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Cerebral Palsy

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Common Complications of CP related to eating and swallowing
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Common Complications of CP Related to Eating and Swallowing:

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Abnormal sensation and perception 
Some children have impaired sensations to touch and pain.  Pain is also created by hip dislocations, repetitive use syndromes, and degenerative joint disease. 

Pain can be a challenge to assess in an individual with cerebral palsy.  Impairment in communication skills or in cognitive function can make it difficult to determine whether or not the individual is experiencing pain.  Caregivers should be alert to changes in mood, temperament, appetite, sleep behaviors or the tolerance of movement.  (Reilly, et. al, 1996).
 
Gastrointestinal problems (GER) 
Caused by delayed gastric emptying, abnormal autonomic control of gastrointestinal motililty, lack of movement, or inadequate oral intake. 
 
GER is a common, persistent disorder often present in individuals with cerebral palsy.  It is theorized that is may be caused by spasticity of abdominal muscles which case increased intra-abdominal pressure, but it is also likely that the incoordination of the esophageal and sphincter muscle may have a role as well.  Other theories include intestinal immotility and delayed gastric emptying, although different studies yield conflicting evidence of this.  It is estimated that the incidence of GER varies from 32% to 75% depending upon the type of cerebral palsy and the population studied.  If the reflux is significant and frequent, it may increase the risk of food aspiration and aspiration pneumonia. 
 
One of the most frequent complication in reflux-positive individuals is iron deficiency, anemia, malnutrition and recurrent upper respiratory tract infections. 
 
Impaired oral-motor functions may cause communication disorders, affect dentition, weak facial movements, dysphagia, drooling (sialorrhea) 

Oral motor difficulties can impact all facets of the swallowing process.  In spastic cerebral palsy, the head is tensely reclined.  The mouth is open and facial movements are tense.  The tone is generally hypertonic and cigar shaped.  There is tongue thrust during swallowing and speaking.  Since the upper lip is underdeveloped, it does not produce enough pressure on the front teeth to align them correctly. (Senner, et. al, 2004).
 
In athetoid cerebral palsy the tongue demonstrates spontaneous wave-like movements.  There may be an abrupt and wide opening of the mouth, which can lead to jaw dislocation.  There is also uncoordinated movement of the tongue, jaw and facial muscles.
 
In hypotonic cerebral palsy the tongue is generally large, flat, and protruded.  Facial movements are weak and the upper lip is inactive. 
 
Excessive drooling or salivation (sialorrhea) is a common problem in individuals with cerebral palsy.  It may be caused by an excessive secretion of saliva, dental malocclusion or postural problems.  It can cause dehydration, odor, and be a social stigma for the individual with cerebral palsy and family. (Sprioglou, et.al, 2004). 
             
Nutritional Issues Due to dysphagia, poor muscle coordination, muscle weakness, and pain. 

Undernutrition is a frequent problem in individuals with severe cerebral palsy (spastic quadriplegia) who often have a significant impairment in eating and swallowing. Figures range from 30% -90% of individuals with cerebral palsy who are likely to suffer from malnutrition. Undernutrition affects both physical development and brain growth.  Undernourished infants and children do not achieve normal length and weight for their ages.  In addition, their neurological development is often impaired. 
 
Spasticity and disordered movement in cerebral palsy poses an extraordinary burden on the metallic system even in nonambulatory individuals.   
 
Increased fluid and caloric needs may be further compromised by the difficulties with chewing and swallowing and with GER. 

Undernourished children generally feel miserable and parents have noted that the child’s mood is improved after nutrition is stabilized.  The timing of the intervention is believed to be crucial.  Intervention that begins within the first 6 months is the most effective.  When nutrition intervention is delayed past 8 years of age, weight gain may be achieve; however, linear growth is likely to be limited. 
 
Cognitive functioning Cognitive impairment is present in two thirds of patients with cerebral palsy.
Neurosis and psychosis also can occur. In severe cognitively impaired individuals with cerebral palsy, it is more difficult to learn and maintain strategies that improve eating and swallowing.  They are more likely to require nonoral feedings to maintain adequate nutrition. 

Communication Due to muscle weakness, incoordination.  Increase caregiver stress, difficulty in assessing needs and wants. 
Some children with cerebral palsy may exhibit delayed language development because they are not able to play and explore like typically developing children.  Not being able to be understood by the people around him can influence the child’s intellectual development and make it difficult to communicate wants and needs  Augmentative communicative may be an option when the oral motor skills do not improve with therapy. 
 
Temporomandibular joint (TMJ) syndrome may be present in individuals with cerebral palsy.  This may be caused by neuromuscular imbalance, malocclusion or be the result of significant overusage.  It can be painful and cause the mandible to “lock” interfering with chewing and bolus preparation.  
 
Family Dynamic Issues Caregiver awareness regarding feeding issues, stress involved with mealtimes.
 
Extended feeding times, the stigma of excessive drooling, stress involved with mealtimes and providing adequate nutrition can negatively impact the relationship between an individual with cerebral palsy and caregivers.  It has been found that improved nutrition and quicker feeding times allow the caregiver to spend additional time in play and other related activities.  Improved nutrition also improves the individual’s mood and enhances the interaction with caregivers. (Nutrition Committee, 1994).
 
Abnormal Neurological Control: Lack selective control of muscle activity and anticipatory regulation, dysphagia, cough and airway clearance difficulties and respiratory muscle weakness.
 
Sucking and swallowing problems in the first 12 months of life are common and a high percentage require nonoral feedings on at least one occasion.  Swallowing is a complex process that involves the sequence of intricate timed maneuvers by a large number of muscles.  Muscle weakness creates a disturbance in the coordination of this sequence and often leads to swallowing difficulties.  Individuals with spastic quadriplegic cerebral palsy are most likely to be affected; however, dysphagia may be present in any of the cerebral palsy types.
 
Both the oral and pharyngeal phases of swallowing may be affected.  In the oral phase, the failure of proper bolus formation may impede swallowing.  In the pharyngeal phase, esophageal peristalsis, glottic closure and the coordination of swallowing and breathing may lead to aspiration of solids and liquids during feeding.  There may also be aspiration of secretions into the airway due to inadequate protective reflexes.  Coughing is also a complex action which requires the strong contraction of the abdominal and intercostal muscles, and precise coordination of these muscles in conjunction with the glottic muscles.  In addition, individuals with cerebral palsy appear to have a diminished sensitivity to cough.  It has been speculated that this may occur due to the result of desensitization of airway irritant receptors from chronic aspiration.  In addition, individuals with cerebral palsy often lead sedentary lifestyles.  Exercise is known to produce deep breathing which aids in the clearance of secretions and opens up underventilated lung regions.  Lack of exercise makes those with cerebral palsy prone to infection and hypoxemia.
 
Other factors that may contribute to dysphagia in children with cerebral palsy are bite reflexes, slowness of oral intake, poor trunk control, and the inability to feed independently. (Reilly, et. al, 1996).

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