start with dietary advice and the modification of oral feeding, if safe and acceptable. However, for prolonged feeding, in the presence of unsafe swallowing and inadequate oral intake, enteral nutrition should be promptly initiated and early gastrostomy placement should be evaluated and discussed with parents/caregivers. Gastrointestinal problems (oropharyngeal dysfunction, gastroesophageal disease, and constipation) in children with CP are frequent and should be actively detected and adequately treated as they can further worsen the feeding process and nutritional status.

Feeding Interventions Are Associated With Improved Outcomes in Children With Laryngeal Penetration

OBJECTIVES

To determine if children with laryngeal penetration on videofluoroscopic swallow study (VFSS) who received feeding interventions (thickened liquids, change in liquid flow rate, and/or method of liquid delivery) had improved symptoms and decreased hospitalizations compared with those without intervention.

METHODS

We performed a retrospective cohort study of children under 2 years with laryngeal penetration on VFSS at our institution in 2015 to determine initial and follow-up VFSS findings, symptom improvement at follow-up, and hospitalization risk before and after VFSS. Proportions were compared with Fisher exact test and hospitalizations with paired t tests.

RESULTS

We evaluated 137 subjects with age 8.93 ± 0.59 months who had laryngeal penetration without aspiration on VFSS. Fifty-five percent had change in management, with 40% receiving thickening and 15% a change in flow rate. There was significant improvement in symptoms for children that had feeding intervention and this improvement was the greatest with thickening (OR 41.8, 95% CI 12.34-141.69, P < 0.001). On repeat VFSS, 26% had evidence of aspiration that was not captured on initial VFSS. Subjects had decreased total and pulmonary hospitalizations with feeding intervention and decreased pulmonary nights with thickening (P < 0.05).

CONCLUSIONS

Laryngeal penetration appears to be clinically significant in children with oropharyngeal dysphagia and interventions to decrease its occurrence are associated with improved outcomes including decreased symptoms of concern and hospitalization nights. Thickening or other feeding intervention should be considered for all symptomatic children with laryngeal penetration on swallow study.