Nutrition and Feeding Rehabilitation

Nutrition and feeding rehabilitation refers to non-medical interventions aimed at treating or managing feeding and swallowing difficulties in children with CP. Depending on the specific issue, the severity of the problem, or the functional status of the child and the type of CP, different approaches or a combination of treatments may be required.

Some of these interventions may include traditional oral motor therapy, behavioral interventions, electrical stimulation, and functional chewing training (FuCT). A short overview of these approaches is provided below.

Oral motor therapy typically includes active and passive exercises of the lips, tongue, and jaw and has the goal of strengthening the muscles in the mouth, increasing tongue mobility, and improving oral motor control while also decreasing abnormal tone and reflexes. This type of therapy also usually involves sensory stimulation of the face and mouth with different textures and/or therapeutic devices.

Behavioral interventions may include:

• postural changes – refers to changing the child’s position to ensure optimal trunk stability; an upright, supported positioning is generally recommended to improve swallowing
• diet modification – consists of changes in food texture, starting with softer, easy to chew foods that the child can easily manage (for example, smooth purees which avoid the need for chewing). It can also include changing the consistency of soups and liquids by adding thickening agents to help make swallowing them easier and safer
• oral appliances – appliances used to stabilize the jaw and promote better swallowing and lip control
• caregiver training –  education sessions for caregivers on different aspects of feeding such as positioning during feeding, food consistency, feeding techniques and use of appropriate utensils

Electrical stimulation (ES) involves the administration of electrical impulses to muscles in order to elicit a contraction. ES has shown promising results in improving swallowing function in adults with neurological disorders. In recent years, it has also been used in children with CP, either alone or in combination with other therapies. The goal of ES is to strengthen weak muscles involved in swallowing and improve motor control.

Functional chewing training (FuCT) is a functional approach that was recently developed to address chewing function and feeding difficulties in children with CP. The protocol consists of 5 steps: (1) positioning the child; (2) positioning the food; (3) sensory stimulation; (4) chewing exercise; and (5) adjustment of food consistency.

The different approaches used in nutrition and feeding rehab all aim to maximize independence in feeding and nutrition and improve the quality of life for children with CP and their families. This must be done while ensuring (1) that the high caloric demands of a growing child are being met and (2) that the child can safely eat without choking and without food and liquid going into their airway (aspiration).

Yes, there are multiple approaches used to address feeding and swallowing problems in children with CP. The ones discussed here are those that have been studied in young children with CP under 5 years of age using randomized controlled trials.

1. Oral motor therapy as described above is an intervention that typically focuses on improving lip, tongue, and jaw function. In the study reviewed for this module, the treatment included additional components such as modification of food texture and drink consistency, education for caregivers on proper positioning as well as spoon feeding and glass use techniques.
2. Electrical Stimulation (ES) was examined in one study reviewed for this module. The intervention involved the use of two small electrodes placed on the jaw bone and on the masseter muscle which plays a major role in mouth closure and chewing of solid foods. Electrical current was then applied to stimulate the muscle bilaterally. ES was provided in combination with oral motor therapy in this study.
3. The Functional chewing training is said to focus on creating repeated positive and successful experiences during feeding. The protocol takes 20 minutes to complete and consists of 5 steps:
   • Step 1: positioning the child in a seated position with the body tilted at 60-90 degrees, the head in the neutral position, and the arms/legs supported
   • Step 2: positioning the food to the molar area at every meal to stimulate lateral and rotational tongue movements
   • Step 3: sensory stimulation in the form of gum massage to decrease tactile hypersensitivity and tongue thrust
   • Step 4: chewing exercise using a chewing tube which is placed in the molar area and is moved around as the child chews
   • Step 5: gradual increase of food consistency
4. A nutrition education program was described in a study of young children with CP in Tanzania. The intervention consisted of:
   • individual and group nutrition education sessions for the caregivers – focused on food consistency, specific feeding techniques, use of appropriate utensils
   • occupational therapy sessions after the nutrition education session to train caregivers how to position and support their child during feeding – pictorial sheets were also provided for reference and to promote understanding.
   • the education sessions took place in clinic and then there was at least one home visit    during which the caregiver could demonstrate how they feed their child.

There is limited evidence regarding the effectiveness of feeding and swallowing interventions in young children with CP. Only four recent studies on four different interventions were found and reviewed for this module.

Oral motor therapy: One fair quality study examined the effectiveness of oral motor therapy in improving problems with feeding in children with CP, 12-42 months old, presenting with poor oral motor function including drooling, swallowing, chewing, sucking, and independent feeding. The results showed that oral motor therapy was more effective in improving oral motor function, feeding skills and drooling compared to routine physiotherapy only.

Electrical stimulation: One high quality study showed that ES combined with oral motor therapy resulted in improved swallowing function and dysphagia level compared to sham stimulation with oral motor therapy. In particular, the study found that children receiving ES had less drooling, increased tongue movements/chewing/ability to eat large food, and shorter feeding times after 4 weeks of treatment. Long term effects of ES were not studied, however.

Functional chewing training (FuCT): The results of one high quality study suggested that a 12 week program of FuCT improved tongue thrust in children with CP more than a typical oral motor exercise program. However, no difference was found in chewing function or drooling between the two groups.

Nutrition education program: One high quality study investigated the effectiveness of a practical nutrition education program on feeding and positioning skills in caregivers of young children with CP. The study found that caregivers participating in the program improved their feeding skills (positioning, feeding speed, and feeding support) more than caregivers receiving only routine care at a clinic. In addition, the intervention led to a significant improvement in caregiver-child interactions (caregivers reported feeling less stressed and child’s mood was reported as improved).

Overall, more research is needed to determine the effectiveness of these and other interventions in different populations with CP as well as the optimal combination of interventions.

Prior to the start of any feeding intervention, a thorough clinical evaluation of your child will be required which is usually done by an occupational therapist or a speech language pathologist. The assessment will include collecting information from the family regarding medical history, development and specific problems the child is having with feeding. An observation of your child at mealtimes may also be required and, in the case of concerns regarding the safety of the swallow and possible aspiration of food/liquids, further investigation may be warranted. This is usually done using a Modified Barium Swallow Test – the child consumes food/liquid with barium in it which then shows up on x-rays so the movement of food through the pharynx and esophagus can be visualized.

Depending on the type of intervention, different healthcare professionals may be involved. Oral motor therapy may be provided by a physiotherapist or a speech-language pathologist (SLP). Behavioral interventions including positioning, diet modifications, etc. may involve an occupational therapist or an SLP. Often, the interventions may also be provided by several healthcare professionals working in an interdisciplinary team which could include a doctor, nurse, dietitian, and therapists.

There is no set protocol for the treatment period. Frequency and duration of treatment would depend on the specific intervention and other variables.

Oral motor therapy: The intervention in the reviewed study involved 1 hour sessions with a physiotherapist, once a week, for 6 months (total of 12 sessions).

Electrical stimulation: Treatment was provided in combination with oral motor therapy. ES was administered for 30min/day, 4 days/week, for 4 weeks.

Functional chewing training:  In the reviewed study, the treatment consisted of performing 5 sets/day (each set taking 20 minutes to complete) for 12 weeks.

Nutrition education program: The program included 6-8 education sessions in a clinic and 1 home visit. The length of the nutrition education sessions was not specified in the reviewed study; the occupational therapy education sessions lasted 30 minutes.

No adverse effects were reported in any of the studies reviewed in this module. However, there is insufficient information regarding long term safety issues. If you have any concerns, we suggest that you discuss these with the treatment provider.

Eating is one of the most important activities for a child especially in terms of development and quality of life. There exist multiple and diverse feeding and swallowing interventions which reflect the range of feeding and swallowing difficulties experienced by children with CP.

Currently, there is still uncertainty and limited evidence regarding what the optimal intervention is for treating any specific type of problem and further research is required to develop clear guidelines. However, lack of evidence does not necessarily mean a treatment is ineffective. Many of the interventions have shown promising results, as discussed above. Electrical stimulation combined with oral motor therapy showed positive effects on dysphagia in children with GMFCS levels II through V. Similarly, the functional chewing training protocol was beneficial to children with GMFCS level II, III and V, while the nutrition education program was studied in children with moderate and severe CP.

If your child is showing signs of problems with feeding or swallowing, an evaluation and a treatment plan are essential to ensure their safety and adequate nutrition.

Information on this website is provided for informational purposes only and is not a substitute for professional medical advice.

One fair quality RCT (Inal et al., 2017) investigated the effects of functional chewing training (FuCT) on chewing function among children with cerebral palsy (GMFCS level II, III, V). In this fair quality RCT, children were randomized to receive FuCT or a classical oral motor exercise program. Chewing function was assessed using the Karaduman Chewing Performance Scale at post-treatment (12 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that functional chewing training is not more effective than a comparison intervention (classical oral motor exercise program) in improving chewing function in children with CP.

One fair quality RCT (Inal et a., 2017) investigated the effects of functional chewing training (FuCT) on drooling among children with CP (GMFCS level II, III, V). In this fair quality RCT, children were randomized to receive FuCT or a classical oral motor exercise program. Drooling was assessed using the Drooling Severity and Frequency Scale at post-treatment (12 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that functional chewing training is not more effective than a comparison intervention (classical oral motor exercise program) in improving drooling in children with CP.

One fair quality RCT (Inal et al., 2017) investigated the effects of functional chewing training (FuCT) on tongue thrust among children with CP (GMFCS level II, III, V). In this fair quality RCT, children were randomized to receive FuCT or a classical oral motor exercise program. Tongue thrust was assessed using the Tongue Thrust Rating Scale at post-treatment (12 weeks). A significant between-group difference was found, favoring FuCT vs. the classical oral motor exercise program.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that functional chewing training is more effective than a comparison intervention (classical oral motor exercise program) in improving tongue thrust in children with CP.

One high quality RCT (Mlinda et al., 2018) investigated the effects of a practical nutrition education program on caregiver-child interactions among families of children with CP. This high quality RCT randomized patients to receive a practical nutrition education program or routine care. Caregiver-child interactions were evaluated by assessing the child’s mood and the caregiver’s stress during feeding at post-treatment (6 months). Significant between-group differences were found for both measures, favoring the practical nutrition education program vs. routine care.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a practical nutrition education program is more effective than a comparison intervention (routine care) in improving caregiver-child interactions in families of children with CP.

One high quality RCT (Mlinda et al., 2018) investigated the effects of a practical nutrition education program on caregiver feeding skills among caregivers of children with CP. This high quality RCT randomized patients to receive a practical nutrition education program or general routine care. Caregiver feeding skills were evaluated by assessing positioning, feeding speed, feeding support & child involvement at post-treatment (6 months). Significant between-group differences were found in all assessed areas, favoring the practical nutrition education program vs. routine care.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a practical nutrition education program is more effective than a comparison intervention (routine care) in improving caregiver feeding skills among caregivers of children with CP.

One high quality RCT (Mlinda et al., 2018) investigated the effects of a practical nutrition education program on child feeding skills in children with CP. This high quality RCT randomized patients to receive a practical nutrition education program or general routine care. Child feeding skills were evaluated by assessing oral motor skills and functional skills at post-treatment (6 months). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a practical nutrition education program is not more effective than a comparison intervention (routine care) in improving child feeding skills in children with CP.

One fair quality RCT (Sigan et al., 2013) investigated the effects of oral motor therapy on overall development among children with cerebral palsy (CP) presenting with oral motor dysfunction. In this fair quality RCT, children were randomized to receive oral motor therapy or no treatment; both groups received routine physiotherapy. Overall development was assessed using the Bayley Scale of Infant Development II at post-treatment (6 months). A significant between-group difference was found, favoring oral motor therapy vs. no treatment.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that oral motor therapy is more effective than no treatment in improving overall development in children with CP presenting with oral motor dysfunction.

One fair quality RCT (Sigan et al., 2013) investigated the effects of oral motor therapy on drooling among children with cerebral palsy (CP) presenting with oral motor dysfunction. In this fair quality RCT, children were randomized to receive oral motor therapy or no treatment; both groups received routine physiotherapy. Drooling was assessed at post-treatment (6 months). A significant between-group difference was found, favoring oral motor therapy vs. no treatment.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that oral motor therapy is more effective than no treatment in reducing drooling in children with CP.

One fair quality RCT (Sigan et al., 2013) investigated the effects of oral motor therapy on feeding skills among children with cerebral palsy (CP) presenting with oral motor dysfunction. In this fair quality RCT, children were randomized to receive oral motor therapy or no treatment; both groups received routine physiotherapy. Feeding skills were assessed using the Multidisciplinary Feeding Profile – Functional Feeding Assessment subscale (FFA: Spoon feeding, Biting, Chewing, Drinking, Swallowing) at post-treatment (6 months). Significant between-group differences were found in all testing sections, favoring oral motor therapy vs. no treatment.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that oral motor therapy is more effective no treatment in improving feeding skills in children with CP presenting with oral motor dysfunction.

One fair quality RCT (Sigan et al., 2013) investigated the effects of oral motor therapy on oral motor function among children with cerebral palsy (CP) presenting with oral motor dysfunction. In this fair quality RCT, children were randomized to receive oral motor therapy or no treatment; both groups received routine physiotherapy.  Oral motor function was assessed using the Oral Motor Assessment Form (OMAF: Oral motor problems; Swallow delay; Aspiration; Choking; Coughing and suffocation; Tongue extension, elevation, lateralization; Jaw lateralization; Jaw stabilization; Mouth Function; Improved tolerated food texture; Swallowing evaluation) at post-treatment (6 months). Significant between-group differences were found in Oral motor problems (chewing, swallowing, drooling, independent feeding and feeding problems), Swallow delay, Choking, Aspiration, Tongue/jaw/mouth function and Tolerated food textures, favoring oral motor therapy vs. no treatment.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that oral motor therapy is more effective than no treatment in improving oral motor function in children with CP, presenting with oral motor dysfunction.

One fair quality RCT (Sigan et al., 2013) investigated the effects of oral motor therapy on related reflexes among children with cerebral palsy (CP) presenting with oral motor dysfunction. In this fair quality RCT, children were randomized to receive oral motor therapy or no treatment; both groups received routine physiotherapy. Asymmetrical tonic neck reflex and swallowing reflex were assessed at post-treatment (6 months). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that oral motor therapy is not more effective than no treatment in affecting related reflexes in children with CP presenting with oral motor dysfunction.

One high quality RCT (Umay et al., 2020) investigated the effects of sensory level electrical stimulation combined with a conventional dysphagia rehabilitation on dysphagia in children with CP (including a mixed population of types and severity of CP). This high quality RCT randomized patients to receive sensory level electrical stimulation (ES) or sham stimulation; both groups received (conventional dysphagia rehabilitation. Dysphagia was evaluated by the Pediatric Eating Assessment Tool-10 and the Flexible Fiberoptic Endoscopic Evaluation of Swallowing at post-treatment (4 weeks). Significant between-group differences were found on both measures, favoring ES vs. sham stimulation

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a sensory level electrical stimulation is more effective than a comparison intervention (sham stimulation) in improving dysphagia for children with CP presenting with oropharyngeal dysphagia symptoms.